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Objective Patient instructions are generally written by clinicians. However, clinician-centered language is challenging for patients to understand; in the case of pediatric medication instructions, consequences can be serious. Using examples of clinician-written medication instructions from an electronic health record, we conducted an experiment to determine whether parental misinterpretations would be reduced by instructions that followed best practices for plain language. Methods We selected examples of dosing instructions from after-visit summaries in a [...]

Background  Patients at risk for sudden cardiac death or having suffered cardiac arrest may receive an implantable cardioverter defibrillator (ICD). This device provides monitoring and therapy for life-threatening heart rhythms. Remote monitoring of ICDs has decreased the time between abnormal heart rhythm events and clinic follow-up. Currently, the data transmitted from the device are reviewed and stored by the clinic, but patients do not have access to the data. While [...]

Background Around the world, people receive care at various institutions; therefore, clinical information is recorded either on paper or distributed on different information systems with reduced capabilities for sharing data. One approach to handling the complex nature of the health information systems and making it interoperable is the two-level modeling, and the ISO 13606 standard is an option to support this model. A regionally governed EHR program in Brazil proposed to [...]

Background and Objective Finnish physicians have been increasingly dissatisfied with poor usability of the electronic patient record (EPR) systems, which they have identified as an overload factor in their work. Our aim is to specify which factors in EPRs are associated with work-related well-being of physicians. Methods A web-based questionnaire was sent to Finnish physicians younger than 65 years; the responses (n = 3,781) represent one-fourth of these. This was a repetition of a [...]

Objective To conduct research to show the value of text mining for automatically identifying suspected bleeding adverse drug events (ADEs) in the emergency department (ED). Methods A corpus of ED admission notes was manually annotated for bleeding ADEs. The notes were taken for patients ≥ 65 years of age who had an ICD-9 code for bleeding, the presence of hemoglobin value ≤ 8 g/dL, or were transfused > 2 units of packed red blood cells. This [...]

Background Conventional classroom Electronic Health Record (EHR) training is often insufficient for new EHR users. Studies suggest that enhanced training with a hands-on approach and closely supported clinical use is beneficial. Objectives Our goals were to develop an enhanced EHR learning curriculum for Post Graduate Year 1 (PGY1) residents and measure changes in EHR skill proficiency, efficiency, and self-efficacy. Methods A novel three-phase, multimodal enhanced EHR curriculum was designed for a cohort of [...]

Scribes are assisting Emergency Physicians by writing their electronic clinical notes at the bedside during consultations. They increase physician productivity and improve their working conditions. The quality of Emergency scribe notes is unevaluated and important to determine.

To determine the impact of the introduction of new pre-written orders for antimicrobials in a computerized provider order entry (CPOE) system on 1) accuracy of documented indications for antimicrobials in the CPOE system, 2) appropriateness of antimicrobial prescribing, and 3) compliance with the hospital's antimicrobial policy. Prescriber opinions of the new decision support were also explored to determine why the redesign was effective or ineffective in altering prescribing practices.

Determine if clinical decision support (CDS) malfunctions occur in a commercial electronic health record (EHR) system, characterize their pathways and describe methods of detection.