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Background Reliable, precise, timely, and clear documentation of diagnoses is difficult. Poor specificity or the absence of diagnostic documentation can lead to decreased revenue and increased payor denials, audits, and queries to providers. Nuance's Dragon Medical Advisor (DMA) is a computer-assisted physician documentation (CAPD) product. Natural language processing is used to present real-time advice on diagnostic specificity during documentation. Objectives This study assessed the feasibility, acceptability, and preliminary efficacy of [...]

 Data exploration in modern electronic health records (EHRs) is often aided by user-friendly graphical interfaces providing "self-service" tools for end users to extract data for quality improvement, patient safety, and research without prerequisite training in database querying. Other resources within the same institution, such as Honest Brokers, may extract data sourced from the same EHR but obtain different results leading to questions of data completeness and correctness.

 Nephrotoxin exposure may worsen kidney injury and impair kidney recovery if continued in patients with acute kidney injury (AKI).

 Commercially available large language models such as Chat Generative Pre-Trained Transformer (ChatGPT) cannot be applied to real patient data for data protection reasons. At the same time, de-identification of clinical unstructured data is a tedious and time-consuming task when done manually. Since transformer models can efficiently process and analyze large amounts of text data, our study aims to explore the impact of a large training dataset on the performance of [...]

 Opioid overdoses have contributed significantly to mortality in the United States. Despite long-standing recommendations from the Centers for Disease Control and Prevention to coprescribe naloxone for patients receiving opioids who are at high risk of overdose, compliance with these guidelines has remained low.

 Primary care pediatricians play an important role in genetic testing, including referrals, test ordering, responding to results, assessing risk, treatment, and managing care. As genetic testing rapidly evolves to include new tests identifying patients at risk for certain conditions, alert-based clinical decision support is insufficient in assisting pediatric primary care providers in working with patients, parents, genetics, and other specialties. Supporting pediatricians in the return of these results requires addressing [...]

 Due to fear of stigma, patients want more control over the sharing of sensitive medical records. The Substance Abuse and Mental Health Administration (SAMHSA) and the Office of the National Coordinator (ONC) supported the development of standards-compliant, consent-respecting medical record exchange technology using metadata labeling (e.g., substance use information). Existing technologies must be updated with newer standards and support more than binary-sensitive categorizations to better align with how physicians categorize [...]

 Interoperability between electronic health records (EHR) and immunization information systems (IIS) may positively influence data quality, affecting timeliness, completeness, and accuracy of these data. However, the extent to which EHR/IIS interoperability may influence the day-to-day vaccination workflow and related recordkeeping tasks performed at medical practices is unclear.

 This study aimed to bridge the educational gap in clinical informatics (CI) at the residency level and stimulate interest in CI as a rewarding career path.

 This research study aims to advance the staging of Parkinson's disease (PD) by incorporating machine learning to assess and include a broader multifunctional spectrum of neurocognitive symptoms in the staging schemes beyond motor-centric assessments. Specifically, we provide a novel framework to modernize and personalize PD staging more objectively by proposing a hybrid feature scoring approach.