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OBJECTIVE: Clinical summarization, the process by which relevant patient information is electronically summarized and presented at the point of care, is of increasing importance given the increasing volume of clinical data in electronic health record systems (EHRs). There is a paucity of research on electronic clinical summarization, including the capabilities of currently available EHR systems. METHODS: We compared different aspects of general clinical summary screens used in twelve different EHR [...]

OBJECTIVES: Clinical decision support (CDS), such as computerized alerts, improves prescribing in the setting of acute kidney injury (AKI), but considerable opportunity remains to improve patient safety. The authors sought to determine whether pharmacy surveillance of AKI patients could detect and prevent medication errors that are not corrected by automated interventions. METHODS: The authors conducted a randomized clinical trial among 396 patients admitted to an academic, tertiary care hospital between [...]

BACKGROUND: The ability to electronically exchange health information among healthcare providers holds enormous promise to improve care coordination and reduce costs. Provider-to-provider data exchange is an explicit goal of the American Recovery and Reinvestment Act of 2009 and may be essential for the long-term success of the Affordable Care Act of 2010. However, little is known about what factors affect clinicians' usage of health information exchange (HIE) functionality. OBJECTIVE: To [...]

BACKGROUND: Standardization of sign-out, the transfer of patient information and responsibility between inpatient providers at shift change, is a Joint Commission National Patient Safety Goal intended to improve communication and reduce risk of error. Computerized systems with free text data entry and limited structure allow clinicians to generate sign-out notes in a variety of ways. OBJECTIVES: The literature lacks a systematic exploration of the range of content generated by users [...]

BACKGROUND: Implementation of Computerized Provider Order Entry (CPOE) can fail or meet high levels of user resistance for a variety of reasons, including lack of attention to users' needs and the significant workflow changes induced and required by CPOE. End-user satisfaction is a critical factor in IT implementation. OBJECTIVE: The goal of this study was to identify criteria to select a valid and reliable questionnaire to measure end-user satisfaction with [...]

Clinical notes summarize interactions that occur between patients and healthcare providers. With adoption of electronic health record (EHR) and computer-based documentation (CBD) systems, there is a growing emphasis on structuring clinical notes to support reusing data for subsequent tasks. However, clinical documentation remains one of the most challenging areas for EHR system development and adoption. The current manuscript describes the Vanderbilt experience with implementing clinical documentation with an EHR system [...]

The International Classification of Functioning, Disability and Health (ICF) is the World Health Organization's standard for describing health and health-related states. Examples of how the ICF has been used in Electronic Health Records (EHRs) have not been systematically summarized and described yet.

Despite near (and rare) consensus that the adoption and diffusion of health information technology (health IT) will bolster outcomes for organizations, individuals, and the healthcare system as a whole, there has been surprisingly little consideration of the structures and processes within organizations that might drive the adoption and effective use of the technology. Management research provides a useful lens through which to analyze both the determinants of investment and the [...]