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A minimum dataset (MDS) can be determined ad hoc by an investigator or small team; by a metadata expert; or by using a consensus method to take advantage of the global knowledge and expertise of a large group of experts. The first method is the most commonly applied.

The aim of this study was to investigate (1) why ordering clinicians use free-text orders to communicate medication information; (2) what risks physicians and nurses perceive when free-text orders are used for communicating medication information; and (3) how electronic health records (EHRs) could be improved to encourage the safe communication of medication information.

The Accreditation Council for Graduate Medical Education establishes minimum case requirements for trainees. In the subspecialty of obstetric anesthesiology, requirements for fellow participation in nonobstetric antenatal procedures pose a particular challenge due to the physical location remote from labor and delivery and frequent last-minute scheduling.

Appropriate documentation of critical care services, including key time-based parameters, is critical to accurate severity of illness metrics and proper reimbursement. Documentation of time-based elements for critical care services performed in emergency departments (ED) remains inconsistent. We integrated electronic medical record and real-time location system (RTLS)-derived data to augment quality improvement methodology.

Spelling during medication ordering is prone to error, which can contribute to frustration, confusion, and, ultimately, errors. Typo correction can be utilized in an effort to mitigate the effects of misspellings by providing results even when no exact matches can be found. Although, typo correction can be beneficial in some scenarios, safety concerns have been raised when utilizing the functionality for medication ordering. Our primary objective was to analyze the [...]

To examine pediatricians' perspectives on administrative tasks including electronic health record (EHR) documentation burden and their effect on work-life balance and life and career satisfaction.

Workflow automation, which involves identifying sequences of tasks that can be streamlined by using technology and modern computing, offers opportunities to address the United States health care system's challenges with quality, safety, and efficiency. Other industries have successfully implemented workflow automation to address these concerns, and lessons learned from those experiences may inform its application in health care.

The operating room is a specialized, complex environment with many factors that can impede effective communication during transitions of care between anesthesia clinicians. We postulated that an efficient, accessible, standardized tool for intraoperative handoffs built into standard workflow would improve communication and handoff safety. Most institutions now use an electronic health record (EHR) system for patient care and have independently designed intraoperative handoff tools, but these home-grown tools are not [...]

There is a lack of evidence on how to best integrate patient-generated health data (PGHD) into electronic health record (EHR) systems in a way that supports provider needs, preferences, and workflows. The purpose of this study was to investigate provider preferences for the graphical display of pediatric asthma PGHD to support decisions and information needs in the outpatient setting.