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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.

To document the perceived frequency, type, and impact of unavailable ("missing") clinical information during pediatric emergency and general ambulatory encounters.

There is increasing recognition that a competent and well-trained workforce is required for successful implementation of health information technology.

Web 2.0 technologies, known as social media, social technologies or Web 2.0, have emerged into the mainstream. As they grow, these new technologies have the opportunity to influence the methods and procedures of many fields. This paper focuses on the clinical implications of the growing Web 2.0 technologies. Five developing trends are explored: information channels, augmented reality, location-based mobile social computing, virtual worlds and serious gaming, and collaborative research networks [...]