Background: Systematic and real-time gathering of data is central to the feedback loop to help providers guide and continuously improve their practice in a Learning Healthcare System (Figure 1). Despite these worthy goals health systems rely on Electronic Medical Record systems (EMRs) that make the routine collection and analysis of data for providers a laborious, [...]

Background: Hospital readmissions within 30 days of discharge have gained national attention and account for more than $17 billion in avoidable U.S. Medicare expenditures each year. (1) In 2011 alone, there were approximately 3.3 million adult 30-day all-cause hospital readmissions, costing the US $41.3 billion.(2) As such, efforts have been made to create algorithms to [...]

Background: Given that nearly 1 in 3 patients are readmitted to the hospital within 90 days of admission for acute exacerbation of COPD (AE-COPD), efforts exist to develop tools to better identify patients at higher risk for readmission. Our group has previously published a model based on International Classification of Disease, Ninth Revision and Tenth [...]

Background: In the years leading up to the COVID-19 pandemic, venture capital investment in digital health increased rapidly. Beginning in March of 2020, the COVID-19 pandemic led to a seismic shift toward asynchronous, remote care delivery to replace in-person care buttressed by passage of the Public Health Emergency Act which established payment parity between in-person [...]

Background: A problem list serves as a central place for hospital-based clinicians to obtain a comprehensive and concise view of the patient’s active medical conditions. Use of the hospital problem list has many potential benefits: it provides a mental model of patient’s health status; streamlines the documentation process; makes chart review more efficient; facilitates communication [...]

Background: Following a hospitalization, older adults, their caregivers, and clinicians caring for them face a complex decision regarding post-acute care (PAC). The purpose of PAC, delivered by a skilled nursing facility (SNF) or home health (HH), is to support the recovery of patients after hospital discharge. However, the transition to PAC is a vulnerable time [...]

Background: Heart Failure (HF) is among the top 10 causes of hospitalization and almost a fifth are readmitted within 30 days. Clinical assessment of lung congestion is subjective and patients may be discharged prior to good resolution. Lung ultrasound (LUS) is helpful in evaluating lung congestion. The presence of B-lines on LUS can reliably indicate [...]

Background: Background: Ultrasound has diagnostic value at the point-of-care among hospitalized patients. In COVID-19 pneumonia, lung ultrasound has been used as a diagnostic and prognostic tool. For example, using the results of nasal PCR test as the reference standard, a modified lung ultrasound score (LUS) ≥ 8 is highly predictive of COVID-19. However, a focused [...]

Background: Understanding patient readiness for discharge requires communication between the many disciplines who care for patients. Team members use different tools in the electronic health record (EHR) to document and communicate discharge-related information, which can result in inefficient communication, delays in discharge, and adverse patient outcomes. EHR-based discharge coordination tools have potential to improve discharge [...]

Background: Many hospitalized adults arrive with pre-existing malnutrition, which is associated with high risk of adverse outcomes. As such, malnutrition is a common variable in cost and quality risk adjustment models based on hospital discharge diagnosis codes. Hospital dietitians assess patients for malnutrition and generally document the details of their evaluations. However, coding professionals cannot [...]