Background: There has been ample speculation about potential future applications of natural language processing and related technologies for clinical documentation, and yet the mechanics of clinical documentation have changed very little since the passage of the HITECH Act in 2009. Purpose: While awaiting the integration of more advanced technologies into electronic health records (EHRs), we [...]

Background: Despite the widespread use of technology across our daily lives, many processes in the hospital remain manual and labor-intensive. As hospital medicine divisions grow, there is an increasing need for automated and scalable solutions. While many hospitals look to external vendors to provide automated solutions, these often lack customizability and gaps remain. Purpose: To [...]

Background: Serious Illness Conversations (SICs) lead to a better understanding of patient values and preferences, improved patient and family satisfaction, and other benefits. Prognostic awareness and early identification of patients who may benefit from an SIC remains a challenge. Epic’s Risk of Unplanned Readmission (Readmission Risk Score), a composite score (0-100) that includes clinical factors [...]

Background: Duplicate as-needed (referred to hereafter as “PRN”) orders for common indications such as pain, nausea, insomnia, and constipation are frequent in hospitalized patients. Without explicit instructions for circumstances or order of administration, therapeutic duplication can cause confusion for nurses and violates both Join Commission and the Centers for Medicare & Medicaid Services (CMS) guidelines. [...]

Background: Confidentiality within adolescent medicine is imperative in establishing a trusting patient-physician relationship. In April 2021, the 21st Century Cures Act granted patients’ guardians immediate access to select patient electronic medical records. Whereas Pediatric Hospital Medicine (PHM) history and physical (H&P) notes are visible to guardians, adolescent sensitive notes (ASN) remain confidential. At our institution, [...]

Background: Hospital-at-Home (HaH) is a safe and effective alternative to high-cost, traditional hospitalization in patients with a range of medical conditions, such as non-severe community-acquired pneumonia (CAP). The COVID-19 pandemic created a unique situation with favorable policy changes, hospital resource constraints, and a clearly defined patient population that helped to increase HaH program deployment and [...]

Background: While the electronic health record (EHR) provides many benefits, its use can easily allow for incomplete documentation of relevant historical information. The EHR is designed to store documentation of a patient’s past medical history (PMH), surgical history (PSH), family history (FH), and active hospital problems in the History tab. When the information is in [...]

Background: There has been ample speculation about potential future applications of natural language processing and related technologies for clinical documentation, and yet the mechanics of clinical documentation have changed very little since the passage of the HITECH Act in 2009. Purpose: While awaiting the integration of more advanced technologies into electronic health records (EHRs), we [...]

Background: Despite the widespread use of technology across our daily lives, many processes in the hospital remain manual and labor-intensive. As hospital medicine divisions grow, there is an increasing need for automated and scalable solutions. While many hospitals look to external vendors to provide automated solutions, these often lack customizability and gaps remain. Purpose: To [...]