Background: Mortality rates are a critical quality metric for hospitals, influencing both clinical outcomes and institutional reputation. The Centers for Medicare and Medicaid Services (CMS) incorporates 30-day mortality rates into its Value-Based Purchasing (VBP) program and Star Ratings, directly impacting hospital reimbursement and public perception. Similarly, U.S. News & World Report factors 30-day mortality into [...]

Background: Capturing appropriate clinical documentation allows providers to best approach treating patients and can also be utilized for quality monitoring of outcomes within health systems. Mortality measures are used by the Centers for Medicare and Medicaid Services (CMS) for reimbursement and payment. (1) Observed mortality includes all deaths which occur in the hospital during a [...]

Background: Documentation burden has been on the rise since the introduction of electronic health records (EHRs). Artificial Intelligence (AI) scribes use ambient documentation technology with the potential to mitigate documentation burden. Few studies have investigated the implications of AI scribes on hospital medicine providers’ workflow and patient interactions. Methods: We conducted a stepped-wedge trial at [...]

Background: Mortality risk assessment is crucial for predicting patient outcomes, assessing patient care delivery, and improving healthcare quality. Although high-quality medical documentation is critical for mortality risk assessment tools, provider documentation may be inconsistent, relies on coding teams for support, and may not directly reflect provider orders. Complete and precise documentation and coding can improve [...]

Background: Accurate clinical documentation is essential for capturing patient severity of illness (SOI) and risk of mortality (ROM). These metrics directly influence hospital quality reporting, including rankings like Vizient and metrics such as Observed-to-Expected Mortality (O:E) ratios. Traditional documentation methods rely heavily on manual input, which in busy clinical practices, results in underrepresented patient risk [...]

Background: Providing patient centered care is a core value of all healthcare systems in our nation. However, having a code status discussion with patients and their families continues to be a challenging endeavor due to multiple factors such as competing priorities and time constraints, especially in the hospital setting. To improve code status discussion and [...]

Background: Current guidelines to decrease the incident of CLABSI (Central Line Associated Blood Stream Infection) recommend daily assessment of line presence and clinical indication for the line (Odada et al., 2023). This helps decrease unnecessary line use and facilitates prompt line removal if not indicated. Daily line documentation including type of line, anatomical location of [...]

Background: Despite 80 years of documentation of the “evil sequellae”(1) of immobility for inpatients, lack of ambulation remains prevalent and deleterious. Hospitalized patients have been shown to spend an average of 83% of their stay in bed(2), leading to complications including loss of independence in activities of daily living, higher rates of discharge to facility, [...]

Background: Risk adjustment indices are frequently used for hospital billing and reimbursements in the United States. Severity of illness (SOI) and risk of mortality (ROM) are two risk adjustment indices used in determining the APR-DRG, a classification system commonly used by insurers to determine hospital reimbursements. Recently, many health systems implemented AI-powered clinical documentation assistants [...]

Background: Patients are often discharged from the hospital with active medical issues needing outpatient follow-up (AINF) – including recommended labs, imaging, procedures, follow-up appointments, and follow-up of incidental findings – but patients and their outpatient providers often fail to complete these recommended workups [1]. Primary care physicians strongly recommend that discharging providers include a brief [...]