Background: The occurrence of adverse events due to unsafe health care is thought to be one of the 10 leading causes of death and disability in the world. The harm can be caused by a range of adverse events, with nearly 50% of them preventable. Broad adoption of electronic health records (EHR) should ideally harness [...]

Background: Accurate problem lists linked to the electronic medical record (EMR) can be a source of structured clinical data useful for communication among clinicians for patient care, clinical decision support design, and EMR phenotyping.  Nevertheless, modifying the electronic problem list is disruptive to clinician workflow under traditional charting methods, resulting in incomplete, inaccurate, and outdated [...]

Background: New York State has identified a list of controlled medications that require frequent monitoring and review. New York State law dictates that these medications, when disbursed in a hospital setting, must be reviewed and re-ordered on a weekly basis. In order to maintain compliance with New York State law, the Electronic Medical Record (EMR) [...]

Background: Outside Medical Records are essential for accurate continuity of care when patients are transferred from one healthcare system to another. Despite their importance, obtaining records in a timely manner is a notoriously difficult process. At Stanford Hospital, the medicine teams were burdened with 5 pages of paperwork per record request for a single patient. [...]

Background: Lab testing is critical for clinical decision-making and used throughout healthcare systems. Overuse of lab testing is known to be commonplace and contributes to shortages in lab testing materials. While practices exist at medical institutions that aim to limit lab test overuse, it is unclear which interventions are effective. Methods: We aimed to reduce [...]

Background: Discharge checklists may reduce medical errors. Traditional paper checklists do not fit into the current workflow in centers that utilize electronic medical records (EMRs). In an era where team-based care is becoming widespread, defining each person’s role in discharge practices is increasingly important.  Methods: Our aim was to develop and implement a standardized discharge [...]

Background: The Intermediate Care Unit (IMU) was developed in the 1960s – 1970s as a level of care between general medicine (GMU) and intensive care units (ICU) [1]. The Society of Critical Care Medicine has established guidelines for admitting patients to an IMU based on severity of illness or need for frequent or complex nursing [...]

Background: Communication breakdown plays a part in the majority of adverse events in healthcare. Physician to physician handoffs are particularly prone to communication errors, yet have been shown to be more complete when systematized according to a standardized bundle. However,  the degree to which individual elements of this bundle, including written versus verbal handoffs, contribute [...]

Background: It has been reported that vaccination rates with pneumococcal vaccine are low in elderly persons in Japan. The primary aim of this study was to examine whether introduction of a vaccination status checkbox in electronic medical records increased the vaccination rates. Methods: Subjects were inpatients and outpatients in the Department of General Medicine at [...]

Background: Physicians increasingly utilize electronic health records (EHR) to deliver healthcare, and the EHR has been identified as leading source of physician burnout and frustration [Shanafelt et al]. Studies report up to 52.6% of hospitalists exhibit symptoms of burnout [Roberts et al]. However, there is no data to inform how hospital medicine physicians spend their [...]