Background: Recent widespread adoption of electronic health records (EHRs) has dramatically increased the amount of information quickly accessible to clinicians. Given recent pushes for interoperability and consumer generated data in EHRs, the volume of information will continue to grow. The result is clinicians who experience information overload and lack the time and ability to comprehensively [...]

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: Recent widespread adoption of electronic health records (EHRs) has dramatically increased the amount of information quickly accessible to clinicians. Given recent pushes for interoperability and consumer generated data in EHRs, the volume of information will continue to grow. The result is clinicians who experience information overload and lack the time and ability to comprehensively [...]

Background: Internal medicine residents face multiple barriers to participating in and documenting goals of care (GOC) meetings in the intensive care unit (ICU). Barriers include heavy workloads, need for urgent stabilization of critically ill patients, and inadequate communication skills training. Guidelines recommend regularly conducting and documenting GOC meetings for critically ill patients, to facilitate communication [...]

Background: Physicians spend more time on documentation and less on direct patient care. Burnout and career disengagement have been linked to time spent documenting in the electronic health record. A scribe program could reduce the documentation burden on hospitalists, increase revenue capture and improve the efficiency of the admission process. Purpose: We implemented a prospective [...]

Background: Clinical documentation integrity (CDI), a process by which documentation is optimized to be both congruent with Centers for Medicare and Medicaid (CMS) terminology and reflect patient severity of illness, is widely used in healthcare to ensure appropriate coding for hospital reimbursement and improve accuracy of research and quality outcomes. CDI optimization is often performed [...]

Background: Unconscious bias within the U.S. health care system has been linked with disparities in the treatment of patients by age, gender, and race (1). While many factors contribute to these disparities, implicit bias may play a significant role. Stigmatizing language often reflects the implicit bias that healthcare providers possess toward patients (2). Recent research [...]

Background: With the advent of the Electronic Medical Record (EMR), documentation occupies up to 50% of doctors’ time1 and prior work has revealed that internal medicine residents spend more than four hours daily on documentation2. Secure messaging (SM) has been recently integrated into the inpatient EMR system, allowing healthcare team members to directly message physicians; [...]

Background: Stigmatizing language in clinical notes can negatively impact physician attitudes, propagate bias, affect prescribing behaviors, and exacerbate healthcare disparities, yet remains prevalent even in the Open Notes era. Prior analyses of stigmatizing terms in clinical notes are limited by the lack of context in which terms are used and multiple meanings of certain words [...]

Background: Clinical documentation is challenging when patients are admitted with many diagnoses of varying severity. Documentation of chronic or low-acuity conditions on the History and Physical (H&P) note can feel less salient than primary admission diagnoses. This can lead to under-documentation of comorbid conditions and an underrepresentation of the complexity of care. Capturing this overlooked [...]