Background: Overnight vital sign assessment can disrupt sleep in the hospital and may be unnecessary in clinically stable patients. However, providers may not feel comfortable determining which patients can safely forego overnight vitals. We studied the effect of a clinical decision support (CDS) tool embedded in the electronic health record (EHR) that automatically identified clinically [...]

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: Clinically stable inpatients may receive potentially unnecessary care, such as overnight vital sign assessment. Nighttime vital signs can disrupt sleep and adversely affect patient satisfaction and contribute to delirium. However, it may be difficult for individual clinicians to determine which patients could safely forego overnight vital signs. Purpose: We developed a predictive algorithm designed [...]

Background: Residents are uniquely positioned to learn from and contribute to informatics. As key electronic health record (EHR) users, they offer practical solutions and feedback. Resident informatics engagement promotes EHR proficiency and accelerates implementation of best practices and quality improvement. Understanding how clinical data are structured creates a foundation for future scientific inquiry using clinical [...]

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: Clinically stable inpatients may receive potentially unnecessary care, such as overnight vital sign assessment. Nighttime vital signs can disrupt sleep and adversely affect patient satisfaction and contribute to delirium. However, it may be difficult for individual clinicians to determine which patients could safely forego overnight vital signs. Purpose: We developed a predictive algorithm designed [...]

Background: Joint physician-nurse rounding is an important best practice that facilitates communication and patient participation in their care while improving outcomes and satisfaction. Interdisciplinary bedside rounding has been shown to reduce mortality, lengths of stay, medication errors, and readmissions while improving staff engagement, teamwork, and patient experience (1, 2, 3). In 2018, our hospital added [...]

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: Determining the quality of medication reconciliation (MR) is a laborious and time-intensive process, often involving chart review and detailed patient interviews. Purpose: To identify meaningful, measurable process measures for high-quality MR obtainable from electronic health records (EHR), and to determine if performance on these measures responded to a campaign focused on improving MR. Description: [...]

Background: Hypoglycemia is common and potentially life-threatening for diabetic patients, often iatrogenic from diabetes treatments. It is important to be able to accurately study rates of hypoglycemia when evaluating the inpatient treatment of diabetes at a systems-level. Discharge diagnosis codes show promise as a tool in the surveillance of hypoglycemic events in large administrative databases [...]