Background: Team-based approaches have been broadly promoted to improve healthcare delivery in the U.S. However, few studies have analyzed the complexities of team-based communication in the current healthcare delivery landscape of increasing electronic health record (EHR) use and the rapidly evolving EHR functionalities. Major hurdles to studying effective communication within and between healthcare teams include: [...]

Background: Electronic Health Records (EHR) systems are broadly used to support the delivery of patient care and to facilitate communication and coordination among providers.  The use of EHR has been demonstrated to improve health care quality and efficiency. However, the impact of how providers utilize EHRs and communicate information in care delivery remains unclear. Specifically, how do [...]

Background: The Center for Disease Control and Prevention estimates that 1.7 million patients per year develop hospital-associated infections (HAI), of whom 99,000 die. HAIs financially impact the United States healthcare system with an estimated cost of $6 billion per year. At Platte Valley Medical Center (PVMC) in 2013, the urinary catheter utilization ratio and rates [...]

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 medical records, where one patient possesses multiple medical record numbers and corresponding charts within a single electronic health record (EHR), pose significant patient safety risks due to incomplete data and repeated interventions, among other areas. The risk is amplified for patients admitted to the hospital, where rapid pace decision making is the norm. [...]

Background: Hospitalized patients receiving direct oral anticoagulants (DOACs) sometimes require bridging with unfractionated heparin (UFH). Monitoring UFH with anti-Xa assays has been shown to correlate with better outcomes. However, DOACs interfere with anti-Xa assays resulting in inappropriate UFH dose adjustments that can negatively impact patient care. In 2015, we deployed an electronic health record (EHR) [...]

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: The importance of accurate patient care records for effective communication and medical education is well documented. However, medical documentation as a tool for financial compensation is not emphasized in graduate medical education. We performed a review and analysis of resident charting errors during inpatient rotations to determine the potential revenue loss and economic impact. [...]

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 [...]