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: Despite the widespread use of technology across our daily lives, many processes in the hospital remain manual and labor-intensive. As hospital medicine divisions grow, there is an increasing need for automated and scalable solutions. While many hospitals look to external vendors to provide automated solutions, these often lack customizability and gaps remain. Purpose: To […]

Background: Constraints on resources require healthcare systems to implement alternative and innovative means for delivering care. The COVID-19 pandemic amplified this issue throughout the world, leading to shortages of ventilators, hospital beds, and healthcare personnel. We report the results of an Acute Care at Home (ACH) program’s response to COVID-19, providing in-home hospital-level care to […]

Background: Hospitals generally have clear protocols, often nursing driven, for management of inpatient hypoglycemia. The American Diabetes Association recommends a standardized approach to hypoglycemia management in the hospital to address hypoglycemia. A frequent cause of hypoglycemia is poor management of the first hypoglycemia episode. Standard treatment protocols include the use of oral carbohydrate agents for […]

Background: The SARS-CoV-2 pandemic has required healthcare systems around the world to rapidly innovate and adapt to unprecedented operational and clinical strain. Anticipated limitations in healthcare resource allocation is coupled by the strife caused by the variable clinical course of COVID-19 and the isolation of families inevitable with an inpatient admission. Many healthcare systems have […]

Background: Residents receive little feedback on their clinical reasoning (CR) documentation due to time constraints of supervisors and lack of a shared mental model. We developed an innovative workplace-based assessment tool using machine learning (ML) to provide feedback on CR documentation. Here, we describe the impact of feedback using this assessment tool. Methods: In earlier […]

Background: Many modern electronic medical record (EMR) systems permit application of templates to hospital After Visit Summaries (AVS). A need remains for enhancement of the document’s completeness and readability to enable successful patient self-management. Such advancements must balance with provider usability of EMR tools. This study evaluates the impact of a novel EMR tool, disappearing […]

Background: Telemedicine has been increasingly relied upon to deliver health care remotely. During the COVID-19 pandemic, telemedicine has been essential to conserving PPE and minimizing potential exposures. Though more frequently used in outpatient settings, telephone and video visits are now also being used to connect hospitalized patients with members of their inpatient care team. Data […]

Background: The diagnostic process is fraught with uncertainty and potential failures, which increases risk of diagnostic error (DE) during hospitalization. One way of improving awareness of DE involves the use of electronic health record (EHR) data to calculate and display risk of DE for individual patients. As a part of our AHRQ-funded Patient Safety Learning […]

Background: Disrupted sleep is a common complaint among hospitalized patients and is associated with adverse outcomes including the development of delirium. Wearable vital sign monitoring devices (VSMDs) are emerging alternatives to nurse-collected vitals that could replace the need for overnight vital checks. This study assesses patient and nurse attitudes toward an FDA-cleared VSMD (Caretaker-4), including […]