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BACKGROUND Accurate knowledge of a patient's medical problems is critical for clinical decision making, quality measurement, research, billing and clinical decision support. Common structured sources of problem information include the patient problem list and billing data; however, these sources are often inaccurate or incomplete. OBJECTIVE To develop and(More)
BACKGROUND Many computerized provider order entry (CPOE) systems include the ability to create electronic order sets: collections of clinically related orders grouped by purpose. Order sets promise to make CPOE systems more efficient, improve care quality and increase adherence to evidence-based guidelines. However, the development and implementation of(More)
PURPOSE The results of a retrospective evaluation of the frequency and preventability of adverse drug events (ADEs) involving multiple drugs among hospital inpatients are reported. METHODS Data collected in a previous cohort study of 180 actual ADEs and 552 potential ADEs (PADEs) at six community hospitals in Massachusetts were analyzed to determine the(More)
OBJECTIVE Identify clinical opportunities to intervene to prevent a malpractice event and determine the proportion of malpractice claims potentially preventable by clinical decision support (CDS). MATERIALS AND METHODS Cross-sectional review of closed malpractice claims over seven years from one malpractice insurance company and seven hospitals in the(More)
BACKGROUND To provide high-quality and safe care, clinicians must be able to optimally collect, distill, and interpret patient information. Despite advances in text summarization, only limited research exists on clinical summarization, the complex and heterogeneous process of gathering, organizing and presenting patient data in various forms. OBJECTIVE To(More)
BACKGROUND Clinical decision support (CDS) is a valuable tool for improving healthcare quality and lowering costs. However, there is no comprehensive taxonomy of types of CDS and there has been limited research on the availability of various CDS tools across current electronic health record (EHR) systems. OBJECTIVE To develop and validate a taxonomy of(More)
OBJECTIVE Clinical decision support (CDS) is a powerful tool for improving healthcare quality and ensuring patient safety; however, effective implementation of CDS requires effective clinical and technical governance structures. The authors sought to determine the range and variety of these governance structures and identify a set of recommended practices(More)
BACKGROUND The clinical problem list is an important tool for clinical decision making, quality measurement and clinical decision support; however, problem lists are often incomplete and provider attitudes towards the problem list are poorly understood. METHODS An ethnographic study of healthcare providers conducted from April 2009 to January 2010 was(More)
BACKGROUND Accurate clinical problem lists are critical for patient care, clinical decision support, population reporting, quality improvement, and research. However, problem lists are often incomplete or out of date. OBJECTIVE To determine whether a clinical alerting system, which uses inference rules to notify providers of undocumented problems,(More)