A pilot trial of a computerized renal template note to improve resident knowledge and documentation of kidney disease.

Abstract:

BACKGROUND:Kidney disease is under-documented in physician notes. The use of template-guided notes may improve physician recognition of kidney disease early in training. OBJECTIVE:The objective of this study was to determine whether a computerized inpatient renal template note with clinical decision support improves resident knowledge and documentation of kidney disease. METHODS:In this prospective study, first year medical residents were encouraged to use the renal template note for documentation over a one-month period. The renal template note included an option for classification of acute kidney injury (AKI) and chronic kidney disease (CKD) categories with a link to standard classifications. Pre- and post-knowledge of AKI and CKD categories was tested with a quiz and surveys of resident experience with the intervention were conducted. Appropriate AKI and/or CKD classification was determined in 100 renal template notes and 112 comparable historical internal medicine resident progress notes from approximately one year prior. RESULTS:2,435 inpatient encounters amongst 15 residents who participated were documented using the renal template note. A significantly higher percent of residents correctly staged earlier stage CKD (CKD3) using the renal template note compared to historical notes (9/46 vs. 0/33, p<0.01). Documentation of AKI and more advanced CKD stages (CKD4 and 5) did not improve. Knowledge based on quiz scores increased modestly but was not significant. The renal template note was well received by residents and was perceived as helping improve knowledge and documentation of kidney disease. CONCLUSION:The renal template note significantly improved staging of earlier stage CKD (CKD3) with a modest but non-significant improvement in resident knowledge. Given the importance of early recognition and treatment of CKD, future studies should focus on teaching early recognition using template notes with supplemental educational interventions.

journal_name

Appl Clin Inform

authors

Shirazian S,Wang R,Moledina D,Liberman V,Zeidan J,Strand D,Mattana J

doi

10.4338/ACI-2013-07-RA-0048

subject

Has Abstract

pub_date

2013-11-13 00:00:00

pages

528-40

issue

4

issn

1869-0327

journal_volume

4

pub_type

杂志文章
  • Evaluation of a user guidance reminder to improve the quality of electronic prescription messages.

    abstract:BACKGROUND:Prescribers' inappropriate use of the free-text Notes field in new electronic prescriptions can create confusion and workflow disruptions at receiving pharmacies that often necessitates contact with prescribers for clarification. The inclusion of inappropriate patient direction (Sig) information in the Notes...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2014-03-CR-0022

    authors: Dhavle AA,Corley ST,Rupp MT,Ruiz J,Smith J,Gill R,Sow M

    更新日期:2014-08-06 00:00:00

  • Workarounds and Test Results Follow-up in Electronic Health Record-Based Primary Care.

    abstract:BACKGROUND:Electronic health records (EHRs) have potential to facilitate reliable communication and follow-up of test results. However, limitations in EHR functionality remain, leading practitioners to use workarounds while managing test results. Workarounds can lead to patient safety concerns and signify indications a...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2015-10-RA-0135

    authors: Menon S,Murphy DR,Singh H,Meyer AN,Sittig DF

    更新日期:2016-06-22 00:00:00

  • A Quantitative and Qualitative Analysis of Electronic Prescribing Incidents Reported by Community Pharmacists.

    abstract:BACKGROUND:Electronic prescribing (e-prescribing) technology was introduced as an alternative to handwritten prescriptions allowing health care professionals to send prescriptions directly to pharmacies. While the technology has many advantages, such as improving pharmacy workflow and reducing medication errors, some l...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.1055/s-0039-1691840

    authors: Hincapie AL,Alamer A,Sears J,Warholak TL,Goins S,Weinstein SD

    更新日期:2019-05-01 00:00:00

  • Electronic Health Records in Danish Home Care and Nursing Homes: Inadequate Documentation of Care, Medication, and Consent.

    abstract:BACKGROUND: Electronic health records (EHRs) are used in long-term care to document the patients' condition, medication, and care, thereby supporting communication among caregivers and counteracting adverse drug events. However, the use of EHRs in long-term care has lagged behind EHR use in hospitals. In addition, most...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.1055/s-0040-1721013

    authors: Hertzum M

    更新日期:2021-01-01 00:00:00

  • The contribution of the vaccine adverse event text mining system to the classification of possible Guillain-Barré syndrome reports.

    abstract:BACKGROUND:We previously demonstrated that a general purpose text mining system, the Vaccine adverse event Text Mining (VaeTM) system, could be used to automatically classify reports of an-aphylaxis for post-marketing safety surveillance of vaccines. OBJECTIVE:To evaluate the ability of VaeTM to classify reports to th...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2012-11-RA-0049

    authors: Botsis T,Woo EJ,Ball R

    更新日期:2013-02-27 00:00:00

  • Paradigm shift or annoying distraction: emerging implications of web 2.0 for clinical practice.

    abstract::Web 2.0 technologies, known as social media, social technologies or Web 2.0, have emerged into the mainstream. As they grow, these new technologies have the opportunity to influence the methods and procedures of many fields. This paper focuses on the clinical implications of the growing Web 2.0 technologies. Five deve...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2010-01-CR-0003

    authors: Spallek H,O'Donnell J,Clayton M,Anderson P,Krueger A

    更新日期:2010-04-21 00:00:00

  • Usability Testing of a Sensor-Controlled Digital Game to Engage Older Adults with Heart Failure in Physical Activity and Weight Monitoring.

    abstract:BACKGROUND: Poor self-management of heart failure (HF) has contributed to poor health outcomes. Sensor-controlled digital games (SCDGs) integrates data from behavior-tracking sensors to trigger progress, rewards, content, and positive feedback in a digital game to motivate real-time behaviors. OBJECTIVES: To assess th...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.1055/s-0040-1721399

    authors: Radhakrishnan K,Julien C,O'Hair M,Baranowski T,Lee G,Allen C,Sagna A,Thomaz E,Kim M

    更新日期:2020-10-01 00:00:00

  • The Impact of a Health IT Changeover on Medical Imaging Department Work Processes and Turnaround Times: A mixed method study.

    abstract:OBJECTIVES:To assess the impact of introducing a new Picture Archiving and Communication System (PACS) and Radiology Information System (RIS) on: (i) Medical Imaging work processes; and (ii) turnaround times (TATs) for x-ray and CT scan orders initiated in the Emergency Department (ED). METHODS:We employed a mixed met...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2015-01-RA-0014

    authors: Georgiou A,Prgomet M,Lymer S,Hordern A,Ridley L,Westbrook J

    更新日期:2015-07-08 00:00:00

  • The Pediatric Emergency Care Applied Research Network Registry: A Multicenter Electronic Health Record Registry of Pediatric Emergency Care.

    abstract:BACKGROUND:Electronic health record (EHR)-based registries allow for robust data to be derived directly from the patient clinical record and can provide important information about processes of care delivery and patient health outcomes. METHODS:A data dictionary, and subsequent data model, were developed describing EH...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.1055/s-0038-1651496

    authors: Deakyne Davies SJ,Grundmeier RW,Campos DA,Hayes KL,Bell J,Alessandrini EA,Bajaj L,Chamberlain JM,Gorelick MH,Enriquez R,Casper TC,Scheid B,Kittick M,Dean JM,Alpern ER,Pediatric Emergency Care Applied Research Network.

    更新日期:2018-04-01 00:00:00

  • Usability of selected databases for low-resource clinical decision support.

    abstract:BACKGROUND:Smartphones are increasingly important for clinical decision support, but smartphone and Internet use are limited by cost or coverage in many settings. txt2MEDLINE provides access to published medical evidence by text messaging. Previous studies have evaluated this approach, but we found no comparisons with ...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2012-06-RA-0024

    authors: Sheets L,Callaghan F,Gavino A,Liu F,Fontelo P

    更新日期:2012-09-06 00:00:00

  • Clinical Practice Informs Secure Messaging Benefits and Best Practices.

    abstract::Background Clinical care team members in Department of Veterans' Affairs (VA) facilities nationwide are working to integrate the use of Secure Messaging (SM) into care delivery and identify innovative uses. Identifying best practices for proactive use of SM is a key factor in its successful implementation and sustaine...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2017-05-RA-0088

    authors: Haun JN,Hathaway W,Chavez M,Antinori N,Vetter B,Miller BK,Martin TL,Kendziora L,Nazi KM,Melillo C

    更新日期:2017-10-01 00:00:00

  • The prevalence of obesity documentation in Primary Care Electronic Medical Records. Are we acknowledging the problem?

    abstract:BACKGROUND:Although obesity is a growing problem, primary care physicians often inadequately address it. The objective of this study is to examine the prevalence of obesity documentation in the patient's problem list for patients with eligible body mass indexes (BMI) as contained in the patients' electronic medical rec...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2016-07-RA-0115

    authors: Mattar A,Carlston D,Sariol G,Yu T,Almustafa A,Melton GB,Ahmed A

    更新日期:2017-01-25 00:00:00

  • The Effects of Medication Alerts on Prescriber Response in a Pediatric Hospital.

    abstract:OBJECTIVE:More than 70% of hospitals in the United States have electronic health records (EHRs). Clinical decision support (CDS) presents clinicians with electronic alerts during the course of patient care; however, alert fatigue can influence a provider's response to any EHR alert. The primary goal was to evaluate the...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2016-10-RA-0168

    authors: Dexheimer JW,Kirkendall ES,Kouril M,Hagedorn PA,Minich T,Duan LL,Mahdi M,Szczesniak R,Spooner SA

    更新日期:2017-05-10 00:00:00

  • Common Laboratory Results Frequently Misunderstood by a Sample of Mechanical Turk Users.

    abstract:OBJECTIVES:More patients are receiving their test results via patient portals. Given test results are written using medical jargon, there has been concern that patients may misinterpret these results. Using sample colonoscopy and Pap smear results, our objective was to assess how frequently people can identify the corr...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.1055/s-0039-1679960

    authors: Qureshi N,Mehrotra A,Rudin RS,Fischer SH

    更新日期:2019-03-01 00:00:00

  • Ethical Considerations on Pediatric Genetic Testing Results in Electronic Health Records.

    abstract:BACKGROUND:Advances in technology and access to expanded genetic testing have resulted in more children and adolescents receiving genetic testing for diagnostic and prognostic purposes. With increased adoption of the electronic health record (EHR), genetic testing is increasingly resulted in the EHR. However, this lead...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.1055/s-0040-1718753

    authors: Kanungo S,Barr J,Crutchfield P,Fealko C,Soares N

    更新日期:2020-10-01 00:00:00

  • Evaluation of a Korean version of a tool for assessing the incorporation of human factors into a medication-related decision support system: the I-MeDeSA.

    abstract:OBJECTIVE:The Instrument for Evaluating Human-Factor Principles in Medication-Related Decision Support Alerts (I-MeDeSA) was developed recently in the US with a view towards improving considerations of human-factor principles when designing alerts for clinical decision support (CDS) systems. This study evaluated the ge...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2014-01-RA-0005

    authors: Cho I,Lee J,Han H,Phansalkar S,Bates DW

    更新日期:2014-06-18 00:00:00

  • Empowering Caseworkers to Better Serve the Most Vulnerable with a Cloud-Based Care Management Solution.

    abstract:BACKGROUND:Care-management tools are typically utilized for chronic disease management. Sonoma County government agencies employed advanced health information technologies, artificial intelligence (AI), and interagency process improvements to help transform health and health care for socially disadvantaged groups and o...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.1055/s-0040-1715894

    authors: Snowdon JL,Robinson B,Staats C,Wolsey K,Sands-Lincoln M,Strasheim T,Brotman D,Keating K,Schnitter E,Jackson G,Kassler W

    更新日期:2020-08-01 00:00:00

  • Electronic Ordering System Improves Postoperative Pain Management After Total Knee or Hip Arthroplasty.

    abstract:OBJECTIVES:The authors investigated the impact of computerized provider order entry (CPOE) on the delivery times of analgesia and subsequent patient outcomes. We hypothesized that patients would report less pain and use less pain medications compared with the previous paper-based system. METHODS:Two groups of patients...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2014-12-RA-0114

    authors: Urban MK,Chiu T,Wolfe S,Magid S

    更新日期:2015-09-23 00:00:00

  • Rapid Implementation of an Inpatient Telehealth Program during the COVID-19 Pandemic.

    abstract:BACKGROUND: Relaxation of laws and regulations around privacy and billing during the COVID-19 pandemic provide expanded opportunities to use telehealth to provide patient care at a distance. Many health systems have transitioned to providing outpatient care via telehealth; however, there is an opportunity to utilize te...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.1055/s-0040-1713635

    authors: Hron JD,Parsons CR,Williams LA,Harper MB,Bourgeois FC

    更新日期:2020-05-01 00:00:00

  • Early Detection of Prediabetes and T2DM Using Wearable Sensors and Internet-of-Things-Based Monitoring Applications.

    abstract:BACKGROUND: Prediabetes and type 2 diabetes mellitus (T2DM) are one of the major long-term health conditions affecting global healthcare delivery. One of the few effective approaches is to actively manage diabetes via a healthy and active lifestyle. OBJECTIVES: This research is focused on early detection of prediabete...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.1055/s-0040-1719043

    authors: Baig MM,GholamHosseini H,Gutierrez J,Ullah E,Lindén M

    更新日期:2021-01-01 00:00:00

  • Copy-and-Paste in Medical Student Notes: Extent, Temporal Trends, and Relationship to Scholastic Performance.

    abstract:BACKGROUND:Medical students may observe and subsequently perpetuate redundancy in clinical documentation, but the degree of redundancy in student notes and whether there is an association with scholastic performance are unknown. OBJECTIVES:This study sought to quantify redundancy, defined generally as the proportion o...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.1055/s-0039-1692402

    authors: Monahan K,Ye C,Gould E,Xu M,Huang S,Spickard A 3rd,Rosenbloom ST,Coco J,Fabbri D,Miller B

    更新日期:2019-05-01 00:00:00

  • A Brief Survey on Six Basic and Reduced eHealth Indicators in Seven Countries in 2017.

    abstract:BACKGROUND:Holistic, ubiquitous support of patient-centered health care (eHealth) at all health care institutions and in patients' homes through information processing is increasingly supplementing institution-centered care. While eHealth indicators may measure the transition from institution-centered (e.g., hospital-c...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.1055/s-0038-1669458

    authors: Haux R,Ammenwerth E,Koch S,Lehmann CU,Park HA,Saranto K,Wong CP

    更新日期:2018-07-01 00:00:00

  • Evaluating the Impact of a New Smartphone Texting Tool on Patient Care in Obstetrics, an Emergent Healthcare Setting.

    abstract:BACKGROUND:Hospitals across the country are investing millions of dollars to adopt new Health Insurance Portability and Accountability Act (HIPAA)-compliant secure text messaging systems. However, in nearly all cases, these implementations are occurring without evaluation of their impact on patient care. OBJECTIVE:To ...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.1055/s-0039-1700868

    authors: Feinberg J,Shaw S,Kashyap N,Illuzzi J,Campbell K,Hsiao AL,Pettker CM

    更新日期:2019-10-01 00:00:00

  • Numeracy and Understanding of Quantitative Aspects of Predictive Models: A Pilot Study.

    abstract:BACKGROUND:The assessment of user preferences for performance characteristics of patient-oriented clinical prediction models is lacking. It is unknown if complex statistical aspects of prediction models are readily understandable by a general audience. OBJECTIVE:A pilot study was conducted among nonclinical audiences ...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.1055/s-0038-1669457

    authors: Weissman GE,Yadav KN,Madden V,Courtright KR,Hart JL,Asch DA,Schapira MM,Halpern SD

    更新日期:2018-07-01 00:00:00

  • Quality Initiative Using Theory of Change and Visual Analytics to Improve Controlled Substance Documentation Discrepancies in the Operating Room.

    abstract:BACKGROUND:Discrepancies in controlled substance documentation are common and can lead to legal and regulatory repercussions. We introduced a visual analytics dashboard to assist in a quality improvement project to reduce the discrepancies in controlled substance documentation in the operating room (OR) of our free-sta...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.1055/s-0039-1693688

    authors: Dolan JE,Lonsdale H,Ahumada LM,Patel A,Samuel J,Jalali A,Peck J,DeRosa JC,Rehman M,Varughese AM,Fernandez AM

    更新日期:2019-05-01 00:00:00

  • Health IT Usability Focus Section: Adapting EHR-Based Medication Instructions to Comply with Plain Language Guidance-A Randomized Experiment.

    abstract::Objective Patient instructions are generally written by clinicians. However, clinician-centered language is challenging for patients to understand; in the case of pediatric medication instructions, consequences can be serious. Using examples of clinician-written medication instructions from an electronic health record...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2017-06-RA-0111

    authors: Ancker JS,Send A,Hafeez B,Osorio SN,Abramson E

    更新日期:2017-10-01 00:00:00

  • Code Status Reconciliation to Improve Identification and Documentation of Code Status in Electronic Health Records.

    abstract:BACKGROUND:Code status (CS) of a patient (part of their end-of-life wishes) can be critical information in healthcare delivery, which can change over time, especially at transitions of care. Although electronic health record (EHR) tools exist for medication reconciliation across transitions of care, much less attention...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2016-08-RA-0133

    authors: Jain VG,Greco PJ,Kaelber DC

    更新日期:2017-03-08 00:00:00

  • Multilingual Medical Data Models in ODM Format: A Novel Form-based Approach to Semantic Interoperability between Routine Healthcare and Clinical Research.

    abstract:BACKGROUND:Semantic interoperability between routine healthcare and clinical research is an unsolved issue, as information systems in the healthcare domain still use proprietary and site-specific data models. However, information exchange and data harmonization are essential for physicians and scientists if they want t...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2012-03-RA-0011

    authors: Breil B,Kenneweg J,Fritz F,Bruland P,Doods D,Trinczek B,Dugas M

    更新日期:2012-07-11 00:00:00

  • Time Series Analysis for Forecasting Hospital Census: Application to the Neonatal Intensive Care Unit.

    abstract:BACKGROUND:Accurate prediction of future patient census in hospital units is essential for patient safety, health outcomes, and resource planning. Forecasting census in the Neonatal Intensive Care Unit (NICU) is particularly challenging due to limited ability to control the census and clinical trajectories. The fixed a...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2015-09-RA-0127

    authors: Capan M,Hoover S,Jackson EV,Paul D,Locke R

    更新日期:2016-05-04 00:00:00

  • Registers for Networked Medical Research in Germany: Situation and prospects.

    abstract:BACKGROUND:Several disease specific registers are operated by members of the 'TMF - Technology, Methods, and Infrastructure for Networked Medical Research', an umbrella organization of research networks in Germany. OBJECTIVE:To describe the coverage and the current state as well as financial and organizational issues ...

    journal_title:Applied clinical informatics

    pub_type: 杂志文章

    doi:10.4338/ACI-2010-04-RA-0024

    authors: Stausberg J,Altmann U,Antony G,Drepper J,Sax U,Schütt A

    更新日期:2010-11-24 00:00:00