Background: Annually, more than 200,000 patients die in U.S. hospitals from cardiac arrest1 and over 130,000 patients inpatients deaths are attributed to sepsis.2 These deaths are preventable if patients who are at risk are detected earlier. Our prior work found that nursing documentation within electronic health records (EHRs) contains information that could contribute to early detection and treatment, but these data are not being analyzed and exposed by EHRs to clinicians to initiate interventions quickly enough to save patients.3–6  We defined a new source of predictive data by analyzing the frequency and types of nursing documentation that indicated nurses’ increased surveillance and level of concern for a patient. These data documented in the 48 hours preceding a cardiac arrest and hospital mortality were predictive of the event.3 While clinicians strive to provide the best care, there is a systematic problem within hospital settings of non-optimal communication between nurses and doctors leading to delays in care for patient at risk.6–8,9  Well-designed and tested EHRs are able to trend data and support communication and decision making, but too often fall short of these goals and actually increase clinician cognitive load through fragmented information displays, “note bloat”, and information overload.10 Substitutable Medical Applications & Reusable Technologies (SMARTapps) using Fast Health Interoperability Resource (FHIR) standard allow for open sharing and use of innovations across EHR systems.


Overall Aim:

The aim of this project is to design and evaluate a SMARTapp on FHIR used across two large academic medical centers that exposes to physicians and nurses our predictive data source from nursing documentation to increase care team situational awareness of at risk patients to decrease preventable adverse outcomes. The SMARTapp we will design and evaluate is the Communicating Narrative Concerns Entered by RNs (CONCERN) Clinical Decision Support (CDS) system. This will be integrated at four hospitals part of two health systems, Brigham and Women’s Hospital (BWH) and Newton Wellesley Hospital (NWH), part of Partners Healthcare System (PHS) in Boston, and NewYork-Presbyterian Hospital-Columbia University Medical Center (NYP-CUMC) and The Allen Hospital, part of New York Presbyterian Health System (NYP) in New York.


Specific Aims:

Aim 1) Validate desired thresholds for the CONCERN SMARTapp

Aim 2) Integrate the CONCERN SMARTapp for early warning of risky patient states within CDS tools

Aim 3) Evaluate the CONCERN SMARTapp on primary outcomes of in-hospital mortality and length of stay and secondary outcomes of cardiac arrest, unanticipated transfers to the intensive care unit, and 30-day hospital readmission rates.


Methods: data-mining and natural language processing, factorial design surveys, simulation testing for evaluating team-based situational awareness, and outcomes evaluation in the Medical Intensive Care Units and Acute Care Units (non-ICU) at our study sites.



1            Merchant RM, Yang L, Becker LB, et al. Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit. Care Med. 2011;39:2401–6. doi:10.1097/CCM.0b013e3182257459

2            Liu V, Escobar GJ, Greene JD, et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA 2014;312:90–2. doi:10.1001/jama.2014.5804

3            Collins S, Cato K, Albers DJ, et al. Relationship Between Nursing Documentation and Mortality. Am J Crit Care 2013;22:306–13.

4            Collins SA, Vawdrey DK. ‘Reading between the lines’ of flowsheet data: Nurses’ optional documentation associated with cardiac arrest outcomes. Appl Nurs Res 2012;25:251–7. doi:10.1016/j.apnr.2011.06.002

5            Collins S, Fred MR, Wilcox L, et al. Workarounds Used by Nurses to Overcome Design Constraints of Electronic Health Records. In: NI2012. 2012. 93–7.

6            Collins S, Bakken S, Vawdrey DK, et al. Model development for EHR interdisciplinary information exchange of ICU common goals. Int J Med Inform 2011;80:e141-9. doi:10.1016/j.ijmedinf.2010.09.009

7            Collins S, Currie LM. Interdisciplinary communication in the ICU. Stud Health Technol Inform 2009;146:362–6.

8            Collins S, Bakken S, Vawdrey DK, et al. Agreement between common goals discussed and documented in the ICU. J Am Med Inf Assoc 2011;18:45–50. doi:10.1136/jamia.2010.006437

9            Collins S, Hurley A., Chang F., Benoit A., Illa A., Laperle S. DP. Content and functional specifications for a standards-based multidisciplinary rounding tool to maintain continuity across acute and critical care. J Am Med Inf Assoc 2013;21:438–47.

10         Kuhn T, Basch P, Barr M, et al. Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med 2015;162:301–3. doi:10.7326/M14-2128