Health Information Technology

New clinical decision support system eliminates many grievances about their usefulness

When clinical decision support systems (CDSS) are coupled with electronic medical records, they are supposed to help clinicians make decisions about how to best treat patients. Complaints about current CDSS are numerous, however. For example, CDSS are not thoughtfully integrated with clinicians' workflow and reminders can be interruptive, for example, by using pop-up messages. When a laboratory test is recommended, CDSS often do not link the recommendation to an order for that test, necessitating that the clinician take additional steps to complete the order.

Researchers helped create a documentation-based CDSS, called "Smart Form," to address these shortfalls. Conducting focus groups before and during system development, the team hoped to increase documentation of coded information for patient encounters and raise compliance with evidence-based care management goals for two chronic diseases, coronary artery disease and diabetes mellitus.

The Smart Form is presented as an alternative way to document a visit note. It uses rule-based logic to integrate clinical and patient data to generate guidelines for care. The system suggests medications and laboratory tests, makes appointments and referrals, and prints patient education materials. If the clinician accepts a recommendation for a medication or lab test, the system puts the order in the system (e.g., prints the prescription), updates the medical record, and allows the action to be documented in the visit note with one mouse-click. The Smart Form uses suggested orders, not interruptions, to make recommendations during the clinician's work flow. It documents outpatient visit notes, whether or not all the patient's problems are part of the CDSS logic, and it provides decision support for multiple problems.

At first glance, the Smart Form system appears complicated. Users require training and practice to use it effectively. However, because of its benefits, the authors report that users have found the system to be a worthwhile asset. And for some users, the time of writing a note may be the best time to receive and act on decision support.

This work was funded in part by the Agency for Healthcare Research and Quality (HS15169 and HS14563).

See "'Smart Forms' in an electronic medical record: Documentation-based clinical decision support to improve disease management," by Jeffery L. Schnipper, M.D., M.P.H., Jeffery A. Linder, M.D., M.P.H., Matvey B. Palchuk, M.D., M.S., and others in the July/August 2008 Journal of the American Medical Informatics Association 15(4), pp. 513-523.

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