Clinical decision support systems have demonstrated benefits in the point-of-care setting, though they often aren't adequately integrated into the electronic health record.
The Agency for Healthcare Research and Quality launched a CDS Initiative in 2008 to further develop, adopt, implement and evaluate clinical decision support by providing demonstration contracts to two projects. Project researchers produced a report outlining findings and lessons from their work over the past five years.
Among other items, the report outlined the following five key elements to a clinically-integrated "Smart Form" CDS in the EHR.
1. Point-of-care access. Physicians need access to the Smart Form in the EHR's notes section at the point-of-care. The form displays patient-specific health history and allows the physician to document observations and information both in preexisting and free text forms.
2. Automatic recommendations on care needs. Based on the information in the EHR and established clinical guidelines, the system should automatically present tests and treatments for the physician to consider.
3. Identify and address care and documentation gaps. If a patient misses an appointment or has not received recommended care, the system should prompt the physician to address the shortcomings. Additionally, if there are pieces of health information missing, the physician should be able to fill those in.
4. Patient review. The Smart Form should provide a recap at the end of each visit, outlining the patient's health status, care given and next steps. After reviewing the information together, patients and physicians can determine future care needs and treatment options.
5. Patient education and materials. If education materials are required, the physician should be able to print all documents right then and there. Additionally, the same accessibility should be applied to any needed laboratory order forms or new prescriptions.
For more AHRQ resources on CDS, please click here.
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