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. 2008 Jul-Aug;15(4):513-23.
doi: 10.1197/jamia.M2501. Epub 2008 Apr 24.

"Smart Forms" in an Electronic Medical Record: documentation-based clinical decision support to improve disease management

Jeffrey L Schnipper  1 , Jeffrey A Linder, Matvey B Palchuk, Jonathan S Einbinder, Qi Li, Anatoly Postilnik, Blackford Middleton
Affiliations

"Smart Forms" in an Electronic Medical Record: documentation-based clinical decision support to improve disease management

Jeffrey L Schnipper et al. J Am Med Inform Assoc. 2008 Jul-Aug.

Abstract

Clinical decision support systems (CDSS) integrated within Electronic Medical Records (EMR) hold the promise of improving healthcare quality. To date the effectiveness of CDSS has been less than expected, especially concerning the ambulatory management of chronic diseases. This is due, in part, to the fact that clinicians do not use CDSS fully. Barriers to clinicians' use of CDSS have included lack of integration into workflow, software usability issues, and relevance of the content to the patient at hand. At Partners HealthCare, we are developing "Smart Forms" to facilitate documentation-based clinical decision support. Rather than being interruptive in nature, the Smart Form enables writing a multi-problem visit note while capturing coded information and providing sophisticated decision support in the form of tailored recommendations for care. The current version of the Smart Form is designed around two chronic diseases: coronary artery disease and diabetes mellitus. The Smart Form has potential to improve the care of patients with both acute and chronic conditions.

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Figures

Figure 1
Figure 1
Smart Form application, displaying information in 3 vertical panels: Smart View (patient summary), Visit Note Editor, and Orders Assessment/Plan.
Figure 2
Figure 2
a. Longitudinal Medical Record (LMR) conventional summary screen. b. LMR conventional note writing screen, demonstrating a structured template.
Figure 3
Figure 3
Mini-template for diabetes mellitus.
Figure 4
Figure 4
Patient View, displaying an individual's disease management status using patient-friendly language.
See this image and copyright information in PMC

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