"Smart Forms" in an Electronic Medical Record: Documentation-based Clinical Decision Support to Improve Disease Management

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

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

69 Scopus citations

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.

Original languageEnglish (US)
Pages (from-to)513-523
Number of pages11
JournalJournal of the American Medical Informatics Association
Volume15
Issue number4
DOIs
StatePublished - Jul 2008

ASJC Scopus subject areas

  • Health Informatics

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