Clinical decision support tools play an increasingly critical role in a healthcare organization’s overarching strategy to comply with federal incentive programs and succeed within the quality and performance based reimbursement landscape currently unfolding. When effectively aligned with physician documentation practices at the point of care, these tools can have a powerful impact on error reduction, the standardization of evidence-based practices, quality of care and ultimately saving lives.
Research reveals that a combination of advanced CDS technology working in tandem with computerized physician order entry solutions will be needed to successfully navigate the coming healthcare landscape. Physicians want the ability to express themselves freely when documenting, and there is concern within the physician community that the full patient picture could get lost if the narrative is too highly structured. As a practicing physician, I understand the delicate balance that exists between the need for a technological foundation that promotes accurate information sharing and the desire to protect the individual patient story.
The truth is that there can be risk without allowing for flexibility in creation of narrative content. Poorly designed interfaces have clearly existed with some structured content frameworks historically and still do today within some CDS and CPOE applications that can cause pieces of the patient narrative to get lost. In fact, it’s retroactive. If data mining occurs after the patient narrative has already been input, decision support can, by definition, only be offered after the fact. In essence, physician documentation that is completed in a structured-content environment as opposed to a traditional dictation method is, in itself, a form of CDS. Because documentation can be structured to guide and remind physicians to document important medical elements, it assures that nothing is overlooked.
Reference : John Lynn https://www.healthcareittoday.com/2013/05/10/structuring-for-the-future-of-clinical-decision-support-cds/
