CDS,clinical decision support,clinical documentation,electronic medical records,Electronic Medical Records and Genomics,EMRs,interoperability,medCPU
As long as the healthcare industry lacks true interoperability among dissimilar systems, clinicians will have incomplete patient information at the point of care. This includes gaps over time, as when a clinician is unaware of imaging tests already completed, and gaps across care team members who record documentation in separate systems. Both types of gaps can compromise patient safety.
While we don’t typically think of gap-closing as being a primary clinical decision support (CDS) function, CDS systems do exactly that. Its success in informing decisions depends largely on the ability to analyze information from multiple systems, closing gaps in real-time. As a result, CDS is emerging as an essential tool for improving quality of care.
Decision-making support built with a more complete view of the patient
CDS systems run on top of EMRs, analyzing documentation as it is being entered and issuing alerts in EMR windows when conditions indicate the possibility of a medical error or compromised patient safety. This is often a matter of giving clinicians information of which they were unaware.
To fully inform alerts, advanced CDS systems supplement the structured data in EMRs and pull information retrieved from other systems such as those in labs and imaging departments. CDS leverages its comprehensive patient view by applying rules-based analysis regarding diagnoses and courses of care. By augmenting a physicians’ expertise with real-time information retrieval and gap-closing, CDS systems play a key role in promoting patient safety.