Electronic Health Records Summary

Clinical decision is required when creating orders for tests or prescriptions. Prescription orders may require dose adjustment due to the patient’s diagnosis, age, weight, and other factors. Providers also need to be aware of common or overlapping side effects when prescribing medication. Because doctors are facing multiple prescriptions per day, it would be difficult to spend enough time researching information to make sure their patients do not face any medication-related challenges. Instead, this information can be implemented using CDS in the EHR. For example, doctors can simply hover over an entry using their cursor to view all side effects.
Referral and test orders require clear communication between providers to ensure that the patient gets treated, charted, and billed correctly. Specific contingencies are built into the order using CDS to lessen the risk of errors. Order sets can reduce the risk of omission by including on the template: checkboxes to type of order and diagnosis, and edit portion for doctor/progress notes, and an accept button necessary for the provider to activate the order.
The article focuses on the framework in constructing real-time, useful order sets. The study discovered that order set developers noticed the most effective CDS interventions are those that are clearly integrated at the appropriate point in a user’s workflow [1]. Rewritten orders that providers could simply accept or reject significantly improved the rates of pneumococcal and influenza vaccination, prophylactic heparin administration, and appropriate aspirin prophylaxis at