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First published April 24, 2008 as JAMIA PrePrint; doi:10.1197/jamia.M2501
Journal of the American Medical Informatics Association 2008;15(4):513-523
© 2008 American Medical Informatics Association

A more recent version of this article appeared on July 1, 2008
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Submitted on May 8, 2007
Accepted on February 7, 2008

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

Jeffrey L. Schnipper MD, MPH1*, Jeffrey A. Linder MD, MPH1, Matvey B. Palchuk MD, MS2, Jonathan S. Einbinder MD, MBA3, Qi Li MD, MBA2, Anatoly Postilnik4, and Blackford Middleton MD, MPH, MSc3

Affiliation of the authors: 1 Division of General Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA ; 2 Partners Healthcare Information Systems, Boston, MA; Clinical Informatics Research & Development, Partners HealthCare System, Boston, MA ; 3 Division of General Medicine, Brigham and Women's Hospital, Boston, MA; Partners Healthcare Information Systems, Boston, MA; Clinical Informatics Research & Development, Partners HealthCare System, Boston, MA; Harvard Medical School, Boston, MA ; 4 Partners Healthcare Information Systems, Boston, MA

* To whom correspondence should be addressed.

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 because 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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