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Electronic Health Record Assessment Discussion

Electronic Health Record Assessment Discussion

In what ways are CDS systems moving beyond “alerts and reminders” to include tools that critique decisions, anticipate relevant information needs, and suggest therapeutic interventions? How do patient safety, quality of care, and economic interests contribute to the need to identify CDS best practices and to quantify effective CDS practice? There is a drive to make CDS more of a science than an art- what do you interpret this to mean? How can this drive help in the effort to replicate and disseminate successful CDS systems?

Discussion response should be at least 200 words and include 2 references written within the past 5 years. The discussion is listed below:

Clinical decision support (CDS) systems are able to move beyond use of alerts and reminders as diagnoses or disease processes are further linked to clinician resources. As an example, if a patient comes in with a history of liver injury, the medication administration record supplies an alert about appropriate dosage. Within that alert there is a pick list for a reason for treatment or override. Electronic Health Record  This series of chain reactions has the potential to lead to further consultation with specialists and unveil underlying conditions that may have previously gone un-noticed, further providing well-rounded care (Lewkowicz et al., 2020).

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In my current experience CDS systems are useful in assisting with critical thinking which makes the user question the care they are administering and verify the plan of care is correct. Another example I can think about relates to patient falls. Within our electronic health record (EHR) system we are able to document history of a fall. If yes is selected, even if it was not during current admission, a banner is visualized across the patient chart. Any clinician can quickly see the “risk” and upon entering the room assess if additional needs exist and that safety precautions are in place, supporting patient safety.

CDS systems have an economic impact on best practices as identification of non-adherence to clinical guidelines and superfluous/unnecessary resources may be highlighted, which influence cost of stay (Hardy, 2024). Did a clinician treat a patient in accordance to best practice or were they influenced by what the patient wanted or outdated practice? CDS systems also have the ability to suggest alternative therapies and reduce duplicate orders which may decrease costs over a period of time (Lewkowicz et al., 2020).

Replication of successful CDS systems seems to be leaning in the direction of artificial intelligence (AI), which has the potential to be beneficial but one must not lose critical thinking and allow programming to take over a plan of care without review. CDS systems can be viewed as a science and less than an art as it aims to bridge the gap between technology and healthcare while incorporating clinical guidelines. CDS system programming has the ability to gather more data than ever, contributing and facilitating EBP across healthcare systems (Hardy, 2024).

Electronic Health Record Assessment Discussion

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