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Integration of clinical decision support with on-line encounter documentation for well child care at the point of care.

Abstract

Electronic medical record systems and clinical practice guideline (CPG) support applications are emerging in the clinical environment to document and support care. Applications which integrate online documentation with CPG are often complex systems bound to a proprietary infrastructure and as such, can be difficult to adapt to changing care guidelines. This paper describes integration of point-of-care clinical documentation to an Internet-based CPG system that was easily modified, utilized available software resources, and separated patient information from CPG. The system combined a text-based encounter documentation tool, Inbox, with a web-based CPG system, SIEGFRIED (System for Interactive Electronic Guidelines with Feedback and Resources for Instructional and Educational Development), which interactively presented care guidelines to providers. Age-specific well child care documentation templates were developed using Inbox for point-of-care documentation. SIEGFRIED contained the knowledge base of child safety education guidelines and executed independent of the program presenting the guidelines. The CPG were accessed from within the documentation template via an Internet hyperlink. Patient chart evaluation indicated that 77% of safety topics were reviewed and 32% of the charts contained documentation indicating all the safety topics were reviewed. Last, routine use of the Inbox-SIEGFRIED system was not realized due to the clinical time constraints and workload of the medical providers, and lack of data entry experience. A user survey indicated time cost (network access and software execution) were negative aspects of the system. However, the system function was highly regarded and the Internet-based patient education materials were described as useful and accurate. In summary, the system was functional, met original development goals, and provided valuable patient education materials; however, routine system use was prevented by time requirements. We recommend further development be oriented towards integrating the identified beneficial components of the system into clinician workflow.

Authors+Show Affiliations

Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC, USA.No affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

10566429

Citation

Porcelli, P J., and D F. Lobach. "Integration of Clinical Decision Support With On-line Encounter Documentation for Well Child Care at the Point of Care." Proceedings. AMIA Symposium, 1999, pp. 599-603.
Porcelli PJ, Lobach DF. Integration of clinical decision support with on-line encounter documentation for well child care at the point of care. Proc AMIA Symp. 1999.
Porcelli, P. J., & Lobach, D. F. (1999). Integration of clinical decision support with on-line encounter documentation for well child care at the point of care. Proceedings. AMIA Symposium, 599-603.
Porcelli PJ, Lobach DF. Integration of Clinical Decision Support With On-line Encounter Documentation for Well Child Care at the Point of Care. Proc AMIA Symp. 1999;599-603. PubMed PMID: 10566429.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Integration of clinical decision support with on-line encounter documentation for well child care at the point of care. AU - Porcelli,P J, AU - Lobach,D F, PY - 1999/11/24/pubmed PY - 1999/11/24/medline PY - 1999/11/24/entrez SP - 599 EP - 603 JF - Proceedings. AMIA Symposium JO - Proc AMIA Symp N2 - Electronic medical record systems and clinical practice guideline (CPG) support applications are emerging in the clinical environment to document and support care. Applications which integrate online documentation with CPG are often complex systems bound to a proprietary infrastructure and as such, can be difficult to adapt to changing care guidelines. This paper describes integration of point-of-care clinical documentation to an Internet-based CPG system that was easily modified, utilized available software resources, and separated patient information from CPG. The system combined a text-based encounter documentation tool, Inbox, with a web-based CPG system, SIEGFRIED (System for Interactive Electronic Guidelines with Feedback and Resources for Instructional and Educational Development), which interactively presented care guidelines to providers. Age-specific well child care documentation templates were developed using Inbox for point-of-care documentation. SIEGFRIED contained the knowledge base of child safety education guidelines and executed independent of the program presenting the guidelines. The CPG were accessed from within the documentation template via an Internet hyperlink. Patient chart evaluation indicated that 77% of safety topics were reviewed and 32% of the charts contained documentation indicating all the safety topics were reviewed. Last, routine use of the Inbox-SIEGFRIED system was not realized due to the clinical time constraints and workload of the medical providers, and lack of data entry experience. A user survey indicated time cost (network access and software execution) were negative aspects of the system. However, the system function was highly regarded and the Internet-based patient education materials were described as useful and accurate. In summary, the system was functional, met original development goals, and provided valuable patient education materials; however, routine system use was prevented by time requirements. We recommend further development be oriented towards integrating the identified beneficial components of the system into clinician workflow. SN - 1531-605X UR - https://www.unboundmedicine.com/medline/citation/10566429/Integration_of_clinical_decision_support_with_on_line_encounter_documentation_for_well_child_care_at_the_point_of_care_ DB - PRIME DP - Unbound Medicine ER -