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Clinical Area

Description

Medication Management

A clinician uses an EHR with CDS to prescribe

Concept
t375374009 |Warfarin sodium 4mg tablet|
. The CDSS queries the EHR and discovers that the patient is
Concept
t77386006 |Pregnant|
. The CDSS determines that the proposed drug has
Concept
t372756006 |Warfarin|
as an ingredient . As warfarin in contraindicated during pregnancy, the system triggers an alert to be displayed to the clinician. Relevant clinical guidelines are also displayed to the user. These guidelines suggest a safe alternate, such as
Concept
t714788005 |Dabigatran|
, which the clinician then safely prescribes to the patient.

Diagnosis

(e.g. Diabetes)

Footnote Macro

Based on workflow described in DXPlain product literature.


A clinician uses an EHR with CDS in a case analysis scenario to aid in diagnosis. The clinician records the patient’s age and gender, then prepares to enter specific clinical findings, history, symptoms, etc. As the physician records symptoms of

Concept
t55350005 |Hunger|
,
Concept
t84229001 |Fatigue|
, and
Concept
t87715008 |Dry mouth|
, a ranked list of common diseases, associated with these clinical findings, is dynamically presented to the clinician. At the top of this list is
Concept
t73211009 |Diabetes mellitus|
. A scale is used to indicate the level of support for each disease. The CDSS then prompts the clinician for additional findings to help differentiate between diseases. Once a confirmed diagnosis is made, the differential diagnoses can be marked as
Concept
t2667000 |Absent|
,
Concept
t52101004 |Present|
, or
Concept
t261665006 |Unknown|
. An additional finding of
Concept
t17173007 |Always thirsty|
ShowFormatinline
is recorded and the level of support for each disease in the list is adjusted accordingly. Support for
Concept
t73211009 |Diabetes mellitus|
ShowFormatinline
has now increased from minimal evidence to sufficient evidence. The clinician then selects
Concept
t44054006 |Type 2 diabetes mellitus|
ShowFormatinline
which opens an evidence screen displaying the recorded findings which either strongly support, support, or do not support the chosen disease. The clinician is then presented with a link that displays all the PubMed articles associated with
Concept
t44054006 |Type 2 diabetes mellitus|
.

Laboratory

(e.g. Critical Results)

Footnote Macro

Example uses material from Brigham and Women’s Hospital, and was cited in the BC Medical Journal.


A patient presented at Emergency complaining of

Concept
t29857009 |Chest pain|
ShowFormatinline
and was subsequently admitted to the hospital. The attending physician ordered a series of lab tests including a
Concept
t271236005 |Serum potassium measurement|
. Laboratory tests are completed and published to the laboratory information system (LIS). The CDSS then queries the LIS and learns that the
Concept
t365760004 |Potassium level|
ShowFormatinline
is
Concept
t166690008 |Low serum potassium level|
ShowFormatinline
and considered critical. The CDSS then queries the EHR to confirm the patient has been prescribed
Concept
t350608001 |Oral form digoxin|
, which has
Concept
t387461009 |Digoxin|
ShowFormatinline
as an active ingredient. A knowledge base rule has been defined which stipulates, if the drug prescribed contains
Concept
t387461009 |Digoxin|
ShowFormatinline
and the laboratory test indicates a
Concept
t166690008 |Low serum potassium level|
, then inform the user. An alert, in the form of an urgent pager message, is generated and sent to the attending physician. 

Radiology

(e.g. Contraindication)

An ordering physician has requested an upper

Concept
t75679007 |Gastrointestinal tract x-ray|
, which uses
Concept
t25419009 |Barium sulfate|
ShowFormatinline
materials. The patient presents at the imaging clinic on the day of their exam. During study protocoling, the imaging department uses the CDSS to query the patient record and determine the patient has a
Concept
t161524000 |History of hay fever|
. An alert is triggered to advise the imaging technician about the risk of an allergic reaction. The imaging department, in consultation with the GI radiologist, calls the ordering doctor to discuss the associated risks. Additional guidelines related to preparing for reactions and symptom management (
Concept
t247472004 |Hives|
,
Concept
t418290006 |Itching|
,
Concept
t65124004 |Swelling|
, etc.) are provided via the CDSS. An additional medication is administered prior to the contrast material to reduce the risk of an allergic reaction. The imaging department proceeds with the planned procedure.

Radiology

(e.g. Appropriate Imaging)

A clinician records notes into the appropriate fields of an EHR. For example, Clinical notes: “Pt is 75 yo. LBP (lower back pain) for the past 2 weeks. On exam normal SLR (straight leg raise)…”  Using NLP, these notes are encoded as part of the record storage process. (For example, as

Concept
t279039007 |Low back pain|
ShowFormatinline
and
Concept
t164569007 |On examination - straight leg raising normal - left right|
.) The clinician orders a series of imaging tests. The CDSS, based on specific quality metrics (e.g., appropriate use criteria or AUC) , evaluates whether or not imaging guidelines are being followed by analyzing the patient's health record together with the proposed tests. If the guidelines were not followed, the CDSS will display an alert informing the clinician that they may want to consider alternative imaging or additional tests. For example, an alert may indicate: “The patient has
Concept
t279039007 |Low back pain|
ShowFormatinline
and
Concept
t309537005 |Numbness of lower limb|
. A
Concept
t394451000119106 |MRI of lumbar spine without contrast|
ShowFormatinline
for this case has an appropriateness rating of 8 (scale of 10) and is recommended.”

Emergency Department

(e.g. Order sets)

A patient has presented at the Emergency Room (ER) complaining of

Concept
t267036007 |Shortness of breath|
. The attending physician records the appropriate clinical finding codes in the EHR. She then prepares a condition-specific order set in a C omputerized Physician Order Entry (CPOE) system. The selection of the order set triggers the presentation of new clinical guidelines based on an analysis of the patient record with the proposed treatment. The physician then choses alternative treatment. Suggested dosage guidance is provided by relevant contextual links within the order set.

Infectious Disease Reporting

A primary care physician logs on to their EHR with CDS and opens a patient chart to record a condition deemed communicable, such as

Concept
t36989005 |Mumps|
ShowFormatinline
or
Concept
t14189004 |Measles|
. The CDSS then triggers an alert to advise the provider that this condition is considered reportable to the jurisdictional public health office. The CDSS then provides a pre-populated smart form which facilitates quick, consistent, and accurate reporting of the condition to the local officer of medical health. The smart form is completed and submitted to the jurisdictional health office. The clinical findings in the report are terminology-encoded which promotes interoperability and facilitates population based health reporting.

Clinical Treatment Audit

A department head uses an EHR with CDS to conduct a treatment analysis. She uses the system to generate a list of all inpatients with a confirmed diagnosis of

Concept
t128053003 |Deep venous thrombosis|
. She then uses the system to determine which of these patients have received
Concept
t103746007 |Heparin therapy|
ShowFormatinline
for at least 72 hours. The patients which have not met this criteria are flagged for appropriate treatment.

Acute Asthma Management

Staff in an Emergency Department (ED) use their EHR with CDS and clinical management pathways to provide a standardized evidence-based approach to patient assessment of

Concept
t304527002 |Acute asthma|
ShowFormatinline
in adults

Footnote Macro

Uses material from Educational and decision-support tools for asthma-management guideline implementation and Adult Emergency Department Asthma Care Pathway.

. The guidelines help document indications and contraindications to determine eligibility. A triage nurse queries the EHR and learns that the patient is over 16 years of age, has a

Concept
t304527002 |Acute asthma|
, and one or more episode of
Concept
t56018004 |Wheezing|
ShowFormatinline
which necessitated
Concept
t1366004 |Breathing treatment|
. The CDSS then triggers an alert to follow the pathway’s medical directives, which are carried out by a Respiratory Therapist (RT). The directives, in this case of
Concept
t370218001 |Mild asthma|
, include
Concept
t47101004 |Heart rate monitoring|
, establishing various baseline
Concept
t251880004 |Respiratory measurements|
, and administration of a
Concept
t372580007 |Bronchodilator|
ShowFormatinline
and
Concept
t374072009 |Prednisone 50mg tablet|
. The RT then notifies the attending physician who fills out and signs discharge instructions which a nurse then reviews with the patient. The desired clinical outcomes of this pathway include improved adherence to evidence-based management and improved patient outcomes such as reduced number of hospitalizations and lower ED return rates.

Nursing Interventions

Research has provided evidence to show that patients receiving

Concept
t40617009 |Mechanical ventilation|
ShowFormatinline
are at high risk for

Scg expression
ShowPartsterm
ShowFormatnospace
233604007 |Pneumonia|: 42752001 |due to| = 68052005 |Aspiration|

.

Footnote Macro

http://ccn.aacnjournals.org/content/32/3/71.full

Published guidelines recommend

Concept
t423171007 |Elevation of head of bed|
ShowFormatinline
from 30° to 45°, if not contraindicated, to reduce risk of
Concept
t233604007 |Pneumonia|
. A nursing supervisor uses a dashboard-like tool in an ICU to monitor patients in her ward. Patients who meet the criteria for risk of
Concept
t422588002 |Aspiration pneumonia|
ShowFormatinline
are automatically flagged in the system using CDS logic so that the appropriate action may be initiated by nursing staff in the ward. Once the angle of the patient's bed is adjusted, the system is dynamically updated and the flag is removed.

 

...

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