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First published April 24, 2008 as JAMIA PrePrint; doi:10.1197/jamia.M2501
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J Am Med Inform Assoc. 2008;15:513-523. DOI 10.1197/jamia.M2501.
© 2008 American Medical Informatics Association

Application of Information Technology

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

Jeffrey L. Schnipper, MD, MPHa,d,*, Jeffrey A. Linder, MD, MPHa,d, Matvey B. Palchuk, MD, MSb,c, Jonathan S. Einbinder, MD, MBAa,b,c,d, Qi Li, MD, MBAb,c, Anatoly Postilnikb and Blackford Middleton, MD, MPH, MSca,b,c,d

a Division of General Medicine, Brigham and Women's Hospital, Boston, MA
b Partners Healthcare Information Systems, Boston, MA
c Clinical Informatics Research & Development, Partners HealthCare System, Boston, MA
d Harvard Medical School, Boston, MA.

* Correspondence: Jeffrey L. Schnipper, MD, MPH, Division of General Medicine, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120-1613 (Email: jschnipper{at}partners.org).

Received for publication: 05/08/07; accepted for publication: 02/07/08.

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, to the fact that 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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Copyright © 2008 by the American Medical Informatics Association.