A typical use case will illustrate how the Smart Form works and its potential advantages to the user. shows the Smart Form. We purposely chose high information density when designing the application in order to minimize “screen flips” and present enough clinical information at once to allow for sophisticated decision-making by the user. The disadvantages of this approach are a “busy”-looking screen and the occasional need for scrolling (for example, if the patient has a lengthy medical problem list). a shows the conventional summary page in the Partners EMR (known as the Longitudinal Medical Record, or LMR), including non-actionable decision support reminders, and b a conventional note-writing screen in the LMR.
Before the Visit
The Smart Form is invoked by clicking on the Smart Form icon present next to any qualifying medical problem on the Problem List, from the main patient chart menu, or from the notes page. Prior to a visit, a user might review recent labs, studies, and previous notes by the user or other providers. This can easily be done via the Smart View, the left-most column in the Smart Form, which contains most patient data, problems, allergies, medications, vital signs, laboratory test results, and notes. Laboratory data, vital signs, and medications are presented in tabular format by default but can also be viewed graphically. For example, the user could display a graph of the patient's LDL values against the timing and doses of all lipid-lowering medications prescribed.
A new note can also be started in advance by clicking on the “new note” icons above the central note-writing section. Users can choose from any of the following: 1) a blank note, 2) pulling forward a previous note for updating, 3) starting with an “unstructured” note template (i.e., one block of text with auto-imported text specified by the user), or 4) starting with a structured note template (i.e., separate blocks of text for different data elements such as Medications and History of Present Illness). In this example, the user starts with a structured note, which automatically imports the current problem, medication, and allergy lists and health maintenance information (). He then “pulls forward” the “History of Present Illness” and “Assessment and Plan” sections from his last note and saves the preliminary note for later.
During the Visit
When the visit begins, the user reloads the saved Smart Form and begins by verifying the accuracy of the medication list from the Smart View. A medication on the list can be edited or deleted by clicking on its name, which pops up that medication's “prescription pad.” A new medication can be added by clicking on the “plus” icon under Medications. Similarly, the user adds an additional blood pressure reading to the Vital Signs section and updates the smoking status under Health Maintenance.
The user then starts interviewing the patient while typing into the History of Present Illness section of the structured template in the note writing section. Because the patient has diabetes, the user clicks on the Diabetes button in the note writing section. This invokes a “mini-template” for diabetes (), a pop-up window that allows users to record a specific set of observations by clicking checkboxes or radio buttons or choosing predefined statements from drop-down menus. In this case, the mini-template allows documentation of diabetes complications, symptoms of hypoglycemia, typical blood sugars at different times of the day, and compliance with diet and exercise recommendations. Once completed, a textual representation of the results is automatically inserted into the note. Other mini-templates are available for CAD, physical examination (PE), and review of systems (ROS). The CAD and diabetes mini-templates are only available if a qualifying problem is on the problem list. Where possible, a user may indicate a number of observations as normal with one click, and then select the ones that were found to be abnormal and which ones were not assessed. Free text comments can also be added to any data element.
Mini-template for diabetes mellitus.
For the physical examination, the user has several options: using the PE mini-template (which because the patient has diabetes automatically includes a foot exam section), pulling forward the PE section from a previously written structured note, or importing a “canned paragraph” from a drop-down list of customized paragraphs or by typing a period followed by the first few letters of the name of the paragraph (i.e., using “dot-macro” technology).
The user might then use the Smart Form as he would any other EMR documentation tool: documenting information about the patient's other medical problems, renewing medication prescriptions, ordering laboratory tests unrelated to CAD and diabetes, etc.
Throughout the documentation exercise, clinical decision support related to diabetes and CAD is apparent to the user. The Smart View by default is organized around either or both problems, depending on which are present on the problem list (in this case, the patient has both). For example, medications are sorted by antiplatelets, beta-blockers, angiotensin converting enzyme inhibitors (ACE I)/angiotensin receptor blockers (ARB), other antihypertensive medications, HMG CoA reductase inhibitors (statins), other lipid agents, hypoglycemic agents, and other medications. Some of these classes are reserved for CAD patients (e.g., antiplatelets), others for diabetics (e.g., hypoglycemic agents), and others for both (ACE I/ARB). Decision support rules specify which classes will be shown and could theoretically accommodate any number of problems alone or in combination. Filtering by CAD and/or Diabetes can be turned on and off by the user by checking and unchecking boxes at the top of the Smart View.
If a patient is not on one of the recommended classes of medications, the Smart Form presents a link to document contraindications. This allows for coded entry of preexisting conditions (filed in the LMR as problems) or reactions (filed as allergies), which would shut off decision support to order these medications. In this case, the user files a preexisting condition of peptic ulcer disease to explain why the patient is not on an antiplatelet medication.
Because the user has made several changes to the patient's clinical information (e.g., updated the medication list and smoking status, added a new blood pressure reading, documented a contraindication to antiplatelet medications), the user now dynamically regenerates the CDSS logic by clicking on a “regenerate” icon (the approximately 600 rules, codified using ILOG rules engine software (Sunnyvale, CA) and incorporating patient data from the EMR and other enterprise data repositories, are updated in about 1 second). The user now views the Orders/Assessment and Plan section in the right column of the Smart Form. This section begins with an assessment of how the patient is doing in each domain of CAD and/or diabetes management: glycemia control, lipid management, and blood pressure management; antiplatelet, beta-blocker, and ACE I/ARB medication use; weight/body mass index and smoking status; urine protein, eye exam, and foot exam status; immunizations, and follow-up appointments.
As with the Smart View, some domains are specific to CAD (e.g., antiplatelet use), some are specific to diabetes (e.g., annual screening for proteinuria), and some are included in both conditions (e.g., lipid management). The treatment goals are calculated based on the number and types of medical conditions the patient has. For example, a patient with CAD but without diabetes and with cardiac risk factors under good control has an LDL goal of 100 mg/dL, while a patient with both CAD and diabetes has an LDL goal of 70 mg/dL. 40
In this way, the Smart Form logic accommodates patients with one or both conditions, with or without other comborbidities, and can be expanded over time to support other medical conditions.
In this case, the patient's LDL goal is 70 mg/dL and the patient's LDL is above that goal (last LDL within the past 12 months is 110 mg/dL). Because the patient is not in compliance with the guideline, the assessment is in red text. The text of the assessment serves as link to the suggested actions below. Because the patient is already on a statin, the user sees the option to increase its dose: clicking on the option opens the prescription pad for the statin where its dose can be increased. The user can also click on a “help me choose” option, which takes the user to “passive decision support,” in this case a table that displays the dose and type of each statin predicted to achieve the desired LDL reduction. We chose such “passive” decision support rather than making a recommendation for a specific dose and type of statin for two reasons: 1) an acknowledgement that there are limits to how much CDSS can “know” about a patient compared with the patient's PCP, and 2) a desire not to alienate users by making recommendations that limit therapeutic choices unnecessarily. In this case, the user increases the dose of the statin on the prescription pad; the medication list in the EMR is automatically updated.
In addition to increasing the dose of statin, other possible actions are displayed, including starting a fibrate medication, ordering a lipid panel now or in the future (the number of weeks is specified by the user), printing patient instructions for a low cholesterol diet, and making a referral to a lipid specialist. When the option to order a fibrate is selected, the user sees a list of possible medications in that class, sorted by their out-of-pocket expense based on the patient's insurance coverage. Selecting a particular medication then opens up a prescription pad for that medication. Ordering labs and referrals and printing patient instructions only require checking a box next to each action.
In a similar manner, the user then orders other medication changes, laboratory tests, patient educational materials, and referrals related to the other domains of care. Finally, the user schedules a follow-up appointment with himself and with his nurse, selecting the time frame for each appointment.
Once all desired actions have been selected, the user hits the “Execute” button. This sends all laboratory orders, referrals, and patient instructions to the printer. It also “tees up” all orders for easy entry into the visit note (see below). Before the patient leaves, the user prints the “Patient View,” (see ) a patient-friendly version of the assessment and a listing of those actions chosen by the Smart Form user. A time plot of values is presented for glycemic control (HbA1c), blood pressure, lipid management (LDL), and weight (body mass index). Also included in this view is a listing of patient's allergies and their medication list with all Latin abbreviations translated into English. The user reviews the findings with the patient and hands it to him.
Patient View, displaying an individual's disease management status using patient-friendly language.
Finally, the user signs the note, which prints the new prescriptions or refills for the patient. The patient receives the prescriptions and educational material, while the office staff receives the laboratory and referral orders. As the patient leaves the office, the user quickly documents abnormal physical examination findings by clicking on the PE mini-template. The user saves a preliminary version of the note by hitting the save icon.