Examples from JSS

Corollary Orders

When Prednisolone given more than 5 mg per day, calcium has to be given
When methotrexate given, folic acid has to be given
If indomethacin then famotidine or omeprazole (antacid) must
With Phenytoin - folic acid and vitamin D
With Izoniazid, Pyridoxine has to be given

Time-based Suggestions

For hypertensives, BP > 160 or more than 100 at least once then annual RBS, creatinine, urine, albumin, ECG.
If age > 45 years, at least once RBS. If Normal, thereafter every 3 years. (Screening by chance)
Diabetes patients
- Annual creatinine, urine, albumin, Serum cholesterol / LDL, ECG
- Type I DM - TSH at least once and if Normal thereafter every 2 years.
Tuberculosis patients
- After 15 days - ALT, GGT, Sputum AFB, HIV report, CBNAAT report
- After 30, 60, 90 days - ALT, GGT, Sputum AFB, S. creatinine

Event-based Suggestions

if chronic renal failure, then calcium should be given.
If HB electrophoresis is SS from lab, whether patient is started on hydroxyurea or not should be informed to clinical coordinator.
If CBNAAT MTB Detected, then ATT started or not.
If Acute infection, iron may be postponed till beyond 7 days (How to define acute infections?)
Patients with high blood pressure should be prescribed pain killers such as Ibuprofen with caution, since it can cause BP to rise. A notification that the patient is hypertensive can be useful in such conditions.
When diagnosed with TB following blood tests must be done - Hb, S. Albumin, ALT, RBS, HIV, S. Creatinine, GGT. If RBS > 100, FBS, PP2BS.
On prescribing X Ray in a woman over 15 years of age, a warning saying have you checked last menstrual period and it is less than 20 days ago.
Contraindication in Pregnancy
- Chloramphenicol, Doxycycline
- Streptomycin, Kanamycin, Tetracycline, Amikacin
- XRay (chest, Erect Abdomen)
Used in Pregnancy
- Cephalosporin
- NFT, Erythromycin, Penicillin
In Sickle Cell, hydroxyurea must be asked for, except in pregnancy.

Drug Interactions

If patient having warfarin and ATT started then shift heparin
Iron and calcium not to be prescribed to be taken at same time as they reduce each other’s effecitivity.
If ATT going on then patient should not be given OC pills, warfarin

My Notes based on some reading and analysis

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CDS may include information about relevant clinical practice guidelines, clinical reminders, and guidance and safety alerts with respect to drug doses. Sophisticated systems scan patient data to provide individualized clinical recommendations.
CDS is not just for doctors and nurses but for other staff as well involved in patient care, like registration to get ‘return to clinic’ reminders to proactively call patients due for routine screenings and explain patients of pre-visti preparation such as fasting.
A point to be kept in mind while designing would be CDS SHOULD NOT create ‘alert fatigue’ and should not prevent doctors from thinking. Rather than push based a pull based CDS could be helpful as well.

The system should deal correctly with the following cases:

Example 1:

Patient X comes in diagnosed with congestive heart failure (linked to concept "Congestive Heart Failure"). Doctor D completes the Outpatient Encounter without creating a drug order containing a beta blocker (some set of drugs that are beta blockers, or also a drug_group called beta_blockers). Send a message back that says "X has congestive heart failure. Recommend beta blocker."

Example 2:

Patient X comes in, is prescribed with a NSAID drug such as ibuprofen. Patient has already been prescribed ACE inhibitor captopril. Send a message back that says "Drug <ibuprofen> interacts poorly with drug <captopril>. Recommend <different painkiller>."

Example 3:

Patient X comes in, is prescribed drug penicillin. Searching through the patient's obs is concept "ALLERGY" and the value is penicillin, or 'penicillin' is in any concept the has "ALLERGY" or "ALLERGIC" in the name. Send a message back that says "Patient is allergic to <penicillin>. Recommend <different antibiotic>."

CDS during data-entry tasks

- Smart Documentation Forms that are tailored based on patient data to emphasize data elements pertinent to the patient’s conditions and healthcare needs.
- Order Sets, Care Plans and Protocols that encourage correct and efficient ordering, promote evidence-based best practices, and can provide different management recommendations for different patient situations.
- Parameter Guidance to promote correct entry of orders and documentation.
- Critiques and Warnings - the“Immediate Alerts” that are presented just after a user has entered an order, prescription, or documentation item, to show a potential hazard, or a recommendation for further information. E.g. drug you are about to administer is contraindicated for your patient at this time

CDS not triggered by a user task

- Event-driven Alerts (Data-triggered) and Reminders (Time-triggered), which alert the clinical user to a new event occurring asynchronously, such as an abnormal lab result, abnormal vitals
- Filtered Reference Information and Knowledge Resources
- Relevant Data Summary. E.g. preventive care measures - such as flu vaccine, colon cancer screening, cholesterol tests - that are due for your patient, based on age, medical history (problem list), and medication list stored in the EHR.

Duke Family Medicine Center Care Guidelines for Diabetes Mellitus

Foot examination monthly in patients with diabetic neuropathy, peripheral neuropathy, or history of lower limb ulcers.
Annual complete physical examination.
Determination of chronic blood glucose control every 6 months.
Annual urine protein determination.
Annual cholesterol level.
Annual ophthalmologic examination.
Seasonal influenza vaccination (September-January).
Pneumococcal vaccination.

References

https://www.healthit.gov/sites/default/files/clinicaldecisionsupport_tipsheet.pdf

http://www.himss.org/library/clinical-decision-support/scenarios

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Additional Notes

Tuberculosis Patients

Chest X-Ray at the completion of treatment
Monitor vision in patients on ethambutol after two months of treatment

Diabetes Patients

Oral and foot examination every 6 months
Annual eye exam
Screening for retinopathy, nephropathy, peripheral vascular disease every 6 months

Asthma Patients

Spirometry every 6 months

Hypertensive Patients

Electrolyte levels and renal function tests to be done every 6 months
Eye exam once a year

Hyperthyroidism

TSH repeated every 6-12 weeks

In case of renal dysfunction, Acyclovir is contraindicated.

In case of Asthma, NSAIDS and Beta blockers are avoided.

Auto-calculation of drug dosage based on age, sex and weight of the patient.

Alerts for duplicate test orders.

Suggestions for possible diagnosis that match a patient's signs and symptoms and test results.

Suggestions for treatment based on the patient's diagnosis.

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