Clinical Decision Support

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

• 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.