Using clinical decision support to maintain medication and problem lists A pilot study to yield higher patient safety

Abstract

To investigate whether clinical decision support that automates the matching of ordered drugs to problems (clinical diagnoses) on the problem list can enhance the maintenance of both medication and problem lists in the electronic medical record, we designed a clinical decision support system to match ordered drugs on the medication list and ongoing problems on the problem list. We evaluated the capability and performance of this clinical decision support system in medication-problem matching using physician expert chart audits to match ordered drugs to ongoing clinical problems. A clinical decision support system was shown to be useful in improving medication-problem matches in 140 randomly selected audited patient encounters in three inpatient units. Enhanced maintenance of both the medication and problem lists can permit the exploitation of advanced decision support strategies that yield higher patient safety.