Integration of Clinical Decision Support with On-Line Encounter Documentation for Well Child Care at the Point of Care

Abstract 754

Introduction: Electronic medical record systems and clinical decision support applications (CDS) are increasingly used in the clinical environment to document care. System that integrate on-line documentation with CDS are often difficult to adapt to changing care guidelines, and are expensive, complex systems bound within a proprietary infrastructure. We describe integration of an on-line clinical documentation system with a web-based CDS system that is easily modifiable and extendible, that maintains the CDS system independent of the documentation system, and that draws upon available software resources. We hypothesize that integration of on-line documentation with a flexible CDS tool will result in enhanced documentation of educational counseling and improved patient education and comprehension compared to traditional paper-based documentation.

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