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Decision support systems and clinical documentation in healthcare IT implementation

Last reviewed: June 17, 2013 ~15 min read
Abstract

This is an analysis of the clinical notes template package incorporated in the computerized patient record system, CPRS that supports the decision making process of the institution. The analytical system focuses on the holistic overview of the package and its working and usefulness. The paper takes into consideration the functional elements and structure of DSS, as well as the objectives.

Decision Support System

Executive Presentation Paper for Decision Support System (DSS)

Communication remains a crucial element for the success of any organization, relationship or industry. The factor that makes it so crucial is the aspect of decision making in the practice. Communication and decision-making are simply inseparable. It is impossible to make a conclusive and quality design that concerns and affects more than one person. This is especially so for the business and corporate organizations in the world those operate in the lines of consultations and collective decision-making. A conclusive and active model and methodology of making a decision in such organization is the use of effective decision-making system. A decision-making system should facilitate proper and intensive analysis of the information available to make a decision for the future.

Executive summery

The decision support systems are a class of the computerized systems of information that support the business and organizational process of decision-making (Burstein & Holsapple, 2008). A decision support system that has the proper design is an interactive software; that intends to help the makers of the decisions in organizations to compile information that is useful; from the raw data, personal knowledge, business models and other documents to identify and solve the problems of the organization as well as make decisions. The decision support system has various aims, the key aspects being to access all the current information about the assets of the organization, including the legal and relational data sources, warehouses and marts. Additionally, the decision support system provides for the comparison of figures between various components in the business or organization. This comparative analysis ability of the system is useful in identifying areas of weakness of the organization; hence making analytical propositions for the decision making process. Moreover, the decision support system helps in analyzing projected figures concerning the introduction of new ideas or departments in the organization. This is useful in preparing for the future, which leads the organization to have effective and strategic planning culture for the future.

The support system also facilitates the analysis of the consequences of the decision made in the past, experiences and the context of those experiences (Mainardi, Maggioni, Dainese & Zanchin, 2005). This process facilitates the working of the organization towards providing better services to the consumer. The health sector is not lagging in the incorporation and adoption of the technological advancements and developments in the globe. The incorporation of the technology in the running of hospitals and the entire management is quite varying. It incorporates the use of the machine systems to support life, administer treatment, automated systems to help patients and the newest introduction in the field, to support the process of making decisions. The decision making model for use in the hospital setting is inexplicably useful and resourceful for the organization; as it facilitates quick and effective process of making the decisions affecting the patients and the workers.

Clinical Notes Template used by VA in the Computerized Patient Record System (CPRS) description

The Computerized Patient Record System (CPRS) is an Information System Developed by the Veterans Health Information Systems and Technology Architecture (VISTA) application (Burstein & Holsapple, 2008). It is a useful application that incorporates the clinical notes template application. The temp-late system has a design that encounters the user and operator with an easy interface for the user to choose the options they want to perform. The system has several uses in the course of working of the clinicians. For instance, the template allows the clinicians, managers and leaders in the health organization to enter data concerning any patient. This is the first use of the template by the clinicians. Secondly, the template is useful for reviewing and continual updating of data and information about the patient, once they are in the computerized system. Moreover, the clinical template allows the user to order for medications, lab tests, procedures and diets. Moreover, it helps in recording and keeping of neat and easy accessibility of information about the given patient. The CPRS is useful in assisting the hospital and personnel to keep a comprehensive record of the patients. Moreover, the system is useful for the clinicians, managers and the QA staff to review the information and data gathered on the patient in a way that will directly support effective clinical decision-making process (Eliasson, Bastholm, Forsberg, Henriksson, Jacobson, Nilsson & Gustafsson, 2006). The clinical notes template allows professionals to enter the progress notes of the patient, the diagnosis made, discharge summaries and the medications and treatments for each of the patients. The template note system also has a close integration of a Clinical Reminders and Text Integration packages. These packages allow a better record keeping, which comply with the clinical guidelines and medical requirements in the profession. Therefore, the template is a holistic approach system to the setting of the clinical system and provides effective and information management system that are of quality in the hospital setting. It allows for various factors and ethical guidelines incorporated in the medical profession. The features of the notes template are also integral to other types of packages performing other services in the clinical setting.

Identification and Description of the Problem the Decision Support System will solve

The clinical notes template for decision support system has features is a design that facilitates all aspects of communication technology in the industry. The technological systems of information technology help in assisting the country assess the data available in the health center (Mainardi, Maggioni, Dainese & Zanchin, 2005). Therefore, this temp-late system, which allows for capturing and assessing of data; in addition to the record keeping of information about the patients, sill solve a critical problem in the organization of application. The challenges the hospital setting faces include the record keeping system management, the capturing of data and the manipulation and comparative analysis of the information. These are crucial integrals in the process of making a decision concerning any of the patients. Therefore, in view of the challenges the hospital faces, the clinical template incorporated in the CPRS has a perspective that will turn the management of clinical information and data in the hospital.

The system will solve the issue of missing information about the patients. It is a common occurrence to find that information concerning a certain patient is missing when needed. This disappearance of patient information is a retarding and retrogressive factor in the decision making and information management of the clinicians and medical practitioners (Whyte, 2005). Therefore, the system aims to enhance the quality of data taking, the entry and keeping of information about the patient. The system also incorporates an aspect of real time updating of the records concerning any patient. Therefore, the system will solve the issue of the practitioners missing critical information about a patient, yet they took the information. The existing arrangement does not allow for the direct updating of the client information. This could be detrimental in the case of crucial data, such as missing to update if a certain patient had their medication. Another clinician could attend to the patient and give medication, leading to overdose which could lead to death of the patient. This would be due to the issue of poor record keeping, the systems not updated on time; hence the mishap in the course. The system will solve this problem once the implementation is complete. Lastly, the decision making process concerning the final management duties of the health setting incorporates the analysis of the facts and figures recorded in the hospital's records. A hospital with a manual system is worse as the analysis of the data takes time to go through to the huge records of data and information manually. Additionally, the added manual records make the process of compiling the final reports concerning the patients and the hospital in general tiresome. Therefore, this information system allows for the management and leadership to conduct quick and comprehensive analysis of the data in the hospital. The structured system of data organization will guide the leadership to a comprehensive analysis of the figures and the computation of the same. Therefore, the leadership of the clinical setting and hospitals will make informed decisions that are devoid of errors.

The functional components and structures of the DSS

The functional components and structures of the decision support system of the clinical notes template include aspects of adverse reaction tracking. This program in the template setting provides a central and consistent structure of data that is useful in adverse reaction. This tracking component supports the continuation of records of the patient in the past. The second component of the system is that of authorization/subscription utility (Eliasson, Bastholm, Forsberg, Henriksson, Jacobson, Nilsson & Gustafsson, 2006). This component provides the methodology of regulation for identifying the person authorized to perform the various actions on the clinical documents. The component will keep the integration of text and the safety of the patient data, thus maintaining the confidentiality within the practice. Therefore, it provides security key capabilities to manage the needs of the documentation for the clinical purposes efficiently. The third component of the system is clinical reminders. The package incorporates a valuable aid to the treatment of the patient. The reminders are educative in nature as they facilitate the clinical decision-making process and educate the providers of the appropriate care. The clinical reminder component also improves the documentation of the patient information and accurate follow-up on the patient. The last component in the template is that of health summary (Whyte, 2005). The health summary component of the system supports the generation of the report containing all the specified information requested about the patient. This report extracts data from the CPRS system used in the setting, displaying this information in a standard format. This component can generate a wide range of information related to health, such as the demographic data, allergies, active medical issues and the laboratory tests results. These are the key components of the clinical notes template developed for the CPRS in the hospital setting.

Objectives and key decisions made by the DSS

The purpose of the DSS is to grow the clinical setting into quality service delivery that meets the crucial factor of health requirements and needs of the populations. A country with a dysfunctional health system has no future (Mainardi, Maggioni, Dainese & Zanchin, 2005). Therefore, the system aims to engage the professionals and practitioners in the process of making decisions concerning the hospital setting and patient records. Secondly, the system will guide the management and leadership to access structured data that is easy to make a decision. It is difficult to make a conclusive decision with scrambled information. However, with the template, the information about every patient remains structured and organized, thus supporting the organization in the making of decisions that meet the criteria for being complete. Lastly, the clinical note template will guide the management into making future projections concerning the patients and the whole hospital setting.

Applicable healthcare agency of the DSS

The designing of the clinical note template is such that it caters for the needs of the hospital setting. The system making and programming has the features that facilitate all the duties and activities that proceed in the practitioners setting. The clinical setting is the ideal organization for the implementation of the new system; as it will supplement the normal CPRS used in other medical settings (Whyte, 2005). The process of making quick and reliable decisions about a patient needs reliable data analysis systems. This temp-late system provides the qualities and features necessary for the process of making decisions. Therefore, the agency of implementation of the system is the hospital and clinical contexts in the country.

Key decision makers in the agency facilitating working with the DSS

The key decision makers in the agency that will facilitate the working of the decision support system include the leadership of the agency. The personnel allowed to work with the system will have to provide their login details to get authorization to work with the system (Mainardi, Maggioni, Dainese & Zanchin, 2005). Therefore, this aspect of security will ensure that only the authorized persons can manipulate the data in the system. Therefore, the people authorized to work with the system include, authorized clinicians, the allowed medical professionals and staff of the hospital. Moreover, the overall leadership team can have access to the system as they monitor the functioning of the system. The system only requires efficient computer operation skills to manage.

Problems of communication issues

The issues of communication in the organization are the issues applicable to the intention of the DSS system (Burstein & Holsapple, 2008). The hospital system faces challenges in managing the records of information about the patients. This affects the overall process of making a decision, as the decision makers do not have quality and reliable sources of information. Moreover, the organizational structure needs to assess the overall reports of the records to make the quality decision required. However, this information is not available, leading to misinformation; thus a poor decision making process. Additionally, the communication between the professionals is not effective as there is no general source of information. The available records may not have the updated information. Therefore, the misinformed personnel make the wrong decision.

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References
5 sources cited in this paper
  • Burstein, F., & Holsapple, C. W. (2008). Handbook on decision support systems. Berlin: Springer.
  • Berner, E. S. (2007). Clinical decision support systems: Theory and practice. New York: Springer.
  • Whyte, M. (2005). Computerised versus handwritten records. Paediatric Nursing, 17(7), 15-8. Retrieved from http://search.proquest.com/docview/218912961?accountid=458
  • Eliasson, M., Bastholm, P., Forsberg, P., Henriksson, K., Jacobson, L., Nilsson, A., & Gustafsson, L. L. (2006). Janus computerised prescribing system provides pharmacological knowledge at point of care - design, development and proof of concept. European Journal of Clinical Pharmacology, 62(4), 251-8. doi:http://dx.doi.org/10.1007/s00228-006-0114-2
  • Mainardi, F., Maggioni, F., Dainese, F., & Zanchin, G. (2005). Development of a ICHD-II based computerised system for the general practitioner. The Journal of Headache and Pain, 6(4), 211-2. doi:http://dx.doi.org/10.1007/s10194-005-0187-9
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PaperDue. (2013). Decision support systems and clinical documentation in healthcare IT implementation. PaperDue. https://paperdue.com/essay/decision-support-system-executive-presentation-92082

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