"Smart Forms" in an Electronic Medical Record: documentation-based clinical decision support to improve disease management.

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This is a review of a 2008 article by Schnipper et al entitled; "Smart Forms" in an Electronic Medical Record: documentation-based clinical decision support to improve disease management.[1]

The authors describe the development and implementation of an Electronic Medical Record (EMR) based "Smart Form system for physician use in capturing pertinent clinical data for patients with coronary artery disease (CAD) or diabetes mellitus (DM).The "Smart Form" was first pilot studied in Acute Respiratory Infections (ARIs). It was later redesigned based on the success/failures of ARI Smart Form with help of Partners Health care informatics infrastructure into CAD or DM Smart Form. The Design of the "Smart Form" was not only patient centered but also took into account factors that might positively impact physician ease of use while providing them with Clinical Decision Support (CDS)[1]


The article focuses on improving EMR Usability, coupled with integration of a "Smart Form driven" Clinical Decision Support System (CDSS)for the physicians that translates into observable improvement in patient care - as opposed to simply theoretical ones. CDSS -as noted by the authors- has historically been shown to have great potential to enhance patient care. Among the 5-key limitations cited, it appears that success or failure of the CDSS hinges on the ability of the system to be implemented with minimal disruptions to the clinician's workflow. [1]

Features & Functions

Physician (User) input was solicited throughout the design iterations of the "Smart Form". The "Smart Form" is an EMR with two main functions:[1]

  • 1. Documentation of comprehensive patient visit information in a structured format that is stored coded.
  • 2. Clinical Decision Support which provides disease specific (CAD & DM) information relevant patient care - based on Clinical and demographic information gathered via the "Smart Form".
    • Suggested treatment orders can then be reviewed and decided upon.
    • CDS is reported to be timely, meaningful and non disruptive of workflow.


Although the authors report enhanced usability of the system and it's ability to enhance patient care, they mention that it may be a steep learning curve for a new user. They suggest that physicians might be more inclined to use the system if they perceive added value to their workflow.[1]


The Review article presents a very candid and comprehensive look at the pathway towards developing an EMR that could seamlessly be integrated into the physicians workflow providing value added benefits. A crucial aspect was the incorporation of user input and in testing the various iterations of the tool. A cursory look at the patient chart "Smart Form" screenshots provided give the picture of a very "busy" graphical user interface. Although the authors justify this approach as a means of reducing Screen flips it is plausible that this may lead to documentation errors or a failure to note key patient information. It is hard to say if adequate training would compensate for this. Several limitations to the system are cited such as the inability to effectively address both acute and chronic conditions simultaneously. These they are hoping to address with future developments. [1]


  1. 1.0 1.1 1.2 1.3 1.4 1.5 Schnipper, J. L., Linder, J. A., Palchuk, M. B., Einbinder, J. S., Li, Q., Postilnik, A., & Middleton, B. (2008). “Smart Forms” in an Electronic Medical Record: Documentation-based Clinical Decision Support to Improve Disease Management. Journal of the American Medical Informatics Association, 15(4), 513–523. doi:10.1197/jamia.M2501