Order Set Development

[OpenEMRRN (Thomas B)]

I am working with a developer to assist in the conceptual development of Order Sets in Open EMR. I have worked with paper order sets and have an idea how best to lay out the flow and content for providers to follow. Does Open EMR allow for such functionality in an Outpatient / Home Visit setting.

Essentially it is Clinical Decision Support geared to common diagnosis’s for outpatient care.

Ideallly based on the reason for visit, we would want to evaluate the patient’s primary problem and current medications, then based on the order set (Clinical Decision Support) evaluate medications that they may benefit from having on their profile.

[htuck (htuck@mi-squared.com)]

@OpenEMRRN
OpenEMR doesn’t really have a computerized capability directly corresponding to ‘Physician’s Orders’, i.e., the form in physical paper charts where orders are written then transcribed and authenticated by staff.
Different practices handle the function differently. Some have SOAP notes in the encounter summary with the Dr orders in the ‘P’ section, which are checked by staff and carried out, and e-signed when completed. Others use the ‘Physician Request’ type of message in ‘Transactions’ found in the pt dashboard.
But none of those methods include a CDS- style function to assist selecting meds or treatments.

However, if you did develop those order sets, OpenEMR does have a capability to insert all at once onto the encounter fee sheet all the required billing information for one order set:
https://www.open-emr.org/wiki/index.php/HOWTO:_Create_Multiple_Code_Fee_Sheet_List_Categories
These would be the CPT and dx codes that charge for the ordered services.

Good luck HT

[mdsupport]

2 cents from our development experience - driving decisions based on predefined rules is difficult. But you can use past decisions to support your next decision. In practical terms what we have done is once the clinician selects a collection of diagnosis codes (stored as codes in “Problem” type of “Issue”), we offer suggestions for other types “Issues” (such as Medications, Allergy Checks, Secondary problems) ordered by statistical confidence.
Best.

[sjpadgett (Jerry P)]

Doesn’t completely apply here but, I put this feature into procedures in v5.0.2. The intent is to find past dx and issues base on users past procedure history.