Towards a Clinically Meaningful Model to Structure the Development of Interoperable Order Sets, Applicable to the Point of Care in Any EMR

Abstract

Standardized order sets are a pragmatic type of clinical decision support that can improve adherence to clinical guidelines with a list of recommended orders related to a specific clinical context. We developed a structure facilitating the creation of order sets and making them interoperable, to increase their usability. Various orders contained in electronic medical records in different hospitals were identified and included in different categories of orderable items. Clear definitions were provided for each category. A mapping to FHIR resources was performed to relate these clinically meaningful categories to FHIR standards to assure interoperability. We used this structure to implement the relevant user interface in the Clinical Knowledge Platform. The use of standard medical terminologies and the integration of clinical information models like FHIR resources are key factors for creating reusable decision support systems. The content authors should be provided with a clinically meaningful system to use in a non-ambiguous context.