Design electronic medical records with clinical decision support system (CDSS) to prevent interaction of drug content in outpatient department

Abstract

Introduction: Hospitals must provide the best service to patients. The best services include speed in service, being on time, and being safe from medical errors. The best service to patients is to provide electronic medical records. Electronic medical records contain social data and patient medical data. The advantages of medical records are data stored in structured files, timely filling, data can be recalled at any time, patient confidentiality, and patient safety. This study aims to design electronic medical records with Clinical Decision Support System (CDSS) to prevent the interaction of drug content in the outpatient department. Methods: General background of the research is the design of electronic medical records with a clinical decision support system to prevent interaction of drug content for outpatient Departement. The design included: Business Process, Data Flow Diagram (DFD), and Entity Relationship Diagram. Five doctors, two nurses, and a pharmacist assistant were respondents. Qualitative data from FGD were analyzed by transcripts looking for similarities or differences, finding themes, and developing categories. The Design of Electronic Medical Record with Clinical Decision Support System (CDSS) was designed based on paper forms and the Result of FGD. Results: Electronic medical records were designed according to the users' needs in the outpatient department. User requirements had been taken by Focus Group Discussion (FGD). User requirements about Electronic Medical records included: Infrastructure Availability, Software (open source and web application because it was easy to develop according to users' needs, and training on electronic medical records. There are steps to designing electronic medical records: Business Process, DFD, ERD, and Data Dictionary. Conclusion: The design of electronic medical records with CDSS in the form of drug content interactions is a novelty that has the potential to be applied. Implementation of electronic medical records can prevent medical errors and support patient safety.