Grouped Knowledge Elements

Two frequently occurring tasks in the clinical workflow where the health care provider and the computer communicate are during clinical and in computerized-provider order entry (CPOE). These tasks are facilitated by grouped knowledge elements, i.e. structured documentation templates and order sets, respectively. A structured documentation template is an organized collection of data items relevant to a particular clinical context that can be used to collect or present codified information about a patient. An order set, similarly, is an organized collection of actions that can be ordered by a health care provider for the care of a patient in a specific clinical context. These grouped knowledge elements may be considered as vehicles for providing clinical decision support. Those who design the groupings of knowledge elements can use them to drive the behavior of the health care professional user. Additionally, order items and documentation items can be dynamically presented based on the context. By anticipating needs for data entry or access, or for orders, such grouping not only provides CDS but also facilitates workflow, by eliminating extra steps that would otherwise be needed. The specification of an order set’s or a document template’s structure and content is a form of knowledge. Standards are being developed for such specification to encourage the collection of higher quality, more interpretable, more comprehensive data, and to encourage reuse of document specifications, or parts thereof, where appropriate. This chapter reviews those efforts, in terms of their degree of maturity and harmonization, and how they relate to clinical decision support.