Patient Eighteen is admitted to the hospital and treated with Gentamicin for a kidney infection. The patient has a signed consent directive that limits disclosure of HIV and substance abuse information except for emergency situations. The patient’s physician, a young resident named Dr. Greenhorn, orders a routine creatinine lab test in VistA. When the blood test is completed, the hospital Health Information Technology (HIT) system, publishes the result to a centralized EPS and the “Diagnostic Reports topic”. One subscriber to this topic, the CDS system, evaluates the results, determines that it is abnormal, and recognizes that the patient’s medication list contains Gentamicin, a nephrotoxic drug. It then sends an eHMP alert to the author of the order, Dr. Greenhorn, informing them of the elevated creatinine level (1.8 mg/dL) and that an unsigned order for a Gentamicin dose adjustment has been placed in VistA. When Dr. Greenhorn does not respond to the EMR based-alert within a pre-determined amount of time, the system re-routes the alert to the attending physician, Dr. Greybeard. Both providers are requested to either sign, modify, or cancel the recommended order. There is a final option, determined by alert type and content. This option, “Pharmacy Consult”, provides a mechanism for the provider to quickly ask a question of a pharmacist in a secure chat room. | 
