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The patient’s physician, a young resident named Dr. Greenhorn, orders a routine creatinine lab test in VistA/EHR. 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.

Upon filling the medication order, a pharmacy tech questions the dosage recommended by Dr. Greybread and seeks confirmation from the doctor prior to continuing with the medication dispense. The tech uses a VOIP text-to-voice messaging tool to call Dr. Greybeard’s his office phone with a brief message.

When Dr. Greybeard does not answer his phone, the system escalates to an SMS message sent to his registered SMS-enabled mobile device. Upon receiving the text, Dr. Greybeard confirms that the dosage is correct by return texting “YES” and the tech proceeds to fill the order. The communication between the three providers is recorded and documented/linked to the patient’s file as a monitored conversation.

The CDS system sends a recommendation to Dr. Greenhorn recommending an Infectious Disease consult.

Dr. Greybeard accepts the advice, and while  filling out the consult request, he is presented with a variety of order (workflow) requirements.

He addresses each precondition, completes all details of the order in the Computerized Physician Order Entry (CPOE) system and submits the consult request for fulfillment to the Infectious Disease department.

“Service Level Agreements” (SLA) that the organization has in place regarding consult review and appointment wait times.

Based on the organization’s policy, two previously resulted labs for patient Eighteen (an HIV blood test and a cocaine drug screening) in the patient record are treated as protected content. Given the patient’s consent policy vis-à-vis protected content, these are not visible nor accessible except under emergency conditions. The creatinine lab result and its alert, however, are not so restricted.