Utilization of evidence-based computerized order sets in pediatrics

Little is known about utilization of different evidence-based order sets within computerized physician order entry (CPOE) systems. We designed a retrospective study of resident and attending physician order set utilization to evaluate the use of three evidence-based computerized order sets (asthma, post-appendectomy care, and community-acquired pneumonia (CAP)), and examine patient and admission characteristics associated with order set utilization in pediatrics. We studied all 529 asthma patients, 277 appendectomy patients, and 210 CAP patients admitted between 1 November 2001 and 30 November 2003 during implementation of standardized order sets at a large, independent, not-for-profit pediatric institution. We analyzed order set utilization for the three order sets and tested the relationship between order set use and potential factors associated with utilization. Order set utilization varied by condition (X(2)=339.2, p<0.001), with the asthma order set use rate highest (88.1%), followed by appendectomy order set utilization (79.4%), and substantially lower CAP order set use (21.1%). We found that trends in order set utilization also varied by condition. Only the asthma order set showed a trend of increasing use after implementation (z= -3.02, p=0.002). In addition, factors associated with order set utilization varied. Uses of the asthma and post-appendectomy order sets were associated with factors such as admission unit and case complexity. CAP order set utilization was associated with case complexity but not admission source. We conclude that health services organizations looking to implement computerized order sets to reduce unnecessary practice variation while promoting best practices must consider the different factors that may influence the use of each order set rather than relying on a one-size-fits-all implementation strategy. Further, issues such as the level of physician involvement in order set development and consensus around order set content may be particularly important factors influencing order set utilization.     

The need for organizational change in patient safety initiatives

OBJECTIVES: This study describes a computer simulation model that has been developed to explore organizational changes required to improve patient safety based on a medication error reporting system. METHODS: Model parameters for the simulation model were estimated from data submitted to the MEDMARX medication error reporting system from 570 healthcare facilities in the U.S. The model's results were validated with data from the Pittsburgh Regional Healthcare Initiative consisting of 44 hospitals in Pennsylvania that have adopted the MEDMARX medication error reporting system. The model was used to examine the effects of organizational changes in response to the error reporting system. Four interventions were simulated involving the implementation of computerized physician order entry, decision support systems and a clinical pharmacist on hospital rounds. CONCLUSIONS: Results of the analysis indicate that improved patient safety requires more than clinical initiatives and voluntary reporting of errors. Organizational change is essential for significant improvements in patient safety. In order to be successful, these initiatives must be designed and implemented through organizational support structures and institutionalized through enhanced education, training, and implementation of information technology that improves work flow capabilities.     

When requests become orders--a formative investigation into the impact of a computerized physician order entry system on a pathology laboratory service

PURPOSE: The purpose of this study was to identify the key implications of the implementation of a computerized physician order entry (CPOE) system on pathology laboratory services. METHODS: An in-depth qualitative study using observation, focus groups and interviews with pathology staff, managers, clinicians and information systems staff during implementation of a CPOE system in 2004 at a major Australian teaching hospital. RESULTS: Pathology laboratories experienced a shift in their work roles resulting in altered work practices, responsibilities and procedures. These changes were marked by terminological and procedural changes in the test order process from when clinicians issued a request for a test, to the new system that established clinical orders at the point of care. This change was accompanied by some organizational dysfunctions including the emergence of a new category of "frustrated" orders without specimens; problems with the procedure of adding tests to previously existing specimens; the appearance of discrepancies in the recorded time of specimen collection. In response to these changes, hospital and pathology staff adopted a variety of means to cope with their changed circumstances. These ranged from efforts to increase clinical awareness to compensatory laboratory workarounds and enforced rule changes. CONCLUSIONS: CPOE systems can have a major impact on the nature of the work of pathology laboratories. Understanding how and why these changes occur can be enhanced through considering the organizational and social contexts involved. The effectiveness of CPOE systems will rely on how administrators and staff approach and deal with these challenges.     

Development of an instrument for measuring clinicians' power perceptions in the workplace

We report on the development of an instrument to measure clinicians’ perceptions of their personal power in the workplace in relation to resistance to computerized physician order entry (CPOE). The instrument is based on French and Raven’s six bases of social power and uses a semantic differential methodology. A measurement study was conducted to determine the reliability and validity of the survey. The survey was administered online and distributed via a URL by email to 19 physicians, nurses, and health unit coordinators from a university hospital. Acceptable reliability was achieved by removing or moving some semantic differential word pairs used to represent the six power bases (alpha range from 0.76 to 0.89). The Semantic Differential Power Perception (SDPP) survey validity was tested against an already validated instrument and found to be acceptable (correlation range from 0.51 to 0.81). The SDPP survey instrument was determined to be both reliable and valid.     

A computer-based intervention for improving the appropriateness of antiepileptic drug level monitoring

We designed and implemented 2 automated, computerized screens for use at the time of antiepileptic drug (AED) test order entry to improve appropriateness by reminding physicians when a potentially redundant test was ordered and providing common indications for monitoring and pharmacokinetics of the specific AED. All computerized orders for inpatient serum AED levels during two 3-month periods were included in the study. During the 3-month period after implementation of the automated intervention, 13% of all AED tests ordered were canceled following computerized reminders. For orders appearing redundant, the cancellation rate was 27%. For nonredundant orders, 4% were canceled when information on specific AED monitoring and pharmacokinetics was provided. The cancellation rate was sustained after 4 years. There has been a 19.5% decrease in total AED testing volume since implementation of this intervention, despite a 19.3% increase in overall chemistry test volume. Inappropriateness owing to repeated testing before pharmacologic steady state was reached decreased from 54% of all AED orders to 14.6%. A simple, automated, activity-based intervention targeting a specific test-ordering behavior effectively reduced inappropriate laboratory testing. The sustained benefit supports the idea that computerized interventions may durably affect physician behavior. Computerized delivery of such evidence-based boundary guidelines can help narrow the gap between evidence and practice.     

Format change of a laboratory test order form affects physician behavior

Purpose

Our study was designed to find whether a change in physician ordering of laboratory testing could be obtained by the simple strategy of changing the set-up of the check-box laboratory order form that is embedded in a computerized medical record.

Methods

This prospective intervention study was undertaken in Maccabi Healthcare Services, a Preferred Provider Organization that has used a computerized medical record since 1992. We examined data from 865 primary healthcare physicians over 3 years. In May 2005 we changed the order form and reduced the number of tests that can be ordered using a check-box form from 51 to 26. Twenty-seven tests were removed from the form and two tests were added. The total number of laboratory test orders and the median rate of test orders per visit to physician during each of the study periods were calculated separately for each test.

Results

Tests that were added to the computerized laboratory order form showed an increase of 60.7% in the first year and a further 90% increase in the following year. For the unchanged tests the percentage changes over the same periods were +18.4% and −22.4%. For the deleted tests the change was −27% and −19.2% for the respective years.

Conclusions

Changes in format of laboratory test order forms can change physician test ordering and may be useful together with other interventions to improve appropriateness of laboratory testing. A thoughtfully built test ordering form can reinforce clinical guidelines for the performance of some preventive testing and follow-up.     

Outpatient order accuracy. A College of American Pathologists Q-Probes study of requisition order entry accuracy in 660 institutions

CONTEXT: Laboratory test order entry errors potentially delay diagnosis, consume resources, and cause patient inconvenience. OBJECTIVE: To evaluate the frequency and causes of computer order entry errors in outpatients. DESIGN: Cross-sectional survey and prospective sample of errors. Participants answered questions about their test order entry policies and practices. They then examined a sample of outpatient requisitions and compared information on the requisition with information entered into the laboratory computer system. Order entry errors were divided into 4 types: tests ordered on the requisition, but not in the computer; tests performed but not ordered on the requisition; physician name discrepancies; and test priority errors. PARTICIPANTS: Six hundred sixty laboratories enrolled in the College of American Pathologists Q-Probes program. MAIN OUTCOME MEASURE: Overall order entry error rate. RESULTS: A total of 5514 (4.8%) of 114 934 outpatient requisitions were associated with at least 1 order entry error. The median participant reported 1 or more order errors on 6.0% of requisitions; 10% of institutions reported errors with at least 18% of requisitions. Of the 4 specific error types, physician name discrepancies had the highest error rate, and test priority errors the lowest error rate. Four institutional factors were significantly associated with higher overall error rates: orders verbally communicated to the laboratory; no policy requiring laboratory staff to compare a printout or display of ordered tests with the laboratory requisitions to confirm that orders had been entered correctly; failure to monitor the accuracy of outpatient order entry on a regular basis; and a higher percentage of occupied beds (ie, a busier hospital). CONCLUSIONS: Computer order entry errors are common, involving 5% of outpatient requisitions. Laboratories may be able to decrease error rates by regularly monitoring the accuracy of order entry, substituting written and facsimile orders for verbal orders, and instituting a policy in which orders entered into computer systems are routinely rechecked against orders on requisitions.     

Predicting computerized physician order entry system adoption in US hospitals: can the federal mandate be met?

OBJECTIVES: The purpose of this study is four-fold. First, the hospitals' current level of computerized physician order entry (CPOE) adoption is reported; second, internal and external influence factors' roles in determining CPOE adoption rates are described; third, the future diffusion rate of CPOE systems in US hospitals is empirically predicted; finally, the current technology's state-of-the-art is assessed. DATA SOURCE: Secondary data from 3 years of the Leapfrog Group's annual survey (2002-2004) of US tertiary-care hospitals. STUDY DESIGN: This study estimates CPOE market penetration rates applying technology diffusion theory and Bass modeling techniques for three future CPOE adoption scenarios-'Optimistic,' 'Best estimate', and 'Conservative' are empirically derived. PRINCIPAL FINDINGS: Two of the CPOE adoption scenarios have diffusion S-curve that indicates a technology will achieve significant market penetration. Under current conditions, CPOE adoption in urban hospitals will not reach 80% penetration until 2029. CONCLUSIONS: The promise of improved quality of care through medication error reductions and significant cost controls prompted the Institute of Medicine to call for universal CPOE adoption by 1999. However, the CPOE products available as of 2006 represent only a 'second generation technology', characterized by many limitations. Without increased external and internal pressures, such CPOE systems are unlikely to achieve full diffusion in US hospitals in a timely manner. Alternatively, developing a new generation of CPOE technology that is more 'user-friendly' and easily integrated into hospitals' legacy systems may be a more expedient approach to achieving widespread adoption.     

Unintended transformations of clinical relations with a computerized physician order entry system

A socio-technical approach was used to study the qualitative effects of deploying a medication computerized physician order entry system (CPOE with no decision support) at two internal medical wards in a hospital in Denmark. Our results show spatial and temporal transformations of core acts and relations in medication work, i.e. of the intended use of the system inscribed in hardware and software, in the relations of care between doctors and patients, of collaboration between doctors and nurses, and prospectively of the patients' trajectories when readmitted to hospital or another health care institution, reusing data from the system. This study throws light on problems of continuity of patient care paths, patient-related and IT-system-related error handling and time spent on core activities--when ubiquitous IT is used locally in a real physical setting with specific traditions of performing or 'doing medication'. The paper argues for the project organization to support the local collaboration and renegotiation of time and place of enacting medication with CPOE, as well as set up feedback for maturation of the software for future clinical use.     

Selecting physician leaders for clinical service lines: critical success factors.

PURPOSE: Clinical service lines and interdisciplinary centers have emerged as important strategic programs within academic health centers (AHCs). Effective physician leadership is significant to their success, but how these leaders are chosen has not been well studied. The authors conducted a study to identify current models for selecting the physician leaders of clinical service lines, determine critical success factors, and learn how the search process affected service line performance. METHOD: In 2003 and 2004, the authors interviewed clinical and executive personnel involved in 14 programs to establish, or consider establishing, heart or cancer service lines, at 13 AHCs. The responses were coded to identify and analyze trends and themes. RESULTS: The key findings of the survey were (1) the goals and expectations that AHCs set for their service line leaders vary greatly, depending on both the strategic purpose of the service line in the AHC and the service line's stage of development, (2) the matrix organizational structure employed by most AHCs limits the leader's authority over necessary resources, and calls forth a variety of compensating strategies if the service line is to succeed, (3) the AHCs studied used relatively informal processes to identify, evaluate, and select service line leaders, and (4) the leader's job is vitally shaped by the AHC's strategic, structural, and political context, and selection criteria should be determined accordingly. CONCLUSIONS: Institutions should be explicit about the strategic purpose and stage of development of their clinical service lines and be clear about their expectations and requirements in hiring service line leaders.     

An effective computerized reminder for contact isolation of patients colonized or infected with resistant organisms

PURPOSE: To improve contact isolation rates among patients admitted to the hospital with a known history of infection with Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant Enterococci (VRE). METHODS: A before and after interventional study implementing computerized reminders for contact isolation between February 25, 2005 and February 28, 2006. We measured rates of appropriate contact isolation, and time to isolation for the 4 month pre-intervention period, and the 12 month intervention period. We conducted a survey of ordering physicians at the midpoint of the intervention period. RESULTS: Implementing a computerized reminder increased the rate of patients appropriately isolated from 33% to fully 89% (P<0.0001). The median time to writing contact isolation orders decreased from 16.6 to 0.0 h (P<0.0001). Physicians accepted the order 80% of the time on the first or second presentation. Ninety-five percent of physicians felt the reminder had no impact on workflow, or saved them time. CONCLUSION: A human reviewed computerized reminder can achieve high rates of compliance with infection control recommendations for contact isolation, and dramatically reduce the time to orders being written upon admission.     

Programs for the development of physician leaders: a curricular process in its infancy.

Physician leaders are crucial as never before to ensure the proper integration of good care and cost containment; such integration is both a reasonable expectation of patients and essential for the survival of health care delivery systems. In today's health care environment, a critical mass of physician leaders must be developed in a systematic fashion so that physicians may truly lead the health care enterprise. The authors (1) describe, with examples, the various types and levels of physician leadership training programs currently being offered; (2) explain the costs and benefits of each program type; and (3) offer a program rationale and model (using a program at their medical school), which they analyze using traditional management concepts such as strategic planning, net present value, and make-versus-buy. The authors emphasize that physician leadership training should be local, offer long-term instruction, and be led by physicians. They conclude by stating that the concept of physician leadership will not and should not be taken seriously by non-physician health care executives until the physician community becomes as serious about leadership and management training as it is about clinical training.     

Impact of electronic order management on the timeliness of antibiotic administration in critical care patients

ObjectiveTo examine the effect of implementing electronic order management on the timely administration of antibiotics to critical-care patients.MethodsWe used a prospective pre-post design, collecting data on first-dose IV antibiotic orders before and after the implementation of an integrated electronic medication-management system, which included computerized provider order entry (CPOE), pharmacy order processing and an electronic medication administration record (eMAR). The research was performed in a 24-bed adult medical/surgical ICU in a large, rural, tertiary medical center. Data on the time of ordering, pharmacy processing and administration were prospectively collected and time intervals for each stage and the overall process were calculated.ResultsThe overall turnaround time from ordering to administration significantly decreased from a median of 100 min before order management implementation to a median of 64 min after implementation. The first part of the medication use process, i.e., from order entry to pharmacy processing, improved significantly whereas no change was observed in the phase from pharmacy processing to medication administration.DiscussionThe implementation of an electronic order-management system improved the timeliness of antibiotic administration to critical-care patients. Additional system changes are required to further decrease the turnaround time.     

Does Computerized Physician Order Entry Benefit from Dynamic Structured Data Entry? A Quasi-Experimental Study

Background

With advancements in information technology, computerized physician order entry (CPOE) and electronic Medical Records (eMR), have become widely utilized in medical settings. The predominant mode of CPOE in Taiwan is free text entry (FTE). Dynamic structured data entry (DSDE) was introduced more recently, and has increasingly drawn attention from hospitals across Taiwan. This study assesses how DSDE compares to FTE for CPOE.

Methods

A quasi-experimental study was employed to investigate the time-savings, productivity, and efficiency effects of DSDE in an outpatient setting in the gynecological department of a major hospital in Taiwan. Trained female actor patients were employed in trials of both entry methods. Data were submitted to Shapiro-Wilk and Shapiro-Francia tests to assess normality, and then to paired t-tests to assess differences between DSDE and FTE.

Results

Relative to FTE, the use of DSDE resulted in an average of 97% time saved and 55% more abundant and detailed content in medical records. In addition, for each clause entry in a medical record, the time saved is 133% for DSDE compared to FTE.

Conclusion

The results suggest that DSDE is a much more efficient and productive entry method for clinicians in hospital outpatient settings. Upgrading eMR systems to the DSDE format would benefit both patients and clinicians.

     

A computerized reminder system to increase the use of preventive care for hospitalized patients

BACKGROUND: Although they are effective in outpatient settings, computerized reminders have not been proved to increase preventive care in inpatient settings. METHODS: We conducted a randomized, controlled trial to determine the effects of computerized reminders on the rates at which four preventive therapies were ordered for inpatients. During an 18-month study period, a computerized system processed on-line information for all 6371 patients admitted to a general-medicine service (for a total of 10,065 hospitalizations), generating preventive care reminders as appropriate. Physicians who were in the intervention group viewed these reminders when they were using a computerized order-entry system for inpatients. RESULTS: The reminder system identified 3416 patients (53.6 percent) as eligible for preventive measures that had not been ordered by the admitting physician. For patients with at least one indication, computerized reminders resulted in higher adjusted ordering rates for pneumococcal vaccination (35.8 percent of the patients in the intervention group vs. 0.8 percent of those in the control group, P<0.001), influenza vaccination (51.4 percent vs. 1.0 percent, P< 0.001), prophylactic heparin (32.2 percent vs. 18.9 percent, P<0.001), and prophylactic aspirin at discharge (36.4 percent vs. 27.6 percent, P<0.001). CONCLUSIONS: A majority of hospitalized patients in this study were eligible for preventive measures, and computerized reminders significantly increased the rate of delivery of such therapies.     

The story behind the story: physician skepticism about relying on clinical information technologies to reduce medical errors

PurposeIn order to better understand physicians’ perspectives about the use of clinical information technology (CIT) to reduce medical errors, we asked physicians about opportunities and issues around clinical use of computerized physician order entry (CPOE) systems, order sets within CPOE, and handheld computers (HHCs).MethodsWe conducted 10 focus groups including 71 physicians involved in technology implementation efforts across the US between April 2002 and February 2005.ResultsTwo major themes emerged across focus groups around reliance on CIT to reduce errors: (1) can it work? and (2) at what cost to the medical profession? Within the first theme, physicians expressed concern about the appropriateness of physician-directed CIT as a solution for medical errors, concerns regarding the current technical capabilities and level of technical support for CIT solutions, and concern about the introduction of new errors. Within the second theme, physicians were particularly concerned about time efficiency and workload redistribution associated with the introduction of CIT. Across focus groups, physicians tended to generalize about the role of all IT in their lives, potentially biasing opinions about specific technologies.ConclusionsHealth care organizations attempting to promote physician use of CIT are advised to deepen consideration of physicians’ perspectives about technology adoption and use in order to address their concerns, reduce skepticism, and increase the likelihood of implementation success.