Impact of a physician's order entry (POE) system on physicians' ordering patterns and patient length of stay

Strategies for utilisation management of hospital services: a systematic review of interventions

Background

To achieve efficiency and high quality in health systems, the appropriate use of hospital services is essential. We identified the initiatives intended to manage adult hospital services and reduce unnecessary hospital use among the general adult population.

Methods

We systematically reviewed studies published in English using five databases (PubMed, ProQuest, Scopus, Web of Science, and MEDLINE via Ovid). We only included studies that evaluated interventions aiming to reduce the use of hospital services or emergency department, frequency of hospital admissions, length of hospital stay, or the use of diagnostic tests in a general adult population. Studies reporting no relevant outcomes or focusing on a specific patient population or children were excluded.

Results

In total, 64 articles were included in the systematic review. Nine utilisation management methods were identified: care plan, case management, care coordination, utilisation review, clinical information system, physician profiling, consultation, education, and discharge planning. Primary case management was shown to effectively reduce emergency department use. Care coordination reduced 30-day post-discharge hospital readmission or emergency department visit rates. The pre-admission review program decreased elective admissions. The physician profiling, concurrent review, and discharge planning effectively reduced the length of hospital stay. Twenty three studies that evaluated costs, reported cost savings in the hospitals.

Conclusions

Utilisation management interventions can decrease hospital use by improving the use of community-based health services and improving the quality of care by providing appropriate care at the right time and at the right level of care.

Effectiveness of Practices to Support Appropriate Laboratory Test Utilization: A Laboratory Medicine Best Practices Systematic Review and Meta-Analysis

Objectives

To evaluate the effectiveness of practices used to support appropriate clinical laboratory test utilization.

Methods

This review followed the Centers for Disease Control and Prevention (CDC) Laboratory Medicine Best Practices A6 cycle method. Eligible studies assessed one of the following practices for effect on outcomes relating to over- or underutilization: computerized provider order entry (CPOE), clinical decision support systems/tools (CDSS/CDST), education, feedback, test review, reflex testing, laboratory test utilization (LTU) teams, and any combination of these practices. Eligible outcomes included intermediate, systems outcomes (eg, number of tests ordered/performed and cost of tests), as well as patient-related outcomes (eg, length of hospital stay, readmission rates, morbidity, and mortality).

Results

Eighty-three studies met inclusion criteria. Fifty-one of these studies could be meta-analyzed. Strength of evidence ratings for each practice ranged from high to insufficient.

Conclusion

Practice recommendations are made for CPOE (specifically, modifications to existing CPOE), reflex testing, and combined practices. No recommendation for or against could be made for CDSS/CDST, education, feedback, test review, and LTU. Findings from this review serve to inform guidance for future studies.

A Quality Improvement Intervention Reduces the Time to Administration of Stat Medications

INTRODUCTION

The delivery of urgent ("stat") medications to hospitalized children is important for safe quality care. The goal of this study was to evaluate the effect of a set of interventions on the percentage of stat medications administered within 30 minutes of ordering.

METHODS

A pre-post study in 2 pediatric units (36 beds) in a private hospital in Saudi Arabia between January 2015 and September 2016. Interventions included structured communication requirements, introduction of a dedicated electronic inbox for stat medication orders sent by nurses to the pharmacy, and the use of a pink envelope for the delivery of stat medications. A multivariate logistic regression model was used to model percentage of medications administered within goal.

RESULTS

Three hundred four stat orders met inclusion criteria. The proportion of orders meeting the 30-minute goal increased from a mean of 20% to a mean of 49% after the interventions (P < 0.001). In the final month of the study, compliance reached a peak of 67%. The mean turnaround time from ordering to the administration of the medication decreased from 59.7 to 40.7 minutes (P < 0.001). On multivariate analysis, medication type and unit-based availability of medications were statistically significant predictors of turnaround time. The odds of compliance being achieved was 0.3 times less if the medication was not available on the unit.

CONCLUSIONS

A set of interventions significantly increased the percentage of stat medications delivered within 30 minutes.

Does extended CPOE use reduce patient length of stay?

OBJECTIVE

This study compares use of Computerized Provider Order Entry (CPOE) and related clinical systems (i.e., extended CPOE) across 796 clinical teams caring for five distinct patient conditions. Our focus is the relationship between clinical teams' extended CPOE use and extent of prolonged stay (EPS), defined as the deviation in patients' observed length of stay from expected risk-adjusted length of stay.

MATERIALS AND METHODS

Using archival data from two affiliated hospitals in the Southeastern United States, we focused on five different patient conditions of varying mortality risk (vaginal birth, knee/hip replacement, cardiovascular surgery, organ transplant and pneumonia). For each patient, we (1) differentiated between the following three types of care team members-Responsible physician, Core team (excluding the responsible physician), and Support team, (2) created a composite of CPOE orders, documentation entries, patient record lookups, order set adherence, alert acknowledgement, and progress note entries to assess the deep structure use (DSU) of CPOE by the three types of members in the patients' care team, and (3) aggregated DSU of CPOE across all three types of care team members to calculate Total team DSU.

RESULTS

Teams with higher Total team DSU of CPOE had lower EPS for all five patient conditions. Patients of Core teams with higher DSU of CPOE had lower EPS in all conditions except organ transplant, comprising 93% of the patients studied. Higher DSU of CPOE by all three clinician types significantly reduced EPS for vaginal birth and knee/hip replacement, whereas higher DSU by two of the three types of care team members significantly reduced EPS for cardiovascular surgery and pneumonia.

CONCLUSIONS

Our results suggest that a clinician team that uses CPOE in a comprehensive manner is better informed enabling the team to coordinate care more effectively, resulting in reduced EPS.

Impact of a computerized provider radiography order entry system without clinical decision support on emergency department medical imaging requests

BACKGROUND AND OBJECTIVE

The adoption of computerized physician order entry is an important cornerstone of using health information technology (HIT) in health care. The transition from paper to computer forms presents a change in physicians' practices. The main objective of this study was to investigate the impact of implementing a computer-based order entry (CPOE) system without clinical decision support on the number of radiographs ordered for patients admitted in the emergency department.

METHODS

This single-center pre-/post-intervention study was conducted in January, 2013 (before CPOE period) and January, 2014 (after CPOE period) at the emergency department at Nîmes University Hospital. All patients admitted in the emergency department who had undergone medical imaging were included in the study.

RESULTS

Emergency department admissions have increased since the implementation of CPOE (5388 in the period before CPOE implementation vs. 5808 patients after CPOE implementation, p=.008). In the period before CPOE implementation, 2345 patients (44%) had undergone medical imaging; in the period after CPOE implementation, 2306 patients (40%) had undergone medical imaging (p=.008). In the period before CPOE, 2916 medical imaging procedures were ordered; in the period after CPOE, 2876 medical imaging procedures were ordered (p=.006). In the period before CPOE, 1885 radiographs were ordered; in the period after CPOE, 1776 radiographs were ordered (p<.001). The time between emergency department admission and medical imaging did not vary between the two periods.

CONCLUSIONS

Our results show a decrease in the number of radiograph requests after a CPOE system without clinical decision support was implemented in our emergency department.

Impact of the Electronic Medical Record on Mortality, Length of Stay, and Cost in the Hospital and ICU: A Systematic Review and Metaanalysis

OBJECTIVE

To evaluate effects of health information technology in the inpatient and ICU on mortality, length of stay, and cost. Methodical evaluation of the impact of health information technology on outcomes is essential for institutions to make informed decisions regarding implementation.

DATA SOURCES

EMBASE, Scopus, Medline, the Cochrane Review database, and Web of Science were searched from database inception through July 2013. Manual review of references of identified articles was also completed.

STUDY SELECTION

Selection criteria included a health information technology intervention such as computerized physician order entry, clinical decision support systems, and surveillance systems, an inpatient setting, and endpoints of mortality, length of stay, or cost. Studies were screened by three reviewers. Of the 2,803 studies screened, 45 met selection criteria (1.6%).

DATA EXTRACTION

Data were abstracted on the year, design, intervention type, system used, comparator, sample sizes, and effect on outcomes. Studies were abstracted independently by three reviewers.

DATA SYNTHESIS

There was a significant effect of surveillance systems on in-hospital mortality (odds ratio, 0.85; 95% CI, 0.76-0.94; I=59%). All other quantitative analyses of health information technology interventions effect on mortality and length of stay were not statistically significant. Cost was unable to be quantitatively evaluated. Qualitative synthesis of studies of each outcome demonstrated significant study heterogeneity and small clinical effects.

CONCLUSIONS

Electronic interventions were not shown to have a substantial effect on mortality, length of stay, or cost. This may be due to the small number of studies that were able to be aggregately analyzed due to the heterogeneity of study populations, interventions, and endpoints. Better evidence is needed to identify the most meaningful ways to implement and use health information technology and before a statement of the effect of these systems on patient outcomes can be made.

Computerized provider order entry reduces length of stay in a community hospital

OBJECTIVE

Does computerized provider order entry (CPOE) improve clinical, cost, and efficiency outcomes as quantified in shortened hospital length of stay (LOS)? Most prior studies were done in university settings with home-grown electronic records, and are now 20 years old. This study asked whether CPOE exerts a downward force on LOS in the current era of HITECH incentives, using a vendor product in a community hospital.

METHODS

The methodology retrospectively evaluated correlation between CPOE and LOS on a perpatient, per-visit basis over 22 consecutive quarters, organized by discipline. All orders from all areas were eligible, except verbals, and medication orders in the emergency department which were not available via CPOE. These results were compared with quarterly case mix indices organized by discipline. Correlational and regression analyses were cross-checked to ensure validity of R-square coefficients, and data were smoothed for ease of display. Standard models were used to calculate the inflection point.

RESULTS

Gains in CPOE adoption occurred iteratively house-wide, and in each discipline. LOS decreased in a sigmoid shaped curve. The inflection point shows that once CPOE adoption approaches 60%, further lowering of LOS accelerates. Overall there was a 20.2% reduction in LOS correlated with adoption of CPOE. Case mix index increased during the study period showing that reductions in LOS occurred despite increased patient complexity and resource utilization.

CONCLUSIONS

There was a 20.2% reduction in LOS correlated with rising adoption of CPOE. CPOE contributes to improved clinical, cost, and efficiency outcomes as quantified in reduced LOS, over and above other processes introduced to lower LOS. CPOE enabled a reduction in LOS despite an increase in the case mix index during the time frame of this study.

The assessment of stat laboratory test ordering practice and impact of targeted individual feedback in an urban teaching hospital

BACKGROUND

Overuse of inpatient stat laboratory orders ("stat" is an abbreviation of the Latin word "statim," meaning immediately, without delay) is a major problem in the modern healthcare system.

OBJECTIVE

To understand patterns of stat laboratory ordering practices at our institution and to assess the effectiveness of individual feedback in reducing these orders.

INTERVENTION

Medicine and General Surgery residents were given a teaching session about appropriate stat ordering practice in January 2010. Individual feedback was given to providers who were the highest utilizers of stat laboratory orders by their direct supervisors from February through June of 2010.

MEASUREMENTS

The proportion of stat orders out of total laboratory orders per provider was the main outcome measure. All inpatient laboratory orders from September 2009 to June 2010 were analyzed.

RESULTS

The median proportion of stat orders out of total laboratory orders was 41.6% for nontrainee providers (N = 500), 38.7% for Medicine residents (N = 125), 80.2% for General Surgery residents (N = 32), and 24.2% for other trainee providers (N = 150). Among 27 providers who received feedback (7 nontrainees, 16 Medicine residents, and 4 General Surgery residents), the proportion of stat laboratory orders per provider decreased by 15.7% (95% confidence interval: 5.6%-25.9%, P = 0.004) after feedback, whereas the decrease among providers who were high utilizers but did not receive feedback (N = 39) was not significant (4.5%; 95% confidence interval: 2.1%-11.0%, P = 0.18). Monthly trends showed reduction in the proportion of stat orders among Medicine and General Surgery residents, but not among other trainee providers.

CONCLUSIONS

The frequency of stat ordering was highly variable among providers. Individual feedback to the highest utilizers of stat orders was effective in decreasing these orders.

Adoption and meaningful use of computerized physician order entry with an integrated clinical decision support system for radiology: ten-year analysis in an urban teaching hospital

PURPOSE

The aim of this study was to assess whether an integrated imaging computerized physician order entry (CPOE) system with embedded decision support for imaging can be accepted clinically.

METHODS

The study was performed in a health care delivery network with an affiliated academic hospital. After pilot testing and user feedback, a Web-enabled CPOE system with embedded imaging decision support was phased into clinical use between 2000 and 2010 across outpatient, emergency department, and inpatient settings. The primary outcome measure was meaningful use, defined as the proportion of imaging studies performed with orders electronically created (EC) or electronically signed by an authorized provider. The secondary outcome measure was adoption, defined as the proportion of imaging studies that were ordered electronically, irrespective of who entered the order in the CPOE system. Univariate and multivariate regression analyses were performed to estimate trends and the significance of practice settings, examination modality, and body part to outcome measures. Chi-square statistics were used to assess differences across specialties.

RESULTS

A total of 4.1 million imaging studies were performed during the study period. From 2000 to 2010, significant increases in meaningful use (for EC studies, from 0.4% to 61.9%; for electronically signed studies, from 0.4% to 92.2%; P < .005) and the adoption of CPOE (from 0.5% to 94.6%, P < .005) were observed. The use of EC studies was greatest in the emergency department and inpatient settings. Meaningful use varied across specialties; surgical subspecialties had the lowest rates of EC studies.

CONCLUSIONS

Imaging CPOE with embedded decision support integrated into the IT infrastructure of the health care enterprise and clinicians' workflow can be broadly accepted clinically.

Computerized provider order entry in the clinical laboratory

Clinicians have traditionally ordered laboratory tests using paper-based orders and requisitions. However, paper orders are becoming increasingly incompatible with the complexities, challenges, and resource constraints of our modern healthcare systems and are being replaced by electronic order entry systems. Electronic systems that allow direct provider input of diagnostic testing or medication orders into a computer system are known as Computerized Provider Order Entry (CPOE) systems. Adoption of laboratory CPOE systems may offer institutions many benefits, including reduced test turnaround time, improved test utilization, and better adherence to practice guidelines. In this review, we outline the functionality of various CPOE implementations, review the reported benefits, and discuss strategies for using CPOE to improve the test ordering process. Further, we discuss barriers to the implementation of CPOE systems that have prevented their more widespread adoption.

The use of count data models in biomedical informatics evaluation research

OBJECTIVES

Studies on the impact and value of health information technology (HIT) have often focused on outcome measures that are counts of such things as hospital admissions or the number of laboratory tests per patient. These measures with their highly skewed distributions (high frequency of 0s and 1s) are more appropriately analyzed with count data models than the much more frequently used variations of ordinary least squares (OLS). Use of a statistical procedure that does not properly fit the distribution of the data can result in significant findings being overlooked. The objective of this paper is to encourage greater use of count data models by demonstrating their utility with an example based on the authors' current work.

TARGET AUDIENCE

Researchers conducting impact and outcome studies related to HIT.

SCOPE

We review and discuss count data models and illustrate their value in comparison to OLS using an example from a study of the impact of an electronic health record (EHR) on laboratory test orders. The best count data model reveals significant relationships that OLS does not detect. We conclude that comprehensive model checking is highly recommended to identify the most appropriate analytic model when the dependent variable being examined contains count data. This strategy can lead to more valid and precise findings in HIT evaluation studies.

The impact of computerized provider order entry systems on medical-imaging services: a systematic review

BACKGROUND

Computerized provider order entry (CPOE) systems have been strongly promoted as a means to improve the quality and efficiency of healthcare.

METHODS

This systematic review aimed to assess the evidence of the impact of CPOE on medical-imaging services and patient outcomes.

RESULTS

Fourteen studies met the inclusion criteria, most of which (10/14) used a pre-/postintervention comparison design. Eight studies demonstrated benefits, such as decreased test utilization, associated with decision-support systems promoting adherence to test ordering guidelines. Three studies evaluating medical-imaging ordering and reporting times showed statistically significant decreases in turnaround times.

CONCLUSIONS

The findings reveal the potential for CPOE to contribute to significant efficiency and effectiveness gains in imaging services. The diversity and scope of the research evidence can be strengthened through increased attention to the circumstances and mechanisms that contribute to the success (or otherwise) of CPOE and its contribution to the enhancement of patient care delivery.

Multiple perspectives on the impact of electronic ordering on hospital organisational and communication processes

Electronic ordering systems provide many potential benefits for improving the efficiency and effectiveness of healthcare delivery. They also have major implications for organisational and communication processes within hospitals. We undertook a qualitative study using focus groups and interviews with doctors, nurses, IT managers, and pathology laboratory managers to investigate the impact of the system on their work processes and relations within a major teaching hospital. This study revealed that the new electronic ordering system involved major alterations to the information management processes within the hospital, which in turn affected communication processes and work relations.

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.

The use and interpretation of quasi-experimental studies in medical informatics

Quasi-experimental study designs, often described as nonrandomized, pre-post intervention studies, are common in the medical informatics literature. Yet little has been written about the benefits and limitations of the quasi-experimental approach as applied to informatics studies. This paper outlines a relative hierarchy and nomenclature of quasi-experimental study designs that is applicable to medical informatics intervention studies. In addition, the authors performed a systematic review of two medical informatics journals, the Journal of the American Medical Informatics Association (JAMIA) and the International Journal of Medical Informatics (IJMI), to determine the number of quasi-experimental studies published and how the studies are classified on the above-mentioned relative hierarchy. They hope that future medical informatics studies will implement higher level quasi-experimental study designs that yield more convincing evidence for causal links between medical informatics interventions and outcomes.

Can evaluation studies benefit from triangulation? A case study

BACKGROUND

Information and communication technologies (ICTs) are increasingly being used in health care. Rigorous evaluations of ICT applications during both introduction and routine use are of great importance for decision makers and users. Within evaluation research, two main (and often rather distinct) traditions can be found: the objectivistic and the subjectivistic tradition.

METHODS

The theory of triangulation deals with the integration of methods and approaches as to conduct better evaluation studies. In evaluation research, triangulation in general means the multiple employment of various sources of data, observers, methods, and/or theories in investigations of the same phenomenon. We applied triangulation aspects in the analysis of the effects of a computer-based nursing documentation system.

RESULTS

We discuss, based on this case study, what benefits can be obtained from applying triangulation in an evaluation study. We show how both the validation of results and the completeness of results can be supported by triangulation.

DISCUSSION

The decision whether triangulation may be useful for a given research question, and how it may be correctly applied, requires-like other evaluation methods-intensive training and methodological experience. Medical informatics evaluation research may profit from this well-established theory.

Practice-based learning and improvement

Workplace learning is becoming increasingly important in all fields. While workplace learning in medicine, also called practice-based learning and improvement (PBLI) is not new, understanding how it works and how it fits with an individual physician's continuing professional development is new. In this article, we describe seven issues associated with PBLI and then pose questions for reflections, as continuing medical education (CME) planners consider working with PBLI.