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

Decision Support Tools within the Electronic Health Record

Laboratory tests are an integral part of the electronic health record (EHR). Providing clinical decision support (CDS) for the ordering, collection, reporting, viewing, and interpretation of laboratory testing is a fundamental function of the EHR. The implementation of a sustainable, effective laboratory CDS program requires a commitment to standardization and harmonization of the laboratory dictionaries that are the foundation of laboratory-based CDS. In this review, the authors provide an overview of the tools available within the EHR to improve decision making throughout the entire laboratory testing process, from test order to clinical action.

Reducing pediatric asthma hospital length of stay through evidence-based quality improvement and deployment of computerized provider order entry

Objective: Evaluate the impact of multi-component quality improvement for pediatric asthma care focusing on serial use of an evidence-based clinical pathway via paper order sets, pathway integration into computerized provider order entry (CPOE), use of a clinical respiratory score (CRS) and a discharge checklist. Methods: Outcomes were assessed over three intervention periods and 50 months on: time to beta-agonist and steroid first administration, frequency of readmissions and hospital length of stay. A general linear model estimated mean log(LOS) over time and between study periods. Time to discharge was transformed using the natural logarithm. Results: No improvements in time to first beta-agonist or steroid administration were observed. There was a reduction in 100-day readmissions (p = 0.008): decreasing from 7.4 to 2.1% after introduction of paper order sets and CRS (adjusted p = 0.04); to 3.9% after CPOE implementation (adjusted p = 0.53) and to 2.2% when a discharge checklist was added (adjusted p = 0.01). There was a statistically significant reduction in LOS between study periods (p = 0.015). The geometric mean LOS in hours during study periods 1-4 were: 34.8 (95% CI: 32.2, 37.6), 29.3 (95% CI: 27.5, 31.3), 29.0 (95% CI: 27.0, 31.3) and 23.1 (95% CI: 22.1, 24.2). Pair-wise comparisons between periods were statistically significant (adjusted p ≤ 0.003), except for Periods 2 and 3 (adjusted p = 0.83). Conclusions: Hospital length of stay and 100-day readmissions rate in a predominantly Hispanic, Medicaid patient population were reduced by utilization of an evidence-based best practices asthma management pathway and CRS within CPOE, combined with a checklist to expedite discharge.

Personalization and Patient Involvement in Decision Support Systems: Current Trends

OBJECTIVES

This survey aims at highlighting the latest trends (2012-2014) on the development, use, and evaluation of Information and Communication Technologies (ICT) based decision support systems (DSSs) in medicine, with a particular focus on patient-centered and personalized care.

METHODS

We considered papers published on scientific journals, by querying PubMed and Web of ScienceTM. Included studies focused on the implementation or evaluation of ICT-based tools used in clinical practice. A separate search was performed on computerized physician order entry systems (CPOEs), since they are increasingly embedding patient-tailored decision support.

RESULTS

We found 73 papers on DSSs (53 on specific ICT tools) and 72 papers on CPOEs. Although decision support through the delivery of recommendations is frequent (28/53 papers), our review highlighted also DSSs only based on efficient information presentation (25/53). Patient participation in making decisions is still limited (9/53), and mostly focused on risk communication. The most represented medical area is cancer (12%). Policy makers are beginning to be included among stakeholders (6/73), but integration with hospital information systems is still low. Concerning knowledge representation/management issues, we identified a trend towards building inference engines on top of standard data models. Most of the tools (57%) underwent a formal assessment study, even if half of them aimed at evaluating usability and not effectiveness.

CONCLUSIONS

Overall, we have noticed interesting evolutions of medical DSSs to improve communication with the patient, consider the economic and organizational impact, and use standard models for knowledge representation. However, systems focusing on patient-centered care still do not seem to be available at large.

Removing Cerebrospinal Fluid Antibody Orders from the Test Menu Results in a Dramatic Decrease in Order Volume

BACKGROUND

Antibody tests for Borrelia burgdorferi (agent of Lyme disease), Toxoplasma gondii, and cytomegalovirus in cerebrospinal fluid (CSF) are rarely useful. One reason for misutilization of laboratory tests is simply the convenience offered by a computerized physician order entry (CPOE) system.

METHODS

The cytomegalovirus (CMV) antibodies-CSF, B. burgdorferi antibodies-CSF, and T. gondii antibodies-CSF orders were removed from the test menu. A provider could still order these tests using a miscellaneous order. We collected monthly volumes of test orders before and after the tests were removed from the CPOE.

RESULTS

Orders for CSF antibody testing for B. burgdorferi, T. gondii, and CMV decreased by 91%, 93%, and 98%, respectively (P < 0.01), after they were removed from the CPOE test menu. This result correlates to a savings of $50053.44 per year. Additionally, we did not see a paradoxical increase in CMV PCR or T. gondii PCR orders after the intervention.

CONCLUSIONS

Removal of test orders from the CPOE dramatically decreased test order volume, which led to substantial cost savings and availability of CSF for more useful tests. There was no compensatory increase in order volume for related tests, indicating that providers were not looking for alternate tests.

The Impact of Order Source Misattribution on Computerized Provider Order Entry (CPOE) Performance Metrics

BACKGROUND

One strategy to foster adoption of computerized provider order entry (CPOE) by physicians is the monthly distribution of a list identifying the number and use rate percentage of orders entered electronically versus on paper by each physician in the facility. Physicians care about CPOE use rate reports because they support the patient safety and quality improvement objectives of CPOE implementation. Certain physician groups are also motivated because they participate in contracted financial and performance arrangements that include incentive payments or financial penalties for meeting (or failing to meet) a specified CPOE use rate target. Misattribution of order sources can hinder accurate measurement of individual physician CPOE use and can thereby undermine providers' confidence in their reported performance, as well as their motivation to utilize CPOE. Misattribution of order sources also has significant patient safety, quality, and medicolegal implications.

OBJECTIVE

This analysis sought to evaluate the magnitude and sources of misattribution among hospitalists with high CPOE use and, if misattribution was found, to formulate strategies to prevent and reduce its recurrence, thereby ensuring the integrity and credibility of individual and facility CPOE use rate reporting.

METHODS

A detailed manual order source review and validation of all orders issued by one hospitalist group at a midsize community hospital was conducted for a one-month study period.

RESULTS

We found that a small but not dismissible percentage of orders issued by hospitalists-up to 4.18 percent (95 percent confidence interval, 3.84-4.56 percent) per month-were attributed inaccurately. Sources of misattribution by department or function were as follows: nursing, 42 percent; pharmacy, 38 percent; laboratory, 15 percent; unit clerk, 3 percent; and radiology, 2 percent. Order management and protocol were the most common correct order sources that were incorrectly attributed.

CONCLUSION

Order source misattribution can negatively affect reported provider CPOE use rates and should be investigated if providers perceive discrepancies between reported rates and their actual performance. Preventive education and communication efforts across departments can help prevent and reduce misattribution.

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.

Improving Bridging from Informatics Practice to Theory

BACKGROUND

In 1962, Methods of Information in Medicine ( MIM ) began to publish papers on the methodology and scientific fundamentals of organizing, representing, and analyzing data, information, and knowledge in biomedicine and health care. Considered a companion journal, Applied Clinical Informatics ( ACI ) was launched in 2009 with a mission to establish a platform that allows sharing of knowledge between clinical medicine and health IT specialists as well as to bridge gaps between visionary design and successful and pragmatic deployment of clinical information systems. Both journals are official journals of the International Medical Informatics Association.

OBJECTIVES

As a follow-up to prior work, we set out to explore congruencies and interdependencies in publications of ACI and MIM. The objectives were to describe the major topics discussed in articles published in ACI in 2014 and to determine if there was evidence that theory in 2014 MIM publications was informed by practice described in ACI publications in any year. We also set out to describe lessons learned in the context of bridging informatics practice and theory and offer opinions on how ACI editorial policies could evolve to foster and improve such bridging.

METHODS

We conducted a retrospective observational study and reviewed all articles published in ACI during the calendar year 2014 (Volume 5) for their main theme, conclusions, and key words. We then reviewed the citations of all MIM papers from 2014 to determine if there were references to ACI articles from any year. Lessons learned in the context of bridging informatics practice and theory and opinions on ACI editorial policies were developed by consensus among the two authors.

RESULTS

A total of 70 articles were published in ACI in 2014. Clinical decision support, clinical documentation, usability, Meaningful Use, health information exchange, patient portals, and clinical research informatics emerged as major themes. Only one MIM article from 2014 cited an ACI article. There are several lessons learned including the possibility that there may not be direct links between MIM theory and ACI practice articles. ACI editorial policies will continue to evolve to reflect the breadth and depth of the practice of clinical informatics and articles received for publication. Efforts to encourage bridging of informatics practice and theory may be considered by the ACI editors.

CONCLUSIONS

The lack of direct links from informatics theory-based papers published in MIM in 2014 to papers published in ACI continues as was described for papers published during 2012 to 2013 in the two companion journals. Thus, there is little evidence that theory in MIM has been informed by practice in ACI.