Impact of computerised provider order entry on the quality and quantity of clinical information included with investigation requests: an interrupted time series analysis

INTRODUCTION

Relevant clinical information is vital to inform the analytical and interpretative phases of most investigations. The aim of this study is to evaluate the impact of implementation of computerised provider order entry (CPOE), featuring order-specific electronic order entry forms (eOEFs), on the quality and quantity of clinical information included with investigation requests.

METHODS

The CPOE module of a commercially available electronic health record (Cerner Millennium) was implemented at a large, tertiary care centre. The laboratory information management system was interrogated to collect data on specimens sent for microbiological culture 1 year before implementation of CPOE (2018), immediately post implementation (2019) and 6 months post implementation (2020). An interrupted time series analysis was performed, using text mining, to evaluate the quality and quantity of free-text clinical information.

RESULTS

In total, 39 919 specimens were collected from 16 458 patients. eOEFs were used to place 10 071 out of 13 735 orders in 2019 (73.3%), and 9155 out of 12 229 orders in 2020 (74.9%). No clinical details were included with 653 out of 39 919 specimens (1.6%), of which 22 (3.4%) were ordered using eOEFs. The median character count increased from 14 in 2018, to 41 in 2019, and 38 in 2020. An anti-infective agent was specified in 581 out of 13 955 requests (4.2%) in 2018; 5545 out of 13 735 requests (40.4%) in 2019; and 5215 out of 12 229 requests (42.6%) in 2020. Ciprofloxacin or piperacillin-tazobactam (Tazocin) were mentioned in the clinical details included with 421 out of 15 335 urine culture requests (2.7%), of which 406 (96.3%) were ordered using eOEFs. Subsequent detection of in vitro non-susceptibility led to a change in anti-infective therapy for five patients.

CONCLUSIONS

Implementation of CPOE, featuring order-specific eOEFs, significantly and sustainably improves the quality and quantity of clinical information included with investigation requests, resulting in changes to patient management that would not otherwise have occurred.

AIDH Summit 2022 - The effect of digitisation on the safe management of anticoagulants

BACKGROUND

Anticoagulants are high-risk medications and are a common cause of adverse events of hospitalised inpatients. The incidence of adverse events involving anticoagulants has remained relatively unchanged over the past two decades, suggesting novel approaches are required to address this persistent issue. Electronic medication management systems (eMMS) offer strategies to help reduce medication incidents and adverse drug events, yet poor system design can introduce new error types.

OBJECTIVE

To evaluate the effect of the introduction of an electronic medical record (EMR) on the quality and safety of therapeutic anticoagulation management.

METHODS

A retrospective, observational pre/post study was conducted, analysing real-world data across five hospital sites in a single health service. Four metrics were compared one year pre- and one year post-EMR implementation. They included clinician-reported medication incidents, toxic pathology results, hospital-acquired bleeding complications (HACs) and rate of heparin-induced thrombocytopenia. Further sub-analyses of patients experiencing HACs in the post-EMR period, identified key opportunities for intervention to maximise safety and quality of anticoagulation within an eMMS.

RESULTS

A significant reduction in HACs was observed in the post-EMR implementation period (mean (SD) =12.1 (4.4)/month, vs. mean (SD) =7.8 (3.5)/month; p=0.01). The categorisation of potential EMR design enhancements found that new automated clinical decision support or improved pathology result integration would be suitable to mitigate future HACs in an eMMS. There was no significant difference in the mean monthly clinician-reported incident rates for anticoagulants or the rate of toxic pathology results in the pre- versus post-EMR implementation period. A 62.5% reduction in the cases of heparin-induced thrombocytopenia were observed in the post-EMR implementation period.

CONCLUSION

The implementation of an EMR improves clinical care outcomes for patients receiving anticoagulation. System design plays a significant role in mitigating the risks associated with anticoagulants and consideration must be given to optimising eMMS.

International Council for Standardisation in Haematology (ICSH) recommendations for collection of blood samples for coagulation testing

This guidance document has been prepared on behalf of the International Council for Standardisation in Haematology (ICSH). The aim of the document is to provide guidance and recommendations for collection of blood samples for coagulation tests in clinical laboratories throughout the world. The following processes will be covered: ordering tests, sample collection tube and anticoagulant, patient preparation, sample collection device, venous stasis before sample collection, order of draw when different sample types need to be collected, sample labelling, blood-to-anticoagulant ratio (tube filling) and influence of haematocrit. The following areas are excluded from this document, but are included in an associated ICSH document addressing processing of samples for coagulation tests in clinical laboratories: sample transport and primary tube sample stability; centrifugation; interfering substances including haemolysis, icterus and lipaemia; secondary aliquots-transport and storage; and preanalytical variables for platelet function testing. The recommendations are based on published data in peer-reviewed literature and expert opinion.

Laboratory test ordering in inpatient hospitals: a systematic review on the effects and features of clinical decision support systems

Background

Studies have revealed inappropriate laboratory testing as a source of waste. This review aimed at evaluating the effects and features of CDSSs on physicians' appropriate laboratory test ordering in inpatient hospitals.

Method

Medline through PubMed, SCOPUS, Web of Science, and Cochrane were queried without any time period restriction. Studies using CDSSs as an intervention to improve laboratory test ordering as the primary aim were included. The study populations in the included studies were laboratory tests, physicians ordering laboratory tests, or the patients for whom laboratory tests were ordered. The included papers were evaluated for their outcomes related to the effect of CDSSs which were categorized based on the outcomes related to tests, physician, and patients. The primary outcome measures were the number and cost of the ordered laboratory tests. The instrument from The National Heart Lung and Blood Institute (NIH) was used to assess the quality of the included studies. Moreover, we applied a checklist for assessing the quality and features of the CDSSs presented in the included studies. A narrative synthesis was used to describe and compare the designs and the results of included studies.

Result

Sixteen studies met the inclusion criteria. Most studies were conducted based on a quasi-experimental design. The results showed improvement in laboratory test-related outcomes (e.g. proportion and cost of tests) and also physician-related outcomes (e.g. guideline adherence and orders cancellation). Patient-related outcomes (e.g. length of stay and mortality rate) were not well investigated in the included studies. In addition, the evidence about applying CDSS as a decision aid for interpreting laboratory results was rare.

Conclusion

CDSSs increase appropriate test ordering in hospitals through eliminating redundant test orders and enhancing evidence-based practice. Appropriate testing and cost saving were both affected by the CDSSs. However, the evidence is limited about the effects of laboratory test CDSSs on patient-related outcomes.

The efficiency and effectiveness of surgery information systems in Iran

Background

Despite the prevalent use and advantages of information systems in hospitals, some have failed to meet their predefined objectives. Surgery information system (SIS) is a sub-system of a hospital information system. Its effective and efficient operation could enhance patient care in the busy environment of operating rooms with multiple tasks. The objective of this study was to evaluate the effectiveness and efficiency of SIS in three educational hospitals.

Methods

Data were collected using a questionnaire completed by 82 users of SIS. This questionnaire contains three parts: 1) participants’ demographic information, 2) questions regarding the efficiency of SIS, and 3) questions about its effectiveness. An independent sample t-test was used to compare the efficiency and effectiveness among systems. Chi-squared and Fisher tests were used to determine the relationship between the participants’ demographics and efficiency and effectiveness as well as the relationship between efficiency and effectiveness.

Results

About 23% of the participants rated the system’s efficiency as low, 29% as medium, and 48% as high. Besides, 24% of the participants considered the effectiveness of the system as low, 31% as medium, and 45% as high. There was a significant correlation between the efficiency and effectiveness of SIS (p ≤ 0.0001).

Conclusion

Based on the perspective of most participants (44%)the efficiency and effectiveness of both surgery information systems were acceptable. The results suggest that these systems should be designed in a way that facilitate user’s interaction and reduce the time takes to complete tasks. The results could be useful for developing and designing an efficient and effective system.

Interventions designed to improve the safety and quality of therapeutic anticoagulation in an inpatient electronic medical record

IMPORTANCE

Anticoagulants are high-risk medications with the potential to cause significant patient harm or death. Digital transformation is occurring in hospital practice and it is essential to implement effective, evidence-based strategies for these medications in an electronic medical record (EMR).

OBJECTIVE

To systematically appraise the literature to determine which EMR interventions have improved the safety and quality of therapeutic anticoagulation in an inpatient hospital setting.

METHODS

PubMed, Embase, CINAHL, and the International Pharmaceutical Database were searched for suitable publications. Articles that met eligibility criteria up to September 2018 were included. The review was registered with PROSPERO (CRD42018104899). The web-based software platform Covidence® was used for screening and data extraction. Studies were grouped according to the type of intervention and the outcomes measured. Where relevant, a bias assessment was performed.

RESULTS

We found 2624 candidate articles and 27 met inclusion criteria. They included 3 randomised controlled trials, 4 cohort studies and 20 pre/post observational studies. There were four major interventions; computerised physician order entry (CPOE) (n = 4 studies), clinical decision support system (CDSS) methods (n = 21), dashboard utilisation (n = 1) and EMR implementation in general (n = 1). Seven outcomes were used to summarise the study results. Most research focused on prescribing or documentation compliance (n = 18). The remaining study outcome measures were: medication errors (n = 9), adverse drug events (n = 5), patient outcomes (morbidity/mortality/length of hospital stay/re-hospitalisation) (n = 5), quality use of anticoagulant (n = 4), end-user acceptance (n = 4), cost effectiveness (n = 1).

CONCLUSION

Despite the research cited, limited benefits have been demonstrated to date. It appears healthcare organisations are yet to determine optimal, evidence-based-methods to improve EMR utilisation. Further evaluation, collaboration and work are necessary to measure and leverage the potential benefits of digital health systems. Most research evaluating therapeutic anticoagulation management within an EMR focused on prescribing or documentation compliance, with less focus on clinical impact to the patient or cost effectiveness. Evidence suggests that CPOE in conjunction with CDSS is needed to effectively manage therapeutic anticoagulation. Targets for robust research include the integration of 'stealth' alerts, nomograms into digital systems and the use of dashboards within clinical practice.

The usability aspects of medication-related decision support systems in the inpatient setting: A systematic review

Effort has been made to study the effect of medication-related clinical decision support systems in the inpatient setting; however, there is not much known about the usability of these systems. The goal of this study is to systematically review studies that focused on the usability aspects such as effectiveness, efficiency, and satisfaction of these systems. We systematically searched relevant articles in Scopus, Embase, and PubMed from 1 January 2000 to 1 January 2016, and found 22 articles. Based on Van Welie’s usability model, we categorized usability aspects in terms of usage indicators and means. Our results showed that evidence was mainly found for effectiveness and efficiency. They showed positive results in the usage indicators errors and safety and performance speed. The means warnings and adaptability also had mostly positive results. To date, the effects satisfaction of clinical decision support system remains understudied. Aspects such as memorability, learnability, and consistency require more attention.

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.

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.

Optimization of vitamin K antagonist drug dose finding by replacement of the international normalized ratio by a bidirectional factor: validation of a new algorithm

ESSENTIALS: We developed a new algorithm to optimize vitamin K antagonist dose finding. Validation was by comparing actual dosing to algorithm predictions. Predicted and actual dosing of well performing centers were highly associated. The method is promising and should be tested in a randomized trial.

SUMMARY

BACKGROUND

Oral vitamin K antagonists (VKAs) have a narrow therapeutic window and thus require frequent monitoring of its intensity by the international normalized ratio (INR). Improvement of VKA dosing defined as more time in therapeutic range (TTR) can reduce thrombotic disease and bleeding. Computerized decision support programs (CDSs) are used to optimize VKA dosing, but the effects are heterogeneous. CDSs significantly improve the proportion of time in the therapeutic INR range for initiation therapy but not the quality of anticoagulant management in an outpatient setting. One of the major problems of VKA dose finding is that the INR is a ratio and does not present linearity. We developed a new dose-finding algorithm, based on a novel bidirectional factor (BF). This BF is linear transformation of the nonlinear INR.

METHODS

We compared the outcomes of the new algorithm, called BF-N, with dose finding performed at three highly ranked Dutch anticoagulation centers, using both acenocoumarol and phenprocoumon.

RESULTS

The outcomes of the BF-N algorithm showed a linear correlation with VKA doses of the three centers (y = 1.001x, r(2) 0.999 for acenocoumarol and y = 0.999x, r(2) 0.999 for phenprocoumon), with a standard deviation of 3.83%. The rate of automated dosage proposals increased to 100%.

CONCLUSION

The BF-N algorithm performs well in real-life settings and increases the rate of automated dosage proposals. The algorithm can be easily built into existing CDSs. Experienced staff remains necessary for complicated situations. The new algorithm needs to be evaluated in a prospective trial.

Pathologists as Stewards of Laboratory Information

Just as electronic health records are transforming the practice of medicine and health care information management, practicing in the era of the electronic health record offers opportunities, if not imperatives, for pathologists to take on new and “transformative” professional and leadership roles for the organizations they serve. Experience indicates that clinicians will perceive pathologists and laboratories as responsible for all aspects of laboratory testing and information management, including order entry and results reporting, even though such functions may fall beyond the control of the laboratory. As described and expanded upon in the previous 4 articles of this series, the use of electronic health records dictates changes in how clinicians interact with laboratory information. In this environment, pathologists are uniquely positioned to act as the stewards for laboratory information in electronic health records and throughout health care organizations.