Impact of a computerized physician order-entry system

Understanding the impacts of health information systems on patient flow management: A systematic review across several decades of research

Background

Patient flow describes the progression of patients along a pathway of care such as the journey from hospital inpatient admission to discharge. Poor patient flow has detrimental effects on health outcomes, patient satisfaction and hospital revenue. There has been an increasing adoption of health information systems (HISs) in various healthcare settings to address patient flow issues, yet there remains limited evidence of their overall impacts.

Objective

To systematically review evidence on the impacts of HISs on patient flow management including what HISs have been used, their application scope, features, and what aspects of patient flow are affected by the HIS adoption.

Methods

A systematic search for English-language, peer-review literature indexed in MEDLINE and EMBASE, CINAHL, INSPEC, and ACM Digital Library from the earliest date available to February 2022 was conducted. Two authors independently scanned the search results for eligible publications, and reporting followed the PRISMA guidelines. Eligibility criteria included studies that reported impacts of HIS on patient flow outcomes. Information on the study design, type of HIS, key features and impacts was extracted and analysed using an analytical framework which was based on domain-expert opinions and literature review.

Results

Overall, 5996 titles were identified, with 44 eligible studies, across 17 types of HIS. 22 studies (50%) focused on patient flow in the department level such as emergency department while 18 studies (41%) focused on hospital-wide level and four studies (9%) investigated network-wide HIS. Process outcomes with time-related measures such as ‘length of stay’ and ‘waiting time’ were investigated in most of the studies. In addition, HISs were found to address flow problems by identifying blockages, streamlining care processes and improving care coordination.

Conclusion

HIS affected various aspects of patient flow at different levels of care; however, how and why they delivered the impacts require further research.

Patient-Generated Health Data in Surgical Site Infection: Changing Clinical Workflow and Care Delivery

Background: The patient's history of present illness provides an important part of the data with which clinicians diagnose and treat. Once surgical patients are discharged, the ability to incorporate direct observation requires coordinating patient and provider for a clinical visit. Mobile technologies offer the ability to gather and organize the patient's history, supplement that history with photographs and other clinical observations, and convey those data accurately and rapidly to the entire clinical team. Methods: We review our experience with patient-generated health data in surgical site infection, draw parallels with similar work in other domains, and identify principles we have found useful. Results: Health information system implementations require substantial changes in provider workflow. Shared expectations between the patient and the surgical team, an incremental approach to change in clinical processes, and an emphasis on clinical utility all support successful implementation. Conclusions: The data collection and rapid information exchange afforded by monitoring post-operative, post-discharge patients using mobile technologies can support the expectations of both patients and providers and may provide a novel data source for public health surveillance of surgical site infection. Both uses of these data require careful attention to introducing changes in clinical workflow.

Treatment of Hyperkalemia With a Low-Dose Insulin Protocol Is Effective and Results in Reduced Hypoglycemia

Introduction

Complications associated with insulin treatment for hyperkalemia are serious and common. We hypothesize that, in chronic kidney disease (CKD) and end-stage renal disease (ESRD), giving 5 units instead of 10 units of i.v. regular insulin may reduce the risk of causing hypoglycemia when treating hyperkalemia.

Methods

A retrospective quality improvement study on hyperkalemia management (K⁺ ≥ 6 mEq/l) from June 2013 through December 2013 was conducted at an urban emergency department center. Electronic medical records were reviewed, and data were extracted on presentation, management of hyperkalemia, incidence and timing of hypoglycemia, and whether treatment was ordered as a protocol through computerized physician order entry (CPOE). We evaluated whether an educational effort to encourage the use of a protocol through CPOE that suggests the use of 5 units might be beneficial for CKD/ESRD patients. A second audit of hyperkalemia management from July 2015 through January 2016 was conducted to assess the effects of intervention on hypoglycemia incidence.

Results

Treatments ordered using a protocol for hyperkalemia increased following the educational intervention (58 of 78 patients [74%] vs. 62 of 99 patients [62%]), and the number of CKD/ESRD patients prescribed 5 units of insulin as per protocol increased (30 of 32 patients [93%] vs. 32 of 43 [75%], P = .03). Associated with this, the incidence of hypoglycemia associated with insulin treatment was lower (7 of 63 patients [11%] vs. 22 of 76 patients [28%], P = .03), and there were no cases of severe hypoglycemia compared to the 3 cases before the intervention.

Conclusion

Education on the use of a protocol for hyperkalemia resulted in a reduction in the number of patients with severe hypoglycemia associated with insulin treatment.

Effects of computerized physician order entry on medication turnaround time and orders requiring pharmacist intervention

BACKGROUND

Previous studies have demonstrated that computerized physician order entry (CPOE) of prescriptions reduces both turnaround time (TAT) and medication errors. However, these studies have been performed primarily in large academic centers with a relatively small number of medication orders. As such, many studies investigating the impact of CPOE on the level of pharmacist intervention have yielded conflicting results.

OBJECTIVE

The objective of this study was to examine the effects of CPOE on medication order TAT and the frequency of medication orders requiring pharmacist intervention in a community-based medical center.

METHODS

A prospective cohort study was conducted at a community-based medical center. A total of 24,767 prescriptions written for 940 patients over a six-month period were stratified into CPOE or non-CPOE (handwritten) cohorts. TAT between cohorts were tested using analysis of variance and Tukey's Honestly Significant Difference test. The number of orders requiring pharmacist intervention was compared between cohorts and tested using chi-square test or Fisher's exact test. Medication orders requiring pharmacist intervention were stratified by patient characteristics, therapeutic class, and types of medication error.

RESULTS

Medication orders not using CPOE were approximately 8 times more likely to require pharmacist intervention (2.26% versus 0.29%; P < 0.001), with the majority of pharmacist interventions performed to prevent medication errors. The overall mean TAT for medication orders was significantly shorter in the CPOE group in comparison with the non-CPOE group (22.2 ± 86.5 min versus 81 ± 256.7 min; P < 0.001). CPOE orders nearly eliminated medication errors with wrong dosage forms and formulary issues.

CONCLUSIONS

Medication orders entered via CPOE are associated with a significant reduction in medication TAT and less likely to require pharmacist intervention. Use of CPOE may improve quality of patient care and efficiency of health care delivery.

A theoretical approach to electronic prescription system: lesson learned from literature review

CONTEXT

The tendency to use advanced technology in healthcare and the governmental policies have put forward electronic prescription. Electronic prescription is considered as the main solution to overcome the major drawbacks of the paper-based medication prescription, such as transcription errors. This study aims to provide practical information concerning electronic prescription system to a variety of stakeholders.

EVIDENCE ACQUISITION

In this review study, PubMed, ISI Web of Science, Scopus, EMBASE databases, Iranian National Library Of Medicine (INLM) portal, Google Scholar, Google and Yahoo were searched for relevant English publications concerning the problems of paper-based prescription, and concept, features, levels, benefits, stakeholders and standards of electronic prescription system.

RESULTS

There are many problems with the paper prescription system which, according to studies have jeopardized patients' safety and negatively affected the outcomes of medication therapy. All of these problems are remedied through the implementation of e-prescriptions.

CONCLUSIONS

The sophistication of electronic prescription and integration with EHR will become a reality, if all its stakeholders collaborate in developing fast and secure electronic prescription systems. It is plausible that the required infrastructure should be provided for implementation of the national integrated electronic prescription systems in countries without the system. Given the barriers to the implementation and use, policymakers should consider multiple strategies and offer incentives to encourage e-prescription initiatives. This will result in widespread adoption of the system.

Return on investment for vendor computerized physician order entry in four community hospitals: the importance of decision support

BACKGROUND

In-hospital adverse events are a major cause of morbidity and mortality and represent a major cost burden to health care systems. A study was conducted to evaluate the return on investment (ROI) for the adoption of vendor-developed computerized physician oder entry (CPOE) systems in four community hospitals in Massachusetts.

METHODS

Of the four hospitals, two were under one management structure and implemented the same vendor-developed CPOE system (Hospital Group A), while the other two were under a second management structure and implemented another vendor-developed CPOE system (Hospital Group B). Cost savings were calculated on the basis of reduction in preventable adverse drug event (ADE) rates as measured previously. ROI, net cash flow, and the breakeven point during a 10-year cost-and-benefit model were calculated. At the time of the study, none of the participating hospitals had implemented more than a rudimentary decision support system together with CPOE.

RESULTS

Implementation costs were lower for Hospital Group A than B ($7,130,894 total or $83/admission versus $19,293,379 total or $113/admission, respectively), as were preventable ADE-related avoided costs ($7,937,651 and $16,557,056, respectively). A cost-benefit analysis demonstrated that Hospital Group A had an ROI of 11.3%, breaking even on the investment eight years following implementation. Hospital Group B showed a negative return, with an ROI of -3.1%.

CONCLUSIONS

Adoption of vendor CPOE systems in community hospitals was associated with a modest ROI at best when applying cost savings attributable to prevention of ADEs only. The modest financial returns can beattributed to the lack of clinical decision support tools.

Computer Physician Order Entry (CPOE)

In an effort to reduce Adverse Drug Events (ADEs) and to improve patient safety, funding has been earmarked to improve the rate of adoption of Computerized Physician Order Entry (CPOE) among healthcare providers. It has been shown that the ordering stage of medications is where most medication errors and preventable ADEs occur. The purpose of this study was to examine the implementation CPOE systems in hospitals to determine benefits and concerns of this technology in the United States healthcare system. A review of the literature published in the last 13 years (since 2000) in the English language was performed to complete this investigation. CPOE has emerged as a valuable tool to improve medical efficiency and to decrease medication errors and ADEs. Efficiencies were found to reduce the overall workload of nurses, clerical workers and pharmacists. CPOE has proven to be a secure way of transferring physician orders electronically thus helping hospitals and physicians practice a more effective and better quality of care with less medical errors which has led to decreased operating expenses. While barriers such as lack of professional buy in, and cost of implementation have hindered the widespread use and growth of CPOE systems, these barriers are being overcome with the financial incentives from the HITECH Act, and with the increased savings of CPOE implementation, which may motivate more healthcare systems to adopt CPOE.

Characteristics of CPOE systems and obstacles to implementation that physicians believe will affect adoption

BACKGROUND

Computerized Physician Order Entry (CPOE) has the potential to decrease medical errors and improve quality. Our health system plans to implement CPOE in response to the ARRA HITECH Act.

OBJECTIVES

To determine (A) physicians' projections of the most important characteristics of a CPOE system that will affect their willingness to adopt CPOE, and (B) the obstacles they foresee in adopting CPOE.

METHODS

All members of our health system's physician quality organization were invited to participate in a confidential survey.

RESULTS

Two hundred twenty-four of 549 (41%) recipients responded to the survey. Respondents ranked "disruption in my work routine" (72%) and "improve efficiency in placing orders" (63%) as the two most important characteristics that would affect their utilization of CPOE. They believed CPOE would enable orders to be placed more efficiently (3.3, sd = 1.2), carried out rapidly (3.4, sd = 0.9), and have fewer errors (3.7, sd = 0.9). The most commonly cited obstacles to CPOE implementation were: Efficiency-Inefficiency (23%), Hardware Availability (12.7%), Computer Restrictions (10.8%), Training (8.8%), Simplicity - Ease of Use (8.5%), and Physician Buy-in (8.1%).

CONCLUSIONS

The majority of physicians believed CPOE would lead to a reduction of medical errors and more efficient patient care. However, physicians are highly concerned with how CPOE will affect their own work efficiency.

The economics of health information technology in medication management: a systematic review of economic evaluations

OBJECTIVE

To conduct a systematic review and synthesis of the evidence surrounding the cost-effectiveness of health information technology (HIT) in the medication process.

MATERIALS AND METHODS

Peer-reviewed electronic databases and gray literature were searched to identify studies on HIT used to assist in the medication management process. Articles including an economic component were reviewed for further screening. For this review, full cost-effectiveness analyses, cost-utility analyses and cost-benefit analyses, as well as cost analyses, were eligible for inclusion and synthesis.

RESULTS

The 31 studies included were heterogeneous with respect to the HIT evaluated, setting, and economic methods used. Thus the data could not be synthesized, and a narrative review was conducted. Most studies evaluated computer decision support systems in hospital settings in the USA, and only five of the studied performed full economic evaluations.

DISCUSSION

Most studies merely provided cost data; however, useful economic data involves far more input. A full economic evaluation includes a full enumeration of the costs, synthesized with the outcomes of the intervention.

CONCLUSION

The quality of the economic literature in this area is poor. A few studies found that HIT may offer cost advantages despite their increased acquisition costs. However, given the uncertainty that surrounds the costs and outcomes data, and limited study designs, it is difficult to reach any definitive conclusion as to whether the additional costs and benefits represent value for money. Sophisticated concurrent prospective economic evaluations need to be conducted to address whether HIT interventions in the medication management process are cost-effective.

Lean analysis of a pediatric intensive care unit physician group rounding process to identify inefficiencies and opportunities for improvement

OBJECTIVE

A physician group in a pediatric intensive care unit faced challenges when moving to a larger unit. Challenges included increased time for rounds, nonbillable attending physician hours, poor communication with pediatric intensive care unit staff, and meeting resident physician duty hours and teaching requirements. The purpose of this analysis was to identify waste and opportunities for improvement to improve physician efficiency.

DESIGN

Human factor (observational data collection) techniques were used to capture >60 hrs of rounding data. Twelve attending physicians and their rounding teams were shadowed to capture rounds on 130 pediatric intensive care unit patients. Rounding events, times, and patient interactions were recorded. Lean methods and scenario analysis were used to analyze the data and identify opportunities for improvement. Rounding events were categorized to determine value-added and nonvalue-added activities. Value-added activities were subclassified as essential or nonessential to morning rounds.

SETTING

Thirty-bed pediatric intensive care unit in a children's hospital with academic affiliation. PATIENTS OR SUBJECTS: Eight attending pediatric intensivists and their physician rounding teams.

INTERVENTIONS

Eight attending physician-led rounding teams were observed for 12 rounding events and a total of 130 patient contacts.

MEASUREMENTS AND MAIN RESULTS

Large variation existed in the rounding process. Nonessential activities was highly correlated with physician preference and created a wide range in rounding time per patient. Essential activities showed the least variation and represents a "lean process." Scenario analysis was used to determine the impact of removing waste and reallocating the nonessential activities outside of rounds. Results of the analysis indicated that rounds could be reduced by 42% and that plan of care completion would be timelier (decreased from a mean of 157 to 82 mins).

CONCLUSIONS

In a large physician group, essential activities showed the least variation. Practice variation focused on minimizing nonessential activities could have dramatic impacts on standardizing practice. Further study is indicated to determine whether standardizing rounds to focus on essential activities can lead to more effective processes that require fewer resources while improving outcomes for all stakeholders.

Electronic prescribing reduces prescribing error in public hospitals

AIMS AND OBJECTIVES

To examine the incidence of prescribing errors in a main public hospital in Pakistan and to assess the impact of introducing electronic prescribing system on the reduction of their incidence.

BACKGROUND

Medication errors are persistent in today's healthcare system. The impact of electronic prescribing on reducing errors has not been tested in developing world.

DESIGN

Prospective review of medication and discharge medication charts before and after the introduction of an electronic inpatient record and prescribing system.

METHODS

Inpatient records (n = 3300) and 1100 discharge medication sheets were reviewed for prescribing errors before and after the installation of electronic prescribing system in 11 wards.

RESULTS

Medications (13,328 and 14,064) were prescribed for inpatients, among which 3008 and 1147 prescribing errors were identified, giving an overall error rate of 22·6% and 8·2% throughout paper-based and electronic prescribing, respectively. Medications (2480 and 2790) were prescribed for discharge patients, among which 418 and 123 errors were detected, giving an overall error rate of 16·9% and 4·4% during paper-based and electronic prescribing, respectively.

CONCLUSION

Electronic prescribing has a significant effect on the reduction of prescribing errors.

RELEVANCE TO CLINICAL PRACTICE

Prescribing errors are commonplace in Pakistan public hospitals. The study evaluated the impact of introducing electronic inpatient records and electronic prescribing in the reduction of prescribing errors in a public hospital in Pakistan.