Computerized Physician Order Entry System Research Articles

Implementation of a neonatal pain management module in the computerized physician order entry system

BackgroundDespite the recommended guidelines, the neonatal management of pain and discomfort often remains inadequate. The purpose of the present study was to determine whether adding a pain and discomfort module to a computerized physician order entry (CPOE) system would improve pain and discomfort evaluation in premature newborns under invasive ventilation.MethodsAll newborns <37 weeks gestational age (GA) and requiring invasive ventilation were included in a prospective study during two 6-month periods: before and after the inclusion of the pain and discomfort evaluation module. The main outcome measure was the percentage of patients having at least one assessment of pain and discomfort per day of invasive ventilation using the COMFORT scale.ResultsA total of 122 patients were included: 53 before and 69 after the incorporation of the module. The mean age was 30 (3) weeks GA. After the module was included, the percentage of patients who benefited from at least one pain and discomfort assessment per day increased from 64% to 88% (p < 0.01), and the mean number (SD) of scores recorded per day increased from 1 (1) to 3 (1) (p < 0.01). When the score was not within the established range, the nursing staff adapted analgesia/sedation doses more frequently after module inclusion (53% vs. 34%, p < 0.001). Despite higher mean doses of midazolam after module introduction [47 (45) vs. 31 (18) μg/kg/hr, p < 0.05], the durations of invasive ventilation and hospital stay, and the number of nosocomial infections, were not significantly modified.ConclusionsAdding a pain and discomfort tool to the CPOE system was a simple and effective way to improve the systematic evaluation of premature newborns who required ventilatory assistance.

Identification and weighting of the most critical “real-life” drug–drug interactions with acenocoumarol in a tertiary care hospital

The objective of this study was to identify the most clinically relevant drug-drug interactions (DDIs) at risk of affecting acenocoumarol safety in our tertiary care university hospital, a 2,000 bed institution. We identified DDIs occurring with acenocoumarol by combining two different sources of information: a 1-year retrospective analysis of acenocoumarol prescriptions and comedications from our Computerized Physician Order Entry (CPOE) system (n = 2,439 hospitalizations) and a retrospective study of clinical pharmacology consultations involving acenocoumarol over the past 14 years (1994-2007) (n = 407). We classified these DDIs using an original risk-analysis method. A criticality index was calculated for each associated drug by multiplying three scores based on mechanism of interaction, involvement in a supratherapeutic international normalized ratio (INR) (≥ 6) and involvement in a severe bleeding. One hundred and twenty-six DDIs were identified and weighted. Twenty-eight drugs had a criticality index ≥ 20 and were therefore considered at high risk for interacting with acenocoumarol by increasing its effect: 75% of these drugs involved a pharmacokinetic mechanism and 14 % a pharmacodynamic mechanism. An unknown mechanism of interaction was involved in 11 % of drugs. Twenty-eight specific drugs were identified as being at high risk for interacting with acenocoumarol in our hospital using an original risk-analysis method. Most analyzed drugs interact with acenocoumarol via a pharmacokinetic mechanism. Actions such as the implementation of alerts in our CPOE system should be specifically developed for these drugs.

A review of hospital characteristics associated with improved performance

The objective of this review was to critically appraise the literature relating to associations between high-level structural and operational hospital characteristics and improved performance. The Cochrane Library, MEDLINE (Ovid), CINAHL, proQuest and PsychINFO were searched for articles published between January 1996 and May 2010. Reference lists of included articles were reviewed and key journals were hand searched for relevant articles. and data extraction Studies were included if they were systematic reviews or meta-analyses, randomized controlled trials, controlled before and after studies or observational studies (cohort and cross-sectional) that were multicentre, comparative performance studies. Two reviewers independently extracted data, assigned grades of evidence according to the Australian National Health and Medical Research Council guidelines and critically appraised the included articles. Data synthesis Fifty-seven studies were reported within 12 systematic reviews and 47 observational articles. There was heterogeneity in use and definition of performance outcomes. Hospital characteristics investigated were environment (incentives, market characteristics), structure (network membership, ownership, teaching status, geographical setting, service size) and operational design (innovativeness, leadership, organizational culture, public reporting and patient safety practices, information technology systems and decision support, service activity and planning, workforce design, staff training and education). The strongest evidence for an association with overall performance was identified for computerized physician order entry systems. Some evidence supported the associations with workforce design, use of financial incentives, nursing leadership and hospital volume. There is limited, mainly low-quality evidence, supporting the associations between hospital characteristics and healthcare performance. Further characteristic-specific systematic reviews are indicated.

Clinical Decision Support Systems to Improve Utilization of Thromboprophylaxis: A Review of the Literature and Experience with Implementation of a Computerized Physician Order Entry Program

Objective: A literature review was conducted of studies investigating the effectiveness of paper- and computer-based clinical decision support systems (CDSS) used with or without educational programs designed to increase the use of venous thromboembolism (VTE) prophylaxis. Methods: Medline was searched on August 9, 2010, without limits on publication year, but with restrictions to English-language articles only. The search terms used were “venous thromboembolism,” “deep vein thrombosis,” “pulmonary embolism,” “prophylaxis,” “thromboprophylaxis,” “computerized,” “computerised,” “decision support,” “alerts,” “reminder,” “paper system,” “risk assessment,” and “risk score.” All types of studies regarding the effects of CDSS on VTE prophylaxis rates were included. Studies were included if ≥ 1 post-implementation outcome was measured, such as rates of VTE, rates of prophylaxis prescribing, or guideline-adherence measures. Results: Studies evaluating paper-based CDSS used different strategies, including risk-assessment forms with prophylaxis recommendations, standard order sets, and preprinted sticker reminders on patient notes. Paper-based systems consistently improved prophylaxis rates; however, in most studies, there was still room for improvement. Furthermore, the effect of paper-based CDSS on VTE rates was not conclusively established. Studies evaluating computer-based systems used approaches including risk-assessment models integrated in the computerized physician order entry system, with or without alerts, and automatic reminders on operating schedules. Conclusion: Computerized systems are associated with substantial improvements in the prescribing of appropriate prophylaxis and reductions in VTE events, particularly in medical patients. More robust systems can be established with computer-based rather than paper-based CDSS. A drawback of computerized systems is that some hospitals may not have adequate information technology system resources.

The impact of computerised physician order entry with integrated clinical decision support on pharmacist–physician communication in the hospital setting: a systematic review of the literature

ObjectiveTo document the issues and impact that computerised physician order entry (CPOE) with clinical decision support (CDS) can have on pharmacist–physician communication in the hospital setting.HypothesisNovel processes introduced by CPOE...

Clinical decision support systems in the care of inpatients with diabetes in non‐critical care setting: systematic review

Computerized clinical decision support systems have been claimed to reduce prescription errors and improve patient care. They may play an important role in the care of hospitalized patients with diabetes. To collate evidence for the use of clinical decision support systems in improving the care of hospitalized patients with diabetes in a non-critical care setting and to assess their effectiveness. We searched four databases from 1980 to 2010 without language restrictions. All types of studies other than case reports were included. Data extraction and quality assessment were carried out based on the Centre for Review and Dissemination guidance. A narrative synthesis was conducted. Fourteen studies met the inclusion criteria, including two cluster randomized controlled trials, eight before-and-after studies and four other descriptive studies. Generally, the quality of the studies was not very high. Nine out of 10 studies reported reduction in mean blood glucose or similar measures (patient-day-weighted mean blood glucose) during inpatient stay. The reduction using computerized physician order entry system in patient-day-weighted mean blood glucose ranged from 0.6 to 0.8 mmol/l (10.8-15.6 mg/dl). Other beneficial effects during inpatient stay included reduced use of sliding scale insulin and greater use of basal-bolus insulin regimen. Only one study found a significant increase in hypoglycaemic events. Clinical decision support systems have been used, often as part of a complex programme, to improve the care of hospitalized patients with diabetes. There is some evidence that they may have a beneficial effect, but this needs further confirmation.

Evaluation of Computerized Physician Order Entry System—A Satisfaction Survey in Taiwan

In the rapidly developing world of information technology, computers have been used in various settings for clinical medicine application. Studies have focused on computerized physician order entry (CPOE) system interface design and functional development to achieve a successful technology adoption process. Therefore, the purpose of this study was to evaluate physician satisfaction with the CPOE system. This survey included user attitude toward interface design, operation functions/usage effectiveness, interface usability, and user satisfaction. We used questionnaires for data collection from June to August 2008, and 225 valid questionnaires were returned with a response rate of 84.5%. Canonical correlation was applied to explore the relationship of personal attributes and usability with user satisfaction. The results of the data analysis revealed that certain demographic groups showed higher acceptance and satisfaction levels, especially residents, those with less pressure when using computers or those with less experience with the CPOE systems. Additionally, computer use pressure and usability were the best predictors of user satisfaction. Based on the study results, it is suggested that future CPOE development should focus on interface design and content links, as well as providing educational training programs for the new users; since a learning curve period should be considered as an indespensible factor for CPOE adoption.

Medication errors associated with reconciliation in a hospital with computerised physician order entry system with access to primary care treatment

BackgroundA recently introduced computerised physician order entry system (CPOES) in hospital and a primary care electronic record system help prescribing and provide information about patients' medicines. These tools should improve...

Evaluation of a computerised physician order entry system

BackgroundIn a study evaluating polypharmacy in a cohort of older internal-medicine patients in Austria, inappropriate prescribing and adverse drug events (ADEs) were highly prevalent. According to the literature, computerised physician...

Prescriptions analysis by clinical pharmacists in the post‐operative period: a 4‐year prospective study

Clinical pharmacists can help prevent medication errors. However, data are scarce on their role in preventing medication prescription errors in the post-operative period, a high-risk period, as at least two prescribers can intervene, the surgeon and the anesthetist. We aimed to describe and quantify clinical pharmacist' intervention (PIs) during validation of drug prescriptions on a computerized physician order entry system in a post-surgical and post-transplantation ward. We illustrate these interventions, focusing on one clearly identified recurrent problem. In a prospective study lasting 4 years, we recorded drug-related problems (DRPs) detected by pharmacists and whether the physician accepted the PI when prescription modification was suggested. Among 7005 orders, 1975 DRPs were detected. The frequency of PIs remained constant throughout the study period, with 921 PIs (47%) accepted, 383 (19%) refused and 671 (34%) not assessable. The most frequent DRP concerned improper administration mode (26%), drug interactions (21%) and overdosage (20%). These resulted in a change in the method of administration (25%), dose adjustment (24%) and drug discontinuation (23%) with 307 drugs being concerned by at least one PI. Paracetamol was involved in 26% of overdosage PIs. Erythromycin as prokinetic agent, presented a recurrent risk of potentially severe drug-drug interactions especially with other QT interval-prolonging drugs. Following an educational seminar targeting this problem, the rate of acceptation of PI concerning this DRP increased. Pharmacists detected many prescription errors that may have clinical implications and could be the basis for educational measures.

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

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

Impact of Vendor Computerized Physician Order Entry in Community Hospitals

It is uncertain if computerized physician order entry (CPOE) systems are effective at reducing adverse drug event (ADE) rates in community hospitals, where mainly vendor-developed applications are used. To evaluate the impact of vendor CPOE systems on the frequency of ADEs. Prospective before-and-after study conducted from January 2005 to September 2010 at five Massachusetts community hospitals. Participants were adults admitted during the study period. A total of 2,000 charts were reviewed for orders, medication lists, laboratory reports, admission histories, notes, discharge summaries, and flow sheets. The primary outcome measure was the rate of preventable ADEs. Rates of potential ADEs and overall ADEs were secondary outcomes. The rate of preventable ADEs decreased following implementation (10.6/100 vs. 7.0/100 admissions; p = 0.007) with a similar effect observed at each site. However, the associated decrease in preventable ADEs was balanced against an increase in potential ADEs (44.4/100 vs. 57.5/100 admissions; p < 0.001). We observed a reduction of 34.0% for preventable ADEs, but an increase of 29.5% in potential ADEs following implementation. The overall rate of ADEs increased (14.6/100 vs. 18.7/100 admissions; p = 0.03), which was driven by non-preventable events (4.0/100 vs. 11.7/100 admissions; p < 0.001). Adoption of vendor CPOE systems was associated with a decrease in the preventable ADE rate by a third, although the rates of potential ADEs and overall ADEs increased. Our findings support the use of vendor CPOE systems as a means to reduce drug-related injury and harm. The potential ADE rate could be reduced by making refinements to the vendor applications and their associated decision support.

Human Factors Engineering in HI: So What? Who Cares? and What's in It for You?

ObjectivesHuman factors engineering is a discipline that deals with computer and human systems and processes and provides a methodology for designing and evaluating systems as they interact with human beings. This review article reviews important current and past efforts in human factors engineering in health informatics in the context of the current trends in health informatics.MethodsThe methodology of human factors engineering and usability testing in particular were reviewed in this article.ResultsThis methodology arises from the field of human factors engineering, which uses principles from cognitive science and applies them to implementations such as a computer-human interface and user-centered design.ConclusionsPatient safety and best practice of medicine requires a partnership between patients, clinicians and computer systems that serve to improve the quality and safety of patient care. People approach work and problems with their own knowledge base and set of past experiences and their ability to use systems properly and with low error rates are directly related to the usability as well as the utility of computer systems. Unusable systems have been responsible for medical error and patient harm and have even led to the death of patients and increased mortality rates. Electronic Health Record and Computerized Physician Order Entry systems like any medical device should come with a known safety profile that minimizes medical error and harm. This review article reviews important current and past efforts in human factors engineering in health informatics in the context of the current trends in health informatics.

Computerized Physician Order Entry (CPOE) in pediatric and neonatal intensive care

To identify and summarize the requirements of an optimized CPOE application for pediatric intensive care. We analyzed the medication process and its documentation in the pediatric and neonatal intensive care units (PICU/NICU) of two university hospitals using workflow analysis techniques, with the aim of implementing computer-supported physician order entry (CPOE). In both PICU/NICU, we identified similar processes that differed considerably from adult medication routine. For example, both PICU/NICU prepare IV pump syringes on the ward, but receive individualized ready-to-use mixed IV bags for each patient from the hospital pharmacy on the basis of a daily order. For drug dose calculation, both PICU/NICU employ electronic calculation tools that are either incorporated within the CPOE system, or are external modules invoked via interface. On the basis of this analysis, we provide suggestions to optimize CPOE applications for use in the pediatric and neonatal intensive care unit in the form of three catalogues of desiderata for drug order entry support.

A Smart RFID Device for Drugs Administration

Abstract In this work a device is described that can be used in hospitals to lower the risk of Adverse Drug Events (ADE) due to the incorrect link between patients and drugs. The device is a container that can be handled by the patient himself of by the caregivers. It is provided with an internal lock that prevents any openings when there is a mismatch between the patient and the drugs inside the container. It is based on passive RFID (Radio Frequency Identification) technology and is designed to give a visual alert if a wrong drug (tagged with RFID) is accidentally inserted, also preventing its administration by locking the top aperture. The internal RFID reader is designed to read both the patient’s wristband and the drugs inserted into the device (provided that they are tagged with RFID): the device will not open if some un-prescribed drug is found inside the container, alerting the patient/operator using the on-board display. Every single event is logged in an internal memory and can be transferred to a remote information system for analyses, statistics and risk management. The device is also provided with two status LEDs, a green one and a red one, and with a text display that can show information about the patient’s identity, and therapy. We are now working on the mechanical design and on the development of management software in order to link the device with CPOE (Computerized Physician Order Entry) systems and with automated drug storage systems.

Planning for pharmacy information systems among US hospitals

US hospitals are investing in pharmacy information systems to meet accompanying technological and workload demands as well as implement evidence-based medical care. The automation of pharmacy processes, including verification of patient identity and automated medication alerts, when linked to other advanced clinical information systems such as computerised physician order entry (CPOE) systems and the electronic medical record (EMR) has a synergistic effect on improving healthcare quality. Our research shows that US hospitals are actively involved in acquiring pharmacy information systems. One thousand six hundred seventy one US hospitals or 32% have operational pharmacy information systems and 732 of them currently have CPOE systems linked to the pharmacy information system. In addition, 3,995 US hospitals currently have automated dispensing machines (ADM) with 910 planned for future installation. As a result, the increasing investment in pharmacy information systems is providing state-of-the-art medication support which enhances patient safety and healthcare quality.

E‐SPC – delivering drug information in the 21st century: developing new approaches to deliver drug information to prescribers

e‐SPC – delivering drug information in the 21st century: developing new approaches to deliver drug information to prescribers

How to improve the delivery of medication alerts within computerized physician order entry systems: an international Delphi study

To determine what information can be helpful in prioritizing and presenting medication alerts according to the context of the clinical situation. To assess the usefulness of different ways of delivering medication alerts to the user. An international Delphi study with two quantitative rounds. 69 researchers with expertise in computerized physician order entry (CPOE) systems were asked to estimate the usefulness of 20 possible context factors, and to assess the potential impact of six innovative ways of delivering alert information on adverse drug event (ADE) rates. Participants identified the following top five context information items (in descending order of usefulness): (1) severity of the effect of the ADE the alert refers to; (2) clinical status of the patient; (3) probability of occurrence of the ADE the alert refers to; (4) risk factors of the patient; and (5) strength of evidence on which the alert is built. The ways of delivering alert information with the highest estimated ADE reduction potential are active alerting, proactive prescription simulation and a patient medication module that gives patient-oriented alert information. Most participants had a research-oriented focus; therefore the results may not reflect the opinions of CPOE users or CPOE implementers. The study results may provide CPOE system developers and healthcare institutions with information on how to design more effective alert mechanisms.

Strategies for improving documentation and reducing medication errors related to drug allergy

New technologies like computerized physician order entry systems, that includes a support alert for drug allergies, can be an effective tool to prevent medical errors related to drug hypersensitivity most of them caused by lack of documentation and information.

Unintended Consequences of Health Care Legislation

Unintended consequences of health care legislation threaten the financial and social well-being of the United States. Examples of major legislation resulting in unintended and unforeseen consequences include the Social Security Amendments Acts of 1989 and 1993 (the Stark laws), the Balanced Budget Act of 1997, and the Social Security Amendments Act of 1965 (Medicare and Medicaid). Each of these has had unintended financial and social outcomes. Spending for Medicare and Medicaid now equals an unsustainable 23% of the federal budget. Major reasons for unintended consequences include failure to appreciate the complexity of the issues, the open-ended nature of medical advances with attendant increases in costs, the inducement of change in behaviors in response to legislation, and the moral hazard of people spending other people's money. Actions that should be considered to avoid unintended consequences include more involvement of health professionals in the design of legislation, the inclusion of triggers to target review of legislatively defined programs, and the setting of time limits for sun-setting legislation. The ACR has played an important advocacy role and should continue to offer input to legislators, federal policymakers, and other stakeholders. Many opportunities exist to address the current financial situation by reducing the amount of unnecessary care delivered. Both major US political parties need to find the political will to compromise to chart the way forward. Some level of sacrifice is likely to be necessary from patients and providers and other stakeholders.