Computerized Physician Order Entry Research Articles

Development of a Mortality Risk Model in Elderly Hip Fracture Patients by Different Analytical Approaches

Hip fracture is a major health issue that accompanies community aging. The most critical time after a hip fracture should be the first year. Care systems and surgical techniques for hip fractures have improved, so the trend of mortality in elderly hip fracture could be changed with them. Therefore, we observed the changes in the trend and critical factors for first-year mortality for the hip fractures in an elderly population in Taiwan, and mortality of prognosis prediction model was developed for the early diagnosis using a population-based database in Taiwan (National Health Insurance Research Database, NHIRD). A total of 166,274 elderly subjects with an age greater than 60-years-old from 2001 to 2010 were collected for this study. Cox proportional-hazards (PH) regression and logistic regression were calculated to odds ratio and hazard ratio for mortality of those patients and compared it. Data mining algorithms were also used to generate a risk stratification prediction model. The first-year mortality rate of the overall study group was 21.5% in 2001 and 15.0% in 2010 (p for trend < 0.001). In the male subgroup, the first-year mortality rate was 29.3% in 2001 and decreased to 17.3% in 2010; the trend of standardized mortality ratio was significantly decreased from 4.4 to 2.6 (p for trend < 0.001). By logistic regression, mortality significantly increased with age and male gender. Furthermore, gender, age, patients with diabetes mellitus (DM), cardiovascular (CV), and renal comorbidity, and surgical intervention can be variables for constructing the risk stratification model. The findings of the study will be used for helping related field physicians to predict the prognosis risk of hip fracture patients, and provide evidence-based tailored treatment recommendations for those patients. It may consider to build various models for predicting the prognosis of hip fracture or integrating prediction algorithms into the computerized physician order entry system, thus creating a practical clinical decision support system with warning functions.

Association of Electronic Health Record Use Above Meaningful Use Thresholds With Hospital Quality and Safety Outcomes

By 2018, Medicare spent more than $30 billion to incentivize the adoption of electronic health records (EHRs), based partially on the belief that EHRs would improve health care quality and safety. In a time when most hospitals are well past minimum meaningful use (MU) requirements, examining whether EHR implementation beyond the minimum threshold is associated with increased quality and safety may guide the future focus of EHR development and incentive structures. To determine whether EHR implementation above MU performance thresholds is associated with changes in hospital patient satisfaction, efficiency, and safety. This quantile regression analysis of cross-sectional data used publicly available data sets from 2362 acute care hospitals in the United States participating in both the MU and Hospital Value-Based Purchasing (HVBP) programs from January 1 to December 31, 2016. Data were analyzed from August 1, 2019, to May 22, 2020. Seven MU program performance measures, including medication and laboratory orders placed through the EHR, online health information availability and access rates, medication reconciliation through the EHR, patient-specific educational resources, and electronic health information exchange. The HVBP outcomes included patient satisfaction survey dimensions, Medicare spending per beneficiary, and 5 types of hospital-acquired infections. Among the 2362 participating hospitals, mixed associations were found between MU measures and HVBP outcomes, all varying by outcome quantile and in some cases by interaction with EHR vendor. Computerized provider order entry (CPOE) for laboratory orders was associated with decreased ratings of every patient satisfaction outcome at middle quantiles (communication with nurses: β = -0.33 [P = .04]; communication with physicians: β = -0.50 [P < .001]; responsiveness of hospital staff: β = -0.57 [P = .03]; care transition performance: β = -0.66 [P < .001]; communication about medicines: β = -0.52 [P = .002]; cleanliness and quietness: β = -0.58 [P = .007]; discharge information: β = -0.48 [P < .001]; and overall rating: β = -0.95 [P < .001]). However, at middle quantiles, CPOE for medication orders was associated with increased ratings for communication with physicians (τ = 0.5; β = 0.54; P = .009), care transition (τ = 0.5; β = 1.24; P < .001), discharge information (τ = 0.5; β = 0.41; P = .01), and overall hospital ratings (τ = 0.5; β = 0.97; P = .02). At high quantiles, electronic health information exchange was associated with improved ratings of communication with nurses (τ = 0.9; β = 0.23; P = .03). Medication reconciliation had positive associations with increased communication with nursing at low quantiles (τ = 0.1; β = 0.60; P < .001), increased discharge information at middle quantiles (τ = 0.5; β = 0.28; P = .03), and responsiveness of hospital staff at middle (τ = 0.5; β = 0.77; P = .001) and high (τ = 0.9; β = 0.84; P = .001) quantiles. Patients accessing their health information online was not associated with any outcomes. Increased use of patient-specific educational resources identified through the EHR was associated with increased ratings of communication with physicians at high quantiles (τ = 0.9; β = 0.20; P = .02) and with decreased spending at low-spending hospitals (τ = 0.1; β = -0.40; P = .008). Increasing EHR implementation, as measured by MU criteria, was not straightforwardly associated with increased HVBP measures of patient satisfaction, spending, and safety in this study. These results call for a critical evaluation of the criteria by which EHR implementation is measured and increased attention to how different EHR products may lead to differential outcomes.

Trends in the use of computerized physician order entry by health-system affiliated ambulatory clinics in the United States, 2014\u20132016

BackgroundComputerized provider order entry (CPOE) can help providers deliver better quality care. We aimed to understand recent trends in use of CPOE by health system-affiliated ambulatory clinics.MethodsWe analyzed longitudinal data (2014–2016) for 19,109 ambulatory clinics that participated in all 3 years of the Healthcare Information and Management Systems Society Analytics survey to assess use of CPOE and identify characteristics of clinics associated with CPOE use.We calculated descriptive statistics to examine overall trends in use, location of order entry (bedside vs. clinical station), and system-level use CPOE across all clinics. We used linear probability models to explore the association between clinic characteristics (practice size, practice type, and health system type) and two outcomes of interest: CPOE use at any point between 2014 and 2016, and CPOE use beginning in 2015 or 2016.ResultsBetween 2014 and 2016, use of CPOE increased more than 9 percentage points from 58 to 67%. Larger clinics and those affiliated with multi-hospital health systems were more likely to have reported use of CPOE. We found no difference in CPOE use by primary care versus specialty care clinics. When used, most clinics reported using CPOE for most or all of their orders. Health systems that used CPOE usually did so for all system-affiliated clinics.ConclusionsSmall practice size or not being part of a multi-hospital system are associated with lower use of CPOE between 2014 and 2016. Less than optimal use in these environments may be harming patient outcomes.

Operation room IV medication management

Operation room IV Medication Management will discuss the automated device system and activation in the operating room. Discuss the customized IV medication management system. Discuss the experience at CCAD with OR IV Medication management. Completely automated system using automated dispensing machines and computerized physician order entry. ADM and stock of medication in op- erating room are completely managed and controlled by pharmacist.

Computerized prescription order entry and adverse drug events in pediatrics: a systematic review

Abstract Background Potentially harmful errors occur in pediatric patients at a rate three times higher than in adults, mainly due to dosage calculations. Objective. To evaluate the effect of Computerized Prescription Order Entry (CPOE) and Decision Support Systems (DSS) on Adverse Drug Events (ADE) in pediatrics. Method. Systematic review updated up to December 2019 in the PubMed, Scopus, Web of Science and Embase, Lilacs and cross-references, recorded in Prospero CRD 42019126590. Observational and pre- and post-implementation CPOE studies were included. in any language. A scale was used for methodological evaluation of the studies. Relative risk (RR), attributable risk (AR) or number needed to treat (NNT) with 95% CIs were computed for comparing the incidence of total, actual, preventable and potentially harmful ADE. Results Starting with 203 retrieved abstracts, 12 articles were included - eight interventional and four observational studies. Five articles evaluated CPOE and seven CPOE plus DSS. Settings for eleven studies were hospitals and one an outpatient facility. Sample sizes ranged from 514 to 45,615 totaling 112,187 patients. The number of prescriptions ranged from 724 to 92,398, totaling 182,803. A reduction in total ADE was observed in two studies. The risk reduction of preventable ADE ranged from 24% RR 0.76 (0.59 - 0.97) to 47% RR 0.53 (0.29-0.91) in four articles. Potentially harmful ADE (ADE ph) in five studies were reduced from 76% RR = 0.24 (0.09-0.68) to 44% (RR 0.56 (0.46 - 0.70), with an AR variyng from 1.8 to 0.9%. One of the articles stated that 64 (95% CI 25-100) patients would need to be using CPOE in order to avoid one potentially harmful ADE. Studies identified reductions in ADE in various settings- two in wards, one in wards and Pediatric Intensive Care Unit (PICU), the others in PICU and Neonatal Intensive Care Units. Conclusions Implementation of CPOE plus DSS reduces EADs in pediatric settings. Key messages Accumulated evidence favors implementation of CPOE plus DSS as important for prevention of ADE in pediatric settings. Potentially harmful and preventable errors can be avoided by implementing electronic prescribing systems in pediatrics. Its use should be encouraged in countries in low-income countries.

Medication Error and Its Contributing Factors Among Pediatric Patients Diagnosed with Infectious Diseases Admitted to Jimma University Medical Center, Southwest Ethiopia: Prospective Observational Study.

BackgroundMedication errors in pediatric patients are grossly underreported. Pediatric patients are quite susceptible to medication errors. Potential injury by medication error is higher in young children and infants. It results in serious morbidity and mortality. Thus, this study aimed to assess medication error and its contributing factors among pediatric patients diagnosed with infectious diseases admitted to Jimma University Medical Center.MethodsA prospective observational study was conducted among pediatric patients with infectious diseases admitted from April 1 to June 30, 2018. The patient’s written informed consent was obtained after explaining the purpose of the study. The data were collected by structured questionnaire. Data were entered into EpiData version 4.0.2 and then exported to SPSS version 21.0 for analysis. To identify the predictors of medication error, backward logistic regression analysis was done.ResultsFrom a total of the 325 study participants, 136 (41.8%) patients had at least one medication error during their hospital stay. A total of 273 medication errors were identified among 136 patients. Medication errors frequently occurred at prescribing stage 94 (34.4%). The most common types of medication errors were wrong dosing 72 (26.4%) and wrong frequency 47 (17.2%). Presence of disease comorbidity (AOR=1.64, 95%CI=1.01–2.67), being male (AOR=1.79, 95%CI:1.13–2.86) and presence of two infectious diseases (AOR=1.96, 95%CI: 1.20–3.23) and more than three infectious diseases (AOR=2.04, 95%CI: 1.03–4.01) were independent predictors of medication error occurrence.Conclusion and RecommendationMedication errors were common in pediatric patients with infectious diseases in the study area. Presence of comorbidities, being male and the number of infectious diseases were associated with the occurrence of medication errors. Therefore, to reduce medication errors in the study setting, e-prescribing, computerized provider order entry, medication reconciliation, and collaboration of clinical pharmacists with other health professionals are needed.

Clinical Staff Attitude Toward the Computerized Physician Order Entry System in Cardiac Care Unit Based on a Model by the Name of “Technology Acceptance Model in Health Care Centers of Iran”

Background: Currently, many physicians use the computerized physician order entry (CPOE) system, and the adoption of this system is increasing worldwide. The technology acceptance model has been implemented and evaluated. It has become one of the most recognized empirical models. Besides, recent studies showed that this model well anticipates users’ behavioral tendencies in accepting technology in healthcare centers. The use of the technology acceptance model in the implementation of health care systems such as CPOE, which is effective in reducing medical errors, is necessary. Objectives: This applied research has used a descriptive-analytical approach. In the current study the technology acceptance model in Iranian health care centers, which was proposed by Safdari and colleagues aimed to investigate the attitudes of clinical staff toward the computerized physician orders entry system, was used in the Cardiac Care Unit of Alzahra’s Heart Hospital in Shiraz to determine the importance and effectiveness of each dimension on attitudes toward using CPOE by 140 of physicians and nurses. Methods: Three main dimensions, including human, monitoring-management, and organizational strategies factors, were evaluated using a researcher-made questionnaire. Data were analyzed by SPSS version 25 using the descriptive and analytical statistics (i.e., Pearson correlation test and t-test). Results: The results showed that organizational strategies dimension with an average of 3.85 (out of 5) had the highest users’ attention, followed by monitoring-management and human dimensions. The overall average of all dimensions was 3.78. All dimensions had a positive and direct effect on the attitudes toward using the CPOE. Demographic characteristics did not have a meaningful relationship with any dimensions. Conclusions: Finally, the average above 3 in the mean of the total dimensions, as well as each dimension, shows views of the users are appropriate to using the CPOE., the views of the users are appropriated toward using CPOE. It should be noted that the difference in the dimension means is a small amount. The centered focus on organizational strategies with the highest average should not cause to neglect other dimensions.

Electronic ordering and the management of treatment interdependencies: a qualitative study of paediatric chemotherapy

BackgroundThere are serious safety risks associated with chemotherapy, often associated with interdependencies in regimens administered over months or years. Various strategies are used to manage these risks. Computerized provider order entry (CPOE) systems are also implemented to improve medication safety. Little is known regarding the effect of CPOE on how clinicians manage chemotherapy interdependencies and their associated safety strategies.MethodsWe conducted a multi-method qualitative study in a paediatric hospital. We analysed 827 oncology incidents reported following CPOE implementation and carried out semi-structured interviews with doctors (n = 10), nurses (n = 6), a pharmacist, and oncology CPOE team members (n = 2). Results were interpreted according to safety models (ultra-safe, high-reliability organisations [HROs], or ultra-adaptive).ResultsIncident reports highlighted two interrelated types of interdependencies: those within organisation of clinical activities and those inherent in chemotherapy regimens. Clinicians reported strategies to address chemotherapy risks and interdependencies. These included rigid rules and ‘no go’ contexts for treatment to proceed, typical of the ultra-safe model; use of time (e.g. planning only so far ahead) and sensitivity to operations, typical of HROs. We identified three different time horizons in CPOE use in relation to patients’ treatments: life-long, the whole regimen, and the ‘here and now’. CPOE supported ultra-safe strategies through automation and access to rules/standardisation, but also created difficulties and contributed to incidents. It supported the ‘here and now’ better than a life-long or whole regimen view of a patient treatment. Sensitivity to operations was essential to anticipate and resolve uncertainties, hazards, CPOE limitations, and mismatches between CPOE processes and workflow in practice.ConclusionsWithin oncology, CPOE appears to move the ‘mix’ of risk strategies towards ultra-safe models of safety and protocol-mandated care. However, in order to operate ultra-safe strategies embedded in CPOE and stay on protocol it is essential for clinicians to be thoughtful and show sensitivity to operations in CPOE use. CPOE design can be advanced by better consideration of mechanisms to support interdependencies.

Computerized provider order entry-related medication errors among hospitalized patients: An integrative review.

The Institute of Medicine estimates that 7,000 lives are lost yearly as a result of medication errors. Computerized physician and/or provider order entry was one of the proposed solutions to overcome this tragic issue. Despite some promising data about its effectiveness, it has been found that computerized provider order entry may facilitate medication errors.The purpose of this review is to summarize current evidence of computerized provider order entry -related medication errors and address the sociotechnical factors impacting the safe use of computerized provider order entry. By using PubMed and Google Scholar databases, a systematic search was conducted for articles published in English between 2007 and 2019 regarding the unintended consequences of computerized provider order entry and its related medication errors. A total of 288 articles were screened and categorized based on their use within the review. One hundred six articles met our pre-defined inclusion criteria and were read in full, in addition to another 27 articles obtained from references. All included articles were classified into the following categories: rates and statistics on computerized provider order entry -related medication errors, types of computerized provider order entry -related unintended consequences, factors contributing to computerized provider order entry failure, and recommendations based on addressing sociotechnical factors. Identifying major types of computerized provider order entry -related unintended consequences and addressing their causes can help in developing appropriate strategies for safe and effective computerized provider order entry. The interplay between social and technical factors can largely affect its safe implementation and use. This review discusses several factors associated with the unintended consequences of this technology in healthcare settings and presents recommendations for enhancing its effectiveness and safety within the context of sociotechnical factors.

Pragmatic Considerations on Clinical Decision Support from the 2019 Literature.

Summary Objectives : To summarize significant research contributions published in 2019 in the field of computerized clinical decision support and select the best papers for the Decision Support section of the International Medical Informatics Association (IMIA) Yearbook. Methods : Two bibliographic databases were searched for papers referring to clinical decision support systems (CDSSs) and computerized provider order entry (CPOE) systems. From search results, section editors established a list of candidate best papers, which were then peer-reviewed by external reviewers. The IMIA Yearbook editorial committee finally selected the best papers on the basis of all reviews including the section editors’ evaluation. Results : A total of 1,378 articles were retrieved. Fifteen best paper candidates were selected, the reviews of which resulted in the selection of three best papers. One paper reports on a guideline modeling approach based on clinical decision trees, both clinically interpretable and suitable for implementation in CDSSs. In another paper, authors promote the use of extended Timed Transition Diagrams in CDSSs to formalize consistently recurrent medical processes for chronic diseases management. The third paper proposes a conceptual framework and a grid for assessing the performance of predictive tools based on the critical appraisal of published evidence. Conclusions : As showed by the number and the variety of works related to decision support, research in the field is very active. This year’s selection highlighted pragmatic works that promote transparency and trust required by decision support tools.

Appropriateness of Overridden Alerts in Computerized Physician Order Entry: Systematic Review.

BackgroundThe clinical decision support system (CDSS) has become an indispensable tool for reducing medication errors and adverse drug events. However, numerous studies have reported that CDSS alerts are often overridden. The increase in override rates has raised questions about the appropriateness of CDSS application along with concerns about patient safety and quality of care.ObjectiveThe aim of this study was to conduct a systematic review to examine the override rate, the reasons for the alert override at the time of prescribing, and evaluate the appropriateness of overrides.MethodsWe searched electronic databases, including Google Scholar, PubMed, Embase, Scopus, and Web of Science, without language restrictions between January 1, 2000 and March 31, 2019. Two authors independently extracted data and crosschecked the extraction to avoid errors. The quality of the included studies was examined following Cochrane guidelines.ResultsWe included 23 articles in our systematic review. The range of average override alerts was 46.2%-96.2%. An average of 29.4%-100% of the overrides alerts were classified as appropriate, and the rate of appropriateness varied according to the alert type (drug-allergy interaction 63.4%-100%, drug-drug interaction 0%-95%, dose 43.9%-88.8%, geriatric 14.3%-57%, renal 27%-87.5%). The interrater reliability for the assessment of override alerts appropriateness was excellent (kappa=0.79-0.97). The most common reasons given for the override were “will monitor” and “patients have tolerated before.”ConclusionsThe findings of our study show that alert override rates are high, and certain categories of overrides such as drug-drug interaction, renal, and geriatric were classified as inappropriate. Nevertheless, large proportions of drug duplication, drug-allergy, and formulary alerts were appropriate, suggesting that these groups of alerts can be primary targets to revise and update the system for reducing alert fatigue. Future efforts should also focus on optimizing alert types, providing clear information, and explaining the rationale of the alert so that essential alerts are not inappropriately overridden.

The tradeoffs between safety and alert fatigue: Data from a national evaluation of hospital medication-related clinical decision support.

The study sought to evaluate the overall performance of hospitals that used the Computerized Physician Order Entry Evaluation Tool in both 2017 and 2018, along with their performance against fatal orders and nuisance orders. We evaluated 1599 hospitals that took the test in both 2017 and 2018 by using their overall percentage scores on the test, along with the percentage of fatal orders appropriately alerted on, and the percentage of nuisance orders incorrectly alerted on. Hospitals showed overall improvement; the mean score in 2017 was 58.1%, and this increased to 66.2% in 2018. Fatal order performance improved slightly from 78.8% to 83.0% (P < .001), though there was almost no change in nuisance order performance (89.0% to 89.7%; P = .43). Hospitals alerting on one or more nuisance orders had a 3-percentage-point increase in their overall score. Despite the improvement of overall scores in 2017 and 2018, there was little improvement in fatal order performance, suggesting that hospitals are not targeting the deadliest orders first. Nuisance order performance showed almost no improvement, and some hospitals may be achieving higher scores by overalerting, suggesting that the thresholds for which alerts are fired from are too low. Although hospitals improved overall from 2017 to 2018, there is still important room for improvement for both fatal and nuisance orders. Hospitals that incorrectly alerted on one or more nuisance orders had slightly higher overall performance, suggesting that some hospitals may be achieving higher scores at the cost of overalerting, which has the potential to cause clinician burnout and even worsen safety.

Improving surgical antibiotic prophylaxis adherence and reducing hospital readmissions: a bundle of interventions including health information technologies

ObjectivesInfection following orthopaedic surgery is a feared complication and an indicator of the quality of the hospital. Surgical antibiotic prophylaxis (SAP) guidelines are not always properly followed. Our aim was...

Laboratory information system requirements to manage the COVID-19 pandemic: A report from the Belgian national reference testing center.

ObjectiveThe study sought to describe the development, implementation, and requirements of laboratory information system (LIS) functionality to manage test ordering, registration, sample flow, and result reporting during the coronavirus disease 2019 (COVID-19) pandemic.Materials and MethodsOur large (>12 000 000 tests/y) academic hospital laboratory is the Belgian National Reference Center for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing. We have performed a moving total of >25 000 SARS-CoV-2 polymerase chain reaction tests in parallel to standard routine testing since the start of the outbreak. A LIS implementation team dedicated to develop tools to remove the bottlenecks, primarily situated in the pre- and postanalytical phases, was established early in the crisis.ResultsWe outline the design, implementation, and requirements of LIS functionality related to managing increased test demand during the COVID-19 crisis, including tools for test ordering, standardized order sets integrated into a computerized provider order entry module, notifications on shipping requirements, automated triaging based on digital metadata forms, and the establishment of databases with contact details of other laboratories and primary care physicians to enable automated reporting. We also describe our approach to data mining and reporting of actionable daily summary statistics to governing bodies and other policymakers.ConclusionsRapidly developed, agile extendable LIS functionality and its meaningful use alleviates the administrative burden on laboratory personnel and improves turnaround time of SARS-CoV-2 testing. It will be important to maintain an environment that is conducive for the rapid adoption of meaningful LIS tools after the COVID-19 crisis.

Evaluating the Use of a CPOE for Chemotherapy Protocols.

Chemotherapy drugs are one of the most common causes of serious and fatal medication errors, especially during prescribing, where computerized physician order entry (CPOE) take on importance. This study proposes the description of the post-implementation status of a CPOE in a highly specialized hospital between January and June 2018, among patients older than 18 years. Results: a total of 8835 protocols were indicated using the specific CPOE (93% use rate over all protocols) 91% completed the administration, 1.2% were rejected by pharmacy, and 6.8% was canceled. The most frequent cause of rejection by pharmacy and cancellation by oncologist was an inadequate dose. Most of the protocols indicated using the CPOE implemented, with a reject by pharmacy rate of 1.2%, indicates the utility of CPOE as an error prevention strategy.

Challenges of In-House Development and Implementation of a CPOE for Oncology.

Hospital Italiano de Buenos Aires (HIBA) is an academic tertiary care hospital highly specialized that has started the process of informatization of chemotherapy protocols. The objective is to describe the development of a computerized physician order entry (CPOE) oriented to the oncology adult patient and the members of the healthcare team that works with him (physicians, pharmacists, nurses and administrative staf) to improve the process and prevent errors at a critical point in the patient's health care: during prescription, preparation and / or administration. The development of this system consisted of several stages: inquiries about the usual work and perception of needs of the potential users; user-centered design; interoperability with the electronic health record (EHR) and development of a final prototype.

Risk Factors for Electronic Prescription Errors in Pediatric Intensive Care Patients.

To assess risk factors for electronic prescription errors in a PICU. A database of electronic prescriptions issued by a computerized physician order entry with clinical decision support system was analyzed to identify risk factors for prescription errors. Of 6,250 prescriptions, 101 were associated with errors (1.6%). The error rate was twice as high in patients older than 12 years than in patients children 6-12 and 0-6 years old (2.4% vs 1.3% and 1.2%, respectively, p < 0.05). Compared with patients without errors, patients with errors had a significantly higher score on the Pediatric Index of Mortality 2 (-3.7 vs -4.5; p = 0.05), longer PICU stay (6 vs 3.1 d; p < 0.0001), and higher number of prescriptions per patient (40.8 vs. 15.7; p < 0.0001). In addition, patients with errors were more likely to have a neurologic main admission diagnosis (p = 0.008) and less likely to have a cardiologic diagnosis (p = 0.03) than patients without errors. Our findings suggest that older patient age and greater disease severity are risk factors for electronic prescription errors.

National Trends in the Safety Performance of Electronic Health Record Systems From 2009 to 2018

Despite the broad adoption of electronic health record (EHR) systems across the continuum of care, safety problems persist. To measure the safety performance of operational EHRs in hospitals across the country during a 10-year period. This case series included all US adult hospitals nationwide that used the National Quality Forum Health IT Safety Measure EHR computerized physician order entry safety test administered by the Leapfrog Group between 2009 and 2018. Data were analyzed from July 1, 2018 to December 1, 2019. The Health IT Safety Measure test, which uses simulated medication orders that have either injured or killed patients previously to evaluate how well hospital EHRs could identify medication errors with potential for patient harm. Descriptive statistics for performance on the assessment test over time were calculated at the overall test score level, type of decision support category level, and EHR vendor level. Among 8657 hospital-years observed during the study, mean (SD) scores on the overall test increased from 53.9% (18.3%) in 2009 to 65.6% (15.4%) in 2018. Mean (SD) hospital score for the categories representing basic clinical decision support increased from 69.8% (20.8%) in 2009 to 85.6% (14.9%) in 2018. For the categories representing advanced clinical decision support, the mean (SD) score increased from 29.6% (22.4%) in 2009 to 46.1% (21.6%) in 2018. There was considerable variation in test performance by EHR. These findings suggest that despite broad adoption and optimization of EHR systems in hospitals, wide variation in the safety performance of operational EHR systems remains across a large sample of hospitals and EHR vendors. Hospitals using some EHR vendors had significantly higher test scores. Overall, substantial safety risk persists in current hospital EHR systems.

Toward a Common Goal: Improving Safety of Oral Chemotherapy Prescribing Practices at a Jurisdictional Level.

Extending the safety agenda from parenteral to oral chemotherapy was identified as a provincial improvement priority in the 2014-2019 Cancer Care Ontario (CCO) Systemic Treatment Provincial Plan. Elimination of handwritten prescriptions for oral chemotherapy was one of the specific goals and led to a provincial quality improvement (QI) initiative involving systemic treatment facilities across 14 regional cancer programs. The initiative was centrally organized by CCO but locally implemented by the regional partners. CCO provided templates and tools, such as preprinted orders (PPOs), project charters, and an evaluation plan, and facilitated cross-jurisdictional knowledge sharing and exchange. Regions had flexibility in determining their local implementation strategies and were responsible for conducting chart audits to evaluate implementation success. Each participating hospital completed 3 audits-at baseline, immediately after implementation (audit 1), and 1 year later (audit 2)-using either a clinic-based or an outpatient pharmacy-based assessment. Thirty-five facilities providing systemic treatment participated. At baseline, the provincial average for the use of computerized physician order entry (CPOE) or PPOs for prescribing oral chemotherapy was 71%. After implementation of the QI initiative, the provincial average for the use of CPOE or PPO increased to 91% at audit 1 and 95% at audit 2. Although not all facilities met the goal of 100% CPOE or PPO compliance, the QI initiative led to improvement in safe prescribing practices for oral chemotherapy. A coordinated QI approach between a central decision maker and local partners can be an effective strategy to encourage high-quality cancer care and promote a culture of safety across a jurisdiction.

Physician Experience with Electronic Order Sets.

Electronic medical record (EMR) and electronic health record (EHR) are used interchangeably to describe a computerized medical information system that collects, stores and displays patient information (Boonstra and Broekhuis 2010). Blumenthal and Tavenner (2010) suggested that computerized medical implementation improves decision-making and patient management. As part of its EMR, Humber River Hospital has implemented electronic order sets (EOSs) by building them into the computerized physician order entry (CPOE) system. Electronic prescribing renders paper prescriptions obsolete as it reduces errors; increases accuracy; and enhances efficiency, compliance and record-keeping (Canada Health Infoway 2017). The aim of this research was to explore physicians' perspectives and experiences using EOSs. This qualitative study examined the perceptions of various physicians on the impact of EOSs. Data were collected through semi-structured, in-depth interviews with eligible physicians. Domains explored included usability, efficiency, safety and implications for the physician profession. Major themes that emerged included usability, efficiency and safety. Several implications for physician practice were also revealed. The findings from our study support previous studies that describe the benefits of EOSs, including ease of use and efficiency, real-time information that is evidence-based, increased safety and minimization of memory burden. EOSs were not perceived to be a replacement for clinical reasoning.