Hospital Computerized Order Entry Research Articles

Changing the electronic request form proves to be an effective tool for optimizing laboratory test utilization in the emergency department

ObjectivesAppropriate laboratory utilization more often than not needs to be initiated by the laboratory. This study was performed to analyze the impact on test ordering patterns in the emergency department obtained by omitting certain tests from the electronic tick box request form. The tests could still be ordered by writing the full name of the test or by a phone call. MethodsErythrocyte sedimentation rate (ESR), fibrinogen, aspartate aminotransferase (AST), calcium and lipase were omitted from the electronic request form and could subsequently be ordered either by phone or a typed-in request. A reflex testing protocol was elaborated for reduction of creatine kinase (CK) and CK-MB analyses. All interventions were introduced with prior consultation with clinical staff and according to current guidelines. The reduction of test orders and costs in the post-intervention period was assessed. All data were retrieved retrospectively from the laboratory information system (LIS). ResultsDisappearance from the tick box request form resulted in a significant decrease in the number of requests for targeted tests in the post-intervention year, mostly affecting AST and fibrinogen (83% and 79% reduction of ordering, respectively), followed by a 58% reduction in calcium orders, and 54% and 43% reductions in ESR and lipase requests, respectively. A substantial reduction in CK requests was also observed, while CK-MB requests almost disappeared. Annual cost savings that emerged from all implemented interventions were estimated to be 19,445€. ConclusionSignificant reduction in ordering of selected tests was achieved simply by limiting their availability in hospital computerized order entry (COE) system. The present data suggest that removal of laboratory tests from the electronic request form can be an effective tool for changing physicians' test ordering behavior.

Conversion from intravenous to oral medications: assessment of a computerized intervention for hospitalized patients.

Many hospitalized patients continue to receive intravenous medications longer than necessary. Earlier conversion from the intravenous to the oral route could increase patient safety and comfort, reduce costs, and facilitate earlier discharge from the hospital without compromising clinical care. We examined the effect of a computer-based intervention to prompt physicians to switch appropriate patients from intravenous to oral medications. This study was performed at Brigham and Women's Hospital, an academic tertiary care hospital at which all medications are ordered online. We targeted 5 medications with equal oral and intravenous bioavailability: fluconazole, levofloxacin, metronidazole, ranitidine, and amiodarone. We used the hospital's computerized order entry system to prompt physicians to convert appropriate intravenous medications to the oral route. We measured the total use of the targeted medications via each route in the 4 months before and after the implementation of the intervention. We also measured the rate at which physicians responded to the intervention when prompted. The average intravenous defined daily dose declined by 11.1% (P =.002) from the preintervention to the postintervention period, while the average oral defined daily dose increased by 3.7% (P =.002). Length of stay, case-mix index, and total drug use at the hospital increased during the study period. The average total monthly use of the intravenous preparation of all of the targeted medications declined in the 4 months after the intervention began, compared with the 4 months before. In 35.6% of 1045 orders for which a prompt was generated, the physician either made a conversion from the intravenous to the oral version or canceled the order altogether. Computer-generated reminders can produce a substantial reduction in excessive use of targeted intravenous medications. As online prescribing becomes more common, this approach can be used to reduce excess use of intravenous medications, with potential benefits in patient comfort, safety, and cost.