Implementation Of Computerized Physician Order Entry Research Articles

Reduced prevalence of drug-related problems in psychiatric inpatients after implementation of a pharmacist-supported computerized physician order entry system - a retrospective cohort study.

In 2021, a computerized physician order entry (CPOE) system with an integrated clinical decision support system (CDSS) was implemented at a tertiary care center for the treatment of mental health conditions in Lübeck, Germany. To date, no study has been reported on the types and prevalence of drug-related problems (DRPs) before and after CPOE implementation in a psychiatric inpatient setting. The aim of this retrospective before-and-after cohort study was to investigate whether the implementation of a CPOE system with CDSS accompanied by the introduction of regular medication plausibility checks by a pharmacist led to a decrease of DRPs during hospitalization and unsolved DRPs at discharge in psychiatric inpatients. Medication charts and electronic patient records of 54 patients before (cohort I) and 65 patients after (cohort II) CPOE implementation were reviewed retrospectively by a clinical pharmacist. All identified DRPs were collected and classified based on 'The PCNE Classification V9.1', the German database DokuPIK, and the 'NCC MERP Taxonomy of Medication Errors'. 325 DRPs were identified in 54 patients with a mean of 6 DRPs per patient and 151.9 DRPs per 1000 patient days in cohort I. In cohort II, 214 DRPs were identified in 65 patients with a mean of 3.3 DRPs per patient and 81.3 DRPs per 1000 patient days. The odds of having a DRP were significantly lower in cohort II (OR=0.545, 95% CI 0.412-0.721, p<0.001). The most frequent DRP in cohort I was an erroneous prescription (n=113, 34.8%), which was significantly reduced in cohort II (n=12, 5.6%, p<0.001). During the retrospective in-depth review, more DRPs were identified than during the daily plausibility analyses. At hospital discharge, patients had significantly less unsolved DRPs in cohort II than in cohort I. The implementation of a CPOE system with an integrated CDSS reduced the overall prevalence of DRPs, especially of prescription errors, and led to a smaller rate of unsolved DRPs in psychiatric inpatients at hospital discharge. Not all DRPs were found by plausibility analyses based on the medication charts. A more interactive and interdisciplinary patient-oriented approach might result in the resolution of more DRPs.

Workflow, Time Requirement, and Quality of Medication Documentation with or without a Computerized Physician Order Entry System-A Simulation-Based Lab Study.

The introduction of a computerized physician order entry (CPOE) system is changing workflows and redistributing tasks among health care professionals. The aim of this study is to describe exemplary changes in workflow, to objectify the time required for medication documentation, and to evaluate documentation quality with and without a CPOE system (Cerner® i.s.h.med). Workflows were assessed either through direct observation and in-person interviews or through semistructured online interviews with clinical staff involved in medication documentation. Two case scenarios were developed consisting of exemplary medications (case 1 = 6 drugs and case 2 = 11 drugs). Physicians and nurses/documentation assistants were observed documenting the case scenarios according to workflows established prior to CPOE implementation and those newly established with CPOE implementation, measuring the time spent on each step in the documentation process. Subsequently, the documentation quality of the documented medication was assessed according to a previously established and published methodology. CPOE implementation simplified medication documentation. The overall time needed for medication documentation increased from a median of 12:12 min (range: 07:29-21:10 min) without to 14:40 min (09:18-25:18) with the CPOE system (p = 0.002). With CPOE, less time was spent documenting peroral prescriptions and more time documenting intravenous/subcutaneous prescriptions. For physicians, documentation time approximately doubled, while nurses achieved time savings. Overall, the documentation quality increased from a median fulfillment score of 66.7% without to 100.0% with the CPOE system (p < 0.001). This study revealed that CPOE implementation simplified the medication documentation process but increased the time spent on medication documentation by 20% in two fictitious cases. This increased time resulted in higher documentation quality, occurred at the expense of physicians, and was primarily due to intravenous/subcutaneous prescriptions. Therefore, measures to support physicians with complex prescriptions in the CPOE system should be established.

Prescribing errors in children: what is the impact of a computerized physician order entry?

Prescribing errors represent a safety risk for hospitalized patients, especially in pediatrics. Computerized physician order entry (CPOE) might reduce prescribing errors, although its effect has not yet been thoroughly studied on pediatric general wards. This study investigated the impact of a CPOE on prescribing errors in children on general wards at the University Children’s Hospital Zurich. We performed medication reviews on a total of 1000 patients before and after the implementation of a CPOE. The CPOE included limited clinical decision support (CDS) such as drug-drug interaction check and checks for duplicates. Prescribing errors, their type according to the PCNE classification, their severity (adapted NCC MERP index), as well as the interrater reliability (Cohen’s kappa), were analyzed. Potentially harmful errors were significantly reduced from 18 errors/100 prescriptions (95% CI: 17–20) to 11 errors/100 prescriptions (95% CI: 9–12) after CPOE implementation. A large number of errors with low potential for harm (e.g., “missing information”) was reduced after the introduction of the CPOE, and consequently, the overall severity of potential harm increased post-CPOE. Despite general error rate reduction, medication reconciliation problems (PCNE error 8), such as drugs prescribed on paper as well as electronically, significantly increased after the introduction of the CPOE. The most common pediatric prescribing errors, the dosing errors (PCNE errors 3), were not altered on a statistically significant level after the introduction of the CPOE. Interrater reliability showed moderate agreement (Κ = 0.48). Conclusion: Patient safety increased by reducing the rate of prescribing errors after CPOE implementation. The reason for the observed increase in medication reconciliation problems might be the hybrid system with remaining paper prescriptions for special medication. The lacking effect on dosing errors could be explained by the fact that a web application CDS covering dosing recommendations (PEDeDose) was already in use before the implementation of the CPOE. Further investigations should focus on eliminating hybrid systems, interventions to increase the usability of the CPOE, and full integration of CDS tools such as automated dose checks into the CPOE.What is Known:• Prescribing errors, especially dosing errors, are a common safety threat for pediatric inpatients.•The introduction of a CPOE may reduce prescribing errors, though pediatric general wards are poorly studied.What is New:•To our knowledge, this is the first study on prescribing errors in pediatric general wards in Switzerland investigating the impact of a CPOE.•We found that the overall error rate was significantly reduced after the implementation of the CPOE. The severity of potential harm was higher in the post-CPOE period, which implies that low-severity errors were substantially reduced after CPOE implementation. Dosing errors were not reduced, but missing information errors and drug selection errors were reduced. On the other hand, medication reconciliation problems increased.

Design, implementation, and evaluation of a CPOE system in a cancer care setting: A case study on the gastric cancer patients.

Chemotherapy is a complex, multi-disciplinary, and error-prone process. Information technology is being increasingly used in different health care settings with complex work procedures such as cancer care to enhance the quality and safety of care. In this study, we aimed to develop a computerized physician order entry (CPOE) for chemotherapy prescribing in patients with gastric cancer and to evaluate the impact of CPOE on medication errors and order problems. A multi-disciplinary team consisting of a chemotherapy council group and system design and implementation team was formed for chemotherapy process evaluation, requirement analysis, developing computer-based protocols, and implementation of CPOE. A before and after study was conducted to evaluate the impact of CPOE on the chemotherapy process and medication errors and problem orders. To evaluate the level of end-user satisfaction, an ISO Norm 9241/110 usability questionnaire was chosen for the evaluation. Before the implementation of the CPOE system, 37 medication errors (46.25%) and 53 problem orders (66.25%) were recorded for 80 paper-based chemotherapy prescriptions. After implementation of the CPOE system, 7 (8.7%) medication errors and 6 (7.5%) problem orders were recorded for 80 CPOE prescriptions. The implementation of CPOE reduced the medication error by 37.55% and the problematic order by 58.75%. The results for usability evaluation indicate that the CPOE was within the first class of the ISONORM level rating; this shows that a CPOE is with very high satisfaction and a very high functionality rate. Developing a CPOE system significantly improved safety and quality of the chemotherapy process in cancer care settings by reducing the medication error, deleting unnecessary steps, improving communication and coordination between providers, and use of updated evidence-based medicine in direct chemotherapy orders. However, the CPOE system does not prevent all medication errors and may cause new errors. These errors can be human-related factors or associated with the design and implementation of the systems.

RWD11 Effectiveness Analysis of CPOE Implementation in Preventing Duplicate Medication: An Evidence From a Single Medical Center in Taiwan

Medication reconciliation (MR) is an important sector of medication safety use to prevent medication errors. In recent years, National Health Insurance Administration has been concerned about duplicate medication in Taiwan. As the elderly population grows in Taiwan, the demand for MR has increased. This study aims to analyze the effectiveness of Computerized Physician Order Entry (CPOE) implementation in avoiding duplicate medication.

558 Nurse-driven fluid resuscitation protocol - a quality improvement initiative

IntroductionThe migration of paper medical records to electronic health record (EHR) has been in process for a few years now and most facilities have achieved this successfully. EHR has streamlined care and documentation. Further developments such as Computerized Physician Order Entry (CPOE) has been noted as one of the most promising functionalities of Health Information Technology (HIT), as it allows providers to enter orders, medications, diagnostic tests, and procedures, with the intent of improving the clarity and specificity of physician orders, facilitating the rapid communication of orders to pharmacies, and providing significantly enhanced decision support capabilities compared to traditional handwritten orders.1In our experience, initiation of CPOE has been beneficial in many ways, namely in decreasing medication errors related to handwritten orders. However, in the clinical scenario of acute resuscitation of a critically injured burn patient, the CPOE structure did not address each and every need that would arise, especially if fluid titration was necessary. Nursing staff were left unsure of what to do in terms of their role in adjusting fluids and assessing for adequacy of resuscitation. This led to gaps in care in which potential critical situations needed to be addressed. For instance, the possible development of abdominal compartment syndrome and how to respond to it was not part of CPOE set that was implemented. This was placing the patient at risk by delaying initiation of hemodynamic monitoring and delaying electrolyte replacement as well.The goal of this study is to report the outcomes of this quality improvement initiative and to describe the resultant research that is in place to evaluate its effectiveness.MethodsThis is a QI project that will identify and describe how a protocol was developed post- CPOE implementation to address gaps in nursing care during fluid resuscitation of critically ill burned patientsResultsWe created a protocol that allows the nurse to have better insight into what is happening with the patient and what physician orders are most pertinent at any particular time. The protocol sets parameters that alerts the nurse when additional intervention is necessary. For instance, monitoring for abdominal compartment syndrome begins once resuscitation exceeds 6 mL/kg/TBSA and allowing for the nurse to call the primary physician for hypotension that is refractory to fluid bolus. This was not clear before and nurses were not intervening appropriately, which resulted in gaps in delivery of care. We have not had to report any adverse or sentinel event related to fluid resuscitation since the implementation of this protocol.ConclusionsA nurse-driven protocol helped address gaps in care for nurses at the bedside during fluid resuscitation

Implementing computerized physician order entry in a public tertiary care hospital.

It is reported that at least one medication error per day occurs in hospitalized patients. Medication errors are not only harmful but also expensive. Prescription review by pharmacists is the standard to reduce prescribing error; however, due to the manual process, pharmacists lack time to conduct prescription reviews. Computerized physician order entry (CPOE) allows clinicians to directly place medication orders electronically, transmitted directly to the pharmacy. Successfully implemented CPOE systems improve the prescribing process and result in fewer medication errors. However, regardless of its significance, implementation of CPOE is a very difficult task, particularly in a public-sector hospital. Lady Reading Hospital-Medical Teaching Institution has a manual system for indenting medication system; pharmacists could only ensure the current dispensing of medication, but lack time and information to conduct a review to ensure the appropriateness of prescription. The article entails the barriers and the process of implementation of e-prescribing.

Implementation of Computerized Physician Order Entry in Primary Care: A Scoping Review.

PurposeThis scoping review aimed to assess the implementation and outcomes of computerized physician order entry (CPOE) in primary care.MethodsA scoping review was carried out in accordance with the Joanna Briggs Institute’s guidelines (JBI). The databases PubMed, CINAHL, Science Direct, and Google Scholar were all searched. The full text of each article was reviewed for eligibility after the title and abstract were evaluated. JBI data extraction were used to extract data. Donabedian’s framework served as the foundation for the data discussion.ResultsBased on the inclusion criteria, seven studies were included. The studies’ main goal in common was to analyze the outcome or impact of implementing CPOE systems in ambulatory or primary care settings. Several studies described the framework, current state of implementation, and evaluation or recommendation following CPOE system implementation. Many positive effects were felt by physicians or prescribers, pharmacists, patients, and primary care providers, with patient safety being the primary goal.ConclusionAlthough this study discovered some issues and factors associated with CPOE implementation and adoption, such as infrastructure, workflow, level of engagement, and safety culture, CPOE has many positive outcomes for patients, physicians, and primary care. To improve CPOE adoption in healthcare, particularly primary care, more research into the structure, framework, and components of CPOE deployment is required.

The impact of a computerized physician order entry system implementation on 20 different criteria of medication documentation\u2014a before-and-after study

BackgroundThe medication process is complex and error-prone. To avoid medication errors, a medication order should fulfil certain criteria, such as good readability and comprehensiveness. In this context, a computerized physician order entry (CPOE) system can be helpful. This study aims to investigate the distinct effects on the quality of prescription documentation of a CPOE system implemented on general wards in a large tertiary care hospital.MethodsIn a retrospective analysis, the prescriptions of two groups of 160 patients each were evaluated, with data collected before and after the introduction of a CPOE system. According to nationally available recommendations on prescription documentation, it was assessed whether each prescription fulfilled the established 20 criteria for a safe, complete, and actionable prescription. The resulting fulfilment scores (prescription-Fscores) were compared between the pre-implementation and the post-implementation group and a multivariable analysis was performed to identify the effects of further covariates, i.e., the prescription category, the ward, and the number of concurrently prescribed drugs. Additionally, the fulfilment of the 20 criteria was assessed at an individual criterion-level (denoted criteria-Fscores).ResultsThe overall mean prescription-Fscore increased from 57.4% ± 12.0% (n = 1850 prescriptions) before to 89.8% ± 7.2% (n = 1592 prescriptions) after the implementation (p < 0.001). At the level of individual criteria, criteria-Fscores significantly improved in most criteria (n = 14), with 6 criteria reaching a total score of 100% after CPOE implementation. Four criteria showed no statistically significant difference and in two criteria, criteria-Fscores deteriorated significantly. A multivariable analysis confirmed the large impact of the CPOE implementation on prescription-Fscores which was consistent when adjusting for the confounding potential of further covariates.ConclusionsWhile the quality of prescription documentation generally increases with implementation of a CPOE system, certain criteria are difficult to fulfil even with the help of a CPOE system. This highlights the need to accompany a CPOE implementation with a thorough evaluation that can provide important information on possible improvements of the software, training needs of prescribers, or the necessity of modifying the underlying clinical processes.

Design, development, and deployment of an indication- and kidney function-based decision support tool to optimize treatment and reduce medication dosing errors.

Delivering clinical decision support (CDS) at the point of care has long been considered a major advantage of computerized physician order entry (CPOE). Despite the widespread implementation of CPOE, medication ordering errors and associated adverse events still occur at an unacceptable level. Previous attempts at indication- and kidney function-based dosing have mostly employed intrusive CDS, including interruptive alerts with poor usability. This descriptive work describes the design, development, and deployment of the Adult Dosing Methodology (ADM) module, a novel CDS tool that provides indication- and kidney-based dosing at the time of order entry. Inclusion of several antimicrobials in the initial set of medications allowed for the additional goal of optimizing therapy duration for appropriate antimicrobial stewardship. The CDS aims to decrease order entry errors and burden on providers by offering automatic dose and frequency recommendations, integration within the native electronic health record, and reasonable knowledge maintenance requirements. Following implementation, early utilization demonstrated high acceptance of automated recommendations, with up to 96% of provided automated recommendations accepted by users.

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.

Computerized Physician Order Entry in the Neonatal Intensive Care Unit: A Narrative Review.

Computerized physician order entry (CPOE) has grown since the early 1990s. While many systems serve adult patients, systems for pediatric and neonatal populations have lagged. Adapting adult CPOE systems for pediatric use may require significant modifications to address complexities associated with pediatric care such as daily weight changes and small medication doses. This article aims to review the neonatal intensive care unit (NICU) CPOE literature to characterize trends in the introduction of this technology and to identify potential areas for further research. Articles pertaining to NICU CPOE were identified in MEDLINE using MeSH terms "medical order entry systems," "drug therapy," "intensive care unit, neonatal," "infant, newborn," etc. Two physician reviewers evaluated each article for inclusion and exclusion criteria. Consensus judgments were used to classify the articles into five categories: medication safety, usability/alerts, clinical practice, clinical decision Support (CDS), and implementation. Articles addressing pediatric (nonneonatal) CPOE were included if they were applicable to the NICU setting. Sixty-nine articles were identified using MeSH search criteria. Twenty-two additional articles were identified by hand-searching bibliographies and 6 articles were added after the review process. Fifty-five articles met exclusion criteria, for a final set of 42 articles. Medication safety was the focus of 22 articles, followed by clinical practice (10), CDS (10), implementation (11), and usability/alerts (4). Several addressed more than one category. No study showed a decrease in medication safety post-CPOE implementation. Within clinical practice articles, CPOE implementation showed no effect on blood glucose levels or time to antibiotic administration but showed conflicting results on mortality rates. Implementation studies were largely descriptive of single-hospital experiences. CPOE implementation within the NICU has demonstrated improvement in medication safety, with the most consistent benefit involving a reduction in medication errors and wrong-time administration errors. Additional research is needed to understand the potential limitations of CPOE systems in neonatal intensive care and how CPOE affects mortality.

The impact of computerized physician order entry on prescription orders: A quasi-experimental study in Iran.

Background: One way to reduce medical errors associated with physician orders is computerized physician order entry (CPOE) software. This study was conducted to compare prescription orders between 2 groups before and after CPOE implementation in a hospital. Methods: We conducted a before-after prospective study in 2 intensive care unit (ICU) wards (as intervention and control wards) in the largest tertiary public hospital in South of Iran during 2014 and 2016. All prescription orders were validated by a clinical pharmacist and an ICU physician. The rates of ordering the errors in medical orders were compared before (manual ordering) and after implementation of the CPOE. A standard checklist was used for data collection. For the data analysis, SPSS Version 21, descriptive statistics, and analytical tests such as McNemar, chi-square, and logistic regression were used. Results: The CPOE significantly decreased 2 types of errors, illegible orders and lack of writing the drug form, in the intervention ward compared to the control ward (p< 0.05); however, the 2 errors increased due to the defect in the CPOE (p< 0.001). The use of CPOE decreased the prescription errors from 19% to 3% (p= 0.001), However, no differences were observed in the control ward (p<0.05). In addition, more errors occurred in the morning shift (p< 0.001). Conclusion: In general, the use of CPOE significantly reduced the prescription errors. Nonetheless, more caution should be exercised in the use of this system, and its deficiencies should be resolved. Furthermore, it is recommended that CPOE be used to improve the quality of delivered services in hospitals.

Case Not Closed: Prescription Errors 12 Years after Computerized Physician Order Entry Implementation

To assess the prolonged impact of computerized physician order entry (CPOE) on medication prescription errors in pediatric intensive care patients. This observational study was conducted at a pediatric intensive care unit in which a CPOE (Metavision, iMDsoft, Israel) with a limited clinical decision support system was implemented between 2004 and 2007. Since then, no changes were made to the systems. We analyzed 2500 electronic prescriptions (1250 prescriptions from 2015 and 1250 prescriptions from 2016). Prescription errors were identified by a pediatric intensive care physician and classified as potential adverse drug events, medication prescription errors, or rule violations. Their prevalence was compared with the rate in 2007, reported in a previous study from the same unit. A randomly selected 10% of the prescriptions were also analyzed by the pediatric intensive care unit pharmacist, and the level of agreement was determined. The rate of prescription errors increased from 1.4% in 2007 to 3.2% in 2015 (P = .03). Following revision of the clinical decision support system tools, prescription errors decreased to 1% in 2016 (P < .0001). The potential adverse drug event rate dropped from 2% in 2015 to 0.7% in 2016 (P = .006), and the medication prescription error rate, from 1% to 0.2% (P = .01). The agreement between the 2 reviewers was excellent (k = 0.96). The rate of prescription errors may increase with time from implementation of a CPOE. Repeated surveillance of prescription errors is highly advised to plan strategies to reduce them. This approach should be considered in quality improvement of computerized information systems in general.

National trends in safety performance of electronic health record systems in children's hospitals.

To evaluate the safety of computerized physician order entry (CPOE) and associated clinical decision support (CDS) systems in electronic health record (EHR) systems at pediatric inpatient facilities in the US using the Leapfrog Group's pediatric CPOE evaluation tool. The Leapfrog pediatric CPOE evaluation tool, a previously validated tool to assess the ability of a CPOE system to identify orders that could potentially lead to patient harm, was used to evaluate 41 pediatric hospitals over a 2-year period. Evaluation of the last available test for each institution was performed, assessing performance overall as well as by decision support category (eg, drug-drug, dosing limits). Longitudinal analysis of test performance was also carried out to assess the impact of testing and the overall trend of CPOE performance in pediatric hospitals. Pediatric CPOE systems were able to identify 62% of potential medication errors in the test scenarios, but ranged widely from 23-91% in the institutions tested. The highest scoring categories included drug-allergy interactions, dosing limits (both daily and cumulative), and inappropriate routes of administration. We found that hospitals with longer periods since their CPOE implementation did not have better scores upon initial testing, but after initial testing there was a consistent improvement in testing scores of 4 percentage points per year. Pediatric computerized physician order entry (CPOE) systems on average are able to intercept a majority of potential medication errors, but vary widely among implementations. Prospective and repeated testing using the Leapfrog Group's evaluation tool is associated with improved ability to intercept potential medication errors.

Drug-Drug Interactions Among Hospitalized Children Receiving Chronic Antiepileptic Drug Therapy.

Children treated with chronic medications are at risk of drug-drug interactions (DDIs) when hospitalized with an acute illness and prescribed new medications. We aimed to measure the prevalence of potential DDIs (pDDIs) among hospitalized children treated with antiepileptic drugs (AEDs) and to evaluate the impact of computerized physician order entry (CPOE) on pDDIs. We analyzed a national sample of pediatric hospitalizations from 2005 to 2012 associated with administration of an AED and identified those prescribed a second medication with risk of a DDI. The prevalence of hospitalizations associated with a pDDI was calculated for each AED. We identified the drugs most commonly implicated in pDDIs and factors associated with pDDIs. Rates of pDDIs were measured in pre- and post-CPOE implementation periods. A pDDI was identified in 181 380 (41.7%) hospitalizations associated with the use of an AED, with 117 880 (27.1%) classified as severe pDDIs. AEDs most often implicated with a pDDI were phenobarbital, valproic acid, and phenytoin. Hospitalizations with pDDIs were associated with increased length of stay and a greater number of medications, ICU admissions, and operating room procedures. The implementation of CPOE did not result in a change in the rate of pDDIs (42.7% before versus 40.8% after; P = .48). Children treated with AEDs are at risk of pDDIs while hospitalized. The use of CPOE has not been associated with a significant decrease in the rate of pDDIs. Additional investigation to better define the impact of pDDIs and to advance development of clinical decision support within CPOE systems is warranted.

Taxonomy of delays in the implementation of hospital computerized physician order entry and clinical decision support systems for prescribing: a longitudinal qualitative study.

BackgroundImplementation delays are common in health information technology (HIT) projects. In this paper, we sought to explore the reasons for delays in implementing major hospital-based HIT, through studying computerized physician order entry (CPOE) and clinical decision support (CDS) systems for prescribing and to develop a provisional taxonomy of causes of implementation delays.MethodsWe undertook a series of longitudinal, qualitative case studies to investigate the implementation and adoption of CPOE and CDS systems for prescribing in hospitals in the U.K. We used a combination of semi-structured interviews from six case study sites and two whole day expert roundtable discussions to collect data. Interviews were carried out with users, implementers and suppliers of CPOE/CDS systems. We used thematic analysis to examine the results, drawing on perspectives surrounding the biography of artefacts.ResultsWe identified 15 major factors contributing to delays in implementation of CPOE and CDS systems. These were then categorized in a two-by-two delay classification matrix: one axis distinguishing tactical versus unintended causes of delay, and the second axis illustrating internal i.e., (the adopting hospital) versus external (i.e., suppliers, other hospitals, policymakers) related causes.ConclusionsOur taxonomy of delays in HIT implementation should enable system developers, implementers and policymakers to better plan and manage future implementations. More detailed planning at the outset, considering long-term strategies, sustained user engagement, and phased implementation approaches appeared to reduce the risks of delays. It should however be noted that whilst some delays are likely to be preventable, other delays cannot be easily avoided and taking steps to minimize these may negatively affect the longer-term use of the system.

Improvement of the Trauma Care Process by Implementation of a Computerized Physician Order Entry-Based Trauma Team Approach

AbstractOriginal Article Improvement of the Trauma Care Process by Implementation of a Computerized Physician Order Entry-Based Trauma Team Approach1Purpose: The need for the rapid evaluation and treatment of emergency depart-ment patients with major trauma is essential. A computerized physician order entry (CPOE) system can improve communication and provide immediate access to in-formation with the goal of reducing ED time delays. The aim of this study was to report on the operation of a trauma CPOE program and demonstrate its usefulness by comparing time intervals from ED arrival to various evaluation steps before and after implementation of the program.Methods: This was a before-and-after observational study from a single emergen-cy department at an academic center. The CPOE program was implemented for 6 months and compared with the data collected from the pre-CPOE implementation period. The efficacy of the program was assessed by comparing the time difference before and after CPOE implementation based on the following factors: total board-ing time in ED, door-to-disposition decision time, door-to-blood-test report time, door-to-X-ray time, door-to-CT time, and door-to-transfusion time.Results: Over a period of 6 months, the CPOE was activated for a total of 17 pa-tients. Total boarding time was reduced significantly after implementation [medi-an, 641.5 minutes (IQR, 367.3-859.3) versus289.0 minutes (IQR, 140.0-508.0) for pre-CPOE vs. post-CPOE, respectively, p< 0.05). Time intervals for all evaluation steps were reduced after implementation of the program. The improvements in the door-to-blood-test and door-to-CT times were both statistically significant.Conclusion: This study demonstrated that a standard CPOE system can be success-fully implemented and can reduce ED time delays in managing trauma patients. Key wordsEmergency department, Computerized physician order entry, Trauma

Effect of Computerized Physician Order Entry on Imaging Study Indication

PurposeThe effect of computerized physician order entry (CPOE) on imaging indication quality had only been measured in one institution’s emergency department using a homegrown electronic health record with faculty physicians, and only with one instrument. To better understand how many US hospitals’ recent CPOE implementations had affected indication quality, we measured its effect in a generalizable inpatient setting, using one existing and one novel instrument. MethodsWe retrospectively analyzed the indications for 100 randomly selected inpatient abdominal CT studies during 2 calendar months immediately prior to a 3/3/2012 CPOE implementation (1/1/2012-2/29/2012) and during 2 subsequent calendar months (5/1/2012-6/30/2012). We excluded 2 intervening months to avoid behaviors associated with adoption. We measured indication quality using a published 8-point explicit scoring scale and our own, novel, implicit 7-point Likert scale. ResultsExplicit scores increased 93% from a pre-CPOE mean ± 95% confidence interval of 1.4 ± 0.2 to a CPOE mean of 2.7 ± 0.3 (P < .01). Implicit scores increased 26% from a pre-CPOE mean of 4.3 ± 0.3 to a CPOE mean of 5.4 ± 0.2 (P < .05). When presented with a statement that an indication was “extremely helpful,” and choices ranging from “strongly disagree” = 1 to “strongly agree” = 7, implicit scores of 4 and 5 signified “undecided” and “somewhat agree,” respectively. ConclusionsIn an inpatient setting with strong external validity to other US hospitals, CPOE implementation increased indication quality, as measured by 2 independent scoring systems (one pre-existing explicit system and one novel, intuitive implicit system). CPOE thus appears to enhance communication from ordering clinicians to radiologists.

Computerized physician order entry and decision support improves ED analgesic ordering for renal colic

ObjectivesComputerized physician order entry (CPOE) offers the potential for safer, faster patient care, as well as greater use of evidence-based therapy via built-in decision support. However, the effectiveness of CPOE in yielding these benefits has shown mixed results in the emergency department (ED) setting. Our objective was to evaluate the impact of CPOE implementation on analgesic prescribing and dosing practices for renal colic presentations. MethodsThis retrospective pre/post comparative study was conducted in 3 tertiary hospitals that implemented CPOE in 2010. Two patient groups were compared: prior to (pre-CPOE) and after (post-CPOE) CPOE implementation. Each group consisted of 230 randomly selected, high-acuity patients presenting to the ED with renal colic. The primary outcome was the proportion of patients receiving ketorolac in the ED. Secondary outcomes included choice of analgesic and average morphine dose. ResultsThe proportion of patients receiving ketorolac significantly increased after CPOE implementation (65.6% pre-CPOE vs 76.5% post-CPOE, P = .015), as did the proportion of patients receiving fentanyl (pre, 9.7%; post, 16.7%; P = .047). Differences in morphine use (pre, 66.0%; post, 69.1%) and average morphine dose (pre, 10.09 mg; post, 12.28 mg) did not reach statistical significance. ConclusionsThe introduction of CPOE is associated with an increase in ketorolac use for ED renal colic visits. This may reflect the inclusion of ketorolac in the renal colic order set. Computerized physician order entry implementation with condition-specific electronic order sets and decision support may improve evidence-based practice.