Order Entry Process Research Articles

Preventing Overrides of Severe Drug Allergy Alerts Initiative: an Implemented System Upgrade

Administering medications to patients with documented drug hypersensitivity reactions (DHR) poses a significant risk for adverse events, ranging from mild reactions to life-threatening incidents. Electronic healthcare systems have revolutionized the modern clinical decision-making process, with built in warnings. However, as these alerts become a routine part of healthcare provider’s workflow, alert fatigue becomes a challenge. This study was conducted within the Ministry of National Guard Health Affairs (MNGHA), a government healthcare system in Saudi Arabia. A taskforce of experts was formed to develop an electronic path that would prevent unintentional overrides of severe drug allergy alerts. The system underwent rigorous testing, and monitoring parameters were established. We outline the implementation of a system upgrade designed to trigger an alternative interruption in the computerized physician order entry (CPOE) process, distinct from the regular allergy pop-up alerts. The alternate path is activated upon a CPOE with a drug-to-drug match and a documented severe drug allergy symptom, necessitating co-signature form another prescriber before proceeding. The adopted upgrade is a proactive approach to enhance medication safety in electronic healthcare systems, ensuring that serious allergy-related warnings are not overridden, ultimately enhancing patient safety. Further monitoring will confirm the safety and effectiveness of this measure. This study provides a model for institutions seeking to prevent allergy-related harm within their patient population.

A-182 Applications of artificial intelligence optical character recognition in laboratory clerical functions offsetting staffing shortages and error reduction

Abstract Background The clinical laboratory profession has been dealing with a decade long, and now critical retention and staffing problem. The average national turnover rate for laboratory technicians is 17%, and the highest turnover rate exhibited for phlebotomists is 36%. While turnover rates have an impact on a laboratory, or hospitals budget, more importantly they have a substantial impact on quality and error rates, particularly in the pre-analytical stage of testing; with studies showing up to 65.09% of errors impacting the pre-analytical phase. Methods In an effort to remedy this high error rate, a meta-analysis was performed on paper order entry and clerical pre-analytical error, in parallel with performance and accuracy data of advanced optical character recognition driven by artificial intelligence and machine learning (AI OCR). Results AI OCR studies demonstrated an untrained accuracy percentage, to include handwriting of 91.08%, and when trained utilizing both relational and hierarchal logic data bases accuracy increased to 98.4%. The rate at which AI OCR processed and classified medical information was 3-4 pages per second. It is estimated that 99.9%-100% accuracy can be achieved with additional form field training and mapping. The level of accuracy and efficiency for laboratory paper order-entry utilizing AI OCR can also be increased with the addition of natural language processing and data recognition algorithms when combined with logic databases containing information such as medical record numbers, ICD-10 codes, and laboratory test compendiums. Conclusions The performance of this technology demonstrates a strong application to reduce the burden of clerical paper order entry, while addressing the 30.8% dissatisfaction rate regarding manual entry processes among lab professionals surveyed. Moreover, AI OCR clerical data classification, extraction and entry processes augmented with human verification steps examined, demonstrated overall accuracy of 99.99%. The application of AI OCR in laboratory pre-analytical processes has the potential to improve test order accuracy and efficiency, ultimately impacting the quality of patient care and operational costs for healthcare facilities. When examined through the lens of staff retention, studies show that 80% of laboratory employees feel that a workplace with the necessary tools and technology positively impacts their job satisfaction. While organizations investing in technologies that drive both job efficiency and satisfaction see a 125% return on investment through productivity. Demonstrating that the application of sophisticated technologies that both increase productivity and decrease error rates have a substantial impact on job satisfaction and ultimately retention. Although laboratory clerical data and order entry processes were examined for this meta-analysis, the aggregate data compiled showed that the application of AI OCR in clerical processes could also have a substantial impact on the 25.9% annual turnover rate for hospitals as a whole in the United States.

Implement Electronic Decision Support to Decrease Hospital-Onset Clostridium difficile Infections at Two Community Hospitals

Background: Literature supports appropriate testing as a key factor affecting the hospital-onset (HO) Clostridium difficile infections (CDI) standardized infection ratio (SIR). In 2016, facility A was a significant outlier in HO CDI with an SIR of 2.57. In 2017, facility B had a peak SIR of 1.9. Both SIRs were considerably higher than the Centers for Medicare and Medicaid Services (CMS) national SIR of 0.997. Methods: Hospital-onset CDIF cases from both hospitals were reviewed. Current electronic decision support in the electronic health record (EHR) was evaluated for CDI laboratory orders. Literature was reviewed for best practice of appropriate specimen collection and testing. Interventions were implemented at facility A in November 2016 and facility B in June 2018. Results: In total, 67 HO CDIF cases were reviewed from both facilities (October 2015–September 2016 for facility A and April 2017–June 2018 for facility B), and 46% were due to inappropriate testing. A CDI testing order set with decision support and best practice alerts was implemented based on national best-practice guidelines (Fig. 1). Physician and nurse education were completed on appropriate testing for CDI, including symptoms and timely specimen collection. Real-time review of appropriate testing was validated by the infection prevention team, and outliers were communicated to the ordering provider. After implementation, decreases in HO-CDIF SIRs occurred at both facilities (facility A SIR, 0.36; facility B SIR, 0.56). Both facilities have been able to sustain an SIR below the current CMS national average of 0.784. Conclusions: By implementing a sophisticated order-entry process that includes electronic decision support based on best practices, clinician education, and real-time feedback to providers, patients are appropriately tested for CDI. This intervention has allowed for appropriate classification within the NHSN and has decreased the overall HO-CDIF SIR.Funding: NoneDisclosures: None

Information Technology–Assisted Screening for Gonorrhea and Chlamydia in a Pediatric Emergency Department

PurposeThe aim of the study was to design and implement a novel, universally offered, computerized clinical decision support (CDS) gonorrhea and chlamydia (GC/CT) screening tool embedded in the emergency department (ED) clinical workflow and triggered by patient-entered data. MethodsThe study consisted of the design and implementation of a tablet-based screening tool based on qualitative data of adolescent and parent/guardian acceptability of GC/CT screening in the ED and an advisory committee of ED leaders and end users. The tablet was offered to adolescents aged 14–21 years and informed patients of Centers for Disease Control and Prevention GC/CT screening recommendations, described the testing process, and assessed whether patients agreed to testing. The tool linked to CDS that streamlined the order entry process. The primary outcome was the patient capture rate (proportion of patients with tablet data recorded). The secondary outcomes included rates of patient agreement to GC/CT testing and provider acceptance of the CDS. ResultsOutcomes at the main and satellite EDs, respectively, were as follows: 1-year patient capture rates were 64.6% and 64.5%; 9.9% and 4.4% of patients agreed to GC/CT testing, and of those, the provider ordered testing for 73% and 72%. ConclusionsImplementation of this computerized screening tool embedded in the clinical workflow resulted in patient capture rates of almost two-thirds and clinician CDS acceptance rates >70% with limited patient agreement to testing. This screening tool is a promising method for confidential GC/CT screening among youth in an ED setting. Additional interventions are needed to increase adolescent agreement for GC/CT testing.

The effect of restrictive blood transfusion policy on patients undergoing major liver surgery

Presenter: Jonathan DeLong MD | University of California, San Diego Background: Unrestricted transfusion practices expose patients to potentially harmful complications and are major cost drivers in critically ill patients. Our institution adopted a restrictive transfusion policy driven by education, a point of service BestPractice Advisory (BPA), and enhancements to the electronic order entry process starting Q3 2014, completed by Q2 2015, with additional electronic functionality and education completed by Q2 2017. We investigated whether these interventions altered transfusion practices following complex liver surgery, and whether restrictive transfusion practices affected outcomes. Methods: A retrospective review was performed of patients at an academic medical center undergoing major liver surgery at over a six-year period from 2013 to 2018. All patients undergoing total lobectomy, trisegmentectomy, and partial hepatectomy were included. There were 272 total liver resection cases in the entire cohort. Preintervention, transition period, and postintervention periods were considered. Results: Overall blood transfusion decreased from 42.4% preintervention to 21.7% during the intervention to 7.1% postintervention (p < 0.001). Adherence to best practice recommendations improved from 34.6% preintervention to 68.8% during the intervention period to 100% postintervention (p < 0.001). Absolute RBC transfusions were also decreased in the post intervention group (p = 0.006). There was no difference in liver resection type (lobectomy, trisegementectomy, partial lobectomy) between the groups (p = 0.095). There was no difference in major complications (defined as death, cardiac arrest, MI, CVA, and progressive renal failure requiring dialysis) between the three periods (p = 0.863). Infectious complications (defined as surgical site infections, urinary tract infection, or pneumonia) were not significantly different between the groups (p = 0.849). Similarly, there was no difference in bile leak and progression to liver failure (p = 0.251 and p = 0.480 respectively). Surgical take backs readmission rates were not statistically different between the 3 groups (p = 0.229 and p = 0.372). Conclusion: Implementing the institutional policy for restrictive blood transfusion reduced the rate of perioperative blood transfusion for major liver surgery by 35.3%. Adherence to best practice guidelines for blood transfusion improved by 65.4%. Restricting transfusion of RBCs did not result in a statistically significant difference in major post-operative complications, post-operative infections, bile leak, or progression to liver failure. Surgical take backs and readmissions were also unchanged. We conclude that restrictive RBC transfusion practices can safely be adopted in patients undergoing major liver surgery without increasing post-operative complications or exposing patients to unnecessary transfusion risks.

1439. Reducing the Number of Urine Cultures Performed Through Stringent Urinalysis Reflex Criteria

BackgroundAlmost half of urine cultures (UCs) obtained are in asymptomatic patients, which may lead to misdiagnosis of urinary tract infection (UTI) and unnecessary treatment. To decrease misdiagnosis of UTI, changes were made to the order entry and urine culture process at our institution in April 2018. This included removal of a standalone UC from the electronic order entry system and development of a more stringent criterian for urinalysis with reflex culture (UAC). We evaluated the impact of these ordering changes on the total number of UCs performed.MethodsThis was a pre-post retrospective study comparing the hospital UAC rate per 1,000 patient-days and ED UAC rate per 1,000 visits in the pre-intervention period from April 2017 to March 2018 to the intervention period from May 2018 to March 2019 in a 319-bed teaching hospital in northwest Ohio. In April 2018, urine microscopy and UAC were the only available options. Furthermore, UC would only be performed if the following criteria were met: 10 white blood cells (WBC)/HFP. Standalone UC was available for the following patients who were excluded: immunosuppressed patients, pregnant women and patients undergoing invasive urologic procedures. These changes were accompanied by provider education, and providers were given the option to override UAC rules by calling the microbiology lab within 24 hours to request UC.ResultsAfter incorporating these changes, we observed an increase in the use of UAC compared with UC-only in both the ED (80% pre-vs. 94% post-implementation) and inpatient setting (59% pre-vs. 92% post-implementation). This was accompanied by a reduction in the overall UCs performed in both the ED (49.17 per 1,000 visits to 23.53 per 1,000 visits [P < 0.001]) and inpatient units (23.31 per 1,000 patient-days to 9.31 per 1,000 patient-days [P < 0.001]). Chart review of cases where providers overrode UAC criteria and requested UC have demonstrated no false negatives to date; cultures either had no growth or were consistent with contamination by polymicrobial urogenital flora.ConclusionRestricted access to standalone UC, implementation of UAC with more stringent criteria and provider education reduced the number of urine cultures performed without sacrificing sensitivity for detecting UTI and potential antimicrobial use.Disclosures All authors: No reported disclosures.

Sustained Increases in the Quality of Imaging Histories Provided by Ordering Providers Resulting From Multidisciplinary Collaboration and Systems Design.

OBJECTIVE. The purpose of this quality improvement project was to create sustained improvement in the frequency of more complete imaging histories provided with imaging examinations submitted directly by ordering providers. A secondary purpose was increasing the number of characters submitted by ordering providers with imaging examinations. MATERIALS AND METHODS. A multidisciplinary team defined the components of a complete imaging history, a process that underwent several improvement cycles. Audits were regularly performed using consensus, and the project team regularly evaluated the completeness of the imaging histories. The final components of the definition of a complete imaging history included responses regarding what happened, when it happened, where the patient was experiencing pain, and the ordering provider's concern. Prompts were inserted into the electronic physician order entry process, and performance was monitored for an additional 18 months. RESULTS. A total of 10,236 orders were placed by providers in the study clinic from March 13, 2017, to December 16, 2018. Of the orders audited in the baseline period, 16.0% (64/397) of orders audited in the baseline period contained all four history components, which increased to 52.0% (2200/4234; absolute increase of 36.0%, relative increase of 225.0%; p < 0.0001) in the subsequent time periods, and improvement was sustained. The mean number of characters providers entered in the imaging histories they submitted increased from 45.4 characters per order during the baseline period to 75.4 (66.1% increase, p < 0.0001) after the intervention. CONCLUSION. By collaborating with a multidisciplinary team, we created a standardized definition of an imaging history, engineered our systems to include supportive prompts in the order entry interface, and sustainably improved the quality of imaging histories provided.

Can Automated Retrieval of Data from Emergency Department Physician Notes Enhance the Imaging Order Entry Process?

Background When a paucity of clinical information is communicated from ordering physicians to radiologists at the time of radiology order entry, suboptimal imaging interpretations and patient care may result. Objectives Compare documentation of relevant clinical information in electronic health record (EHR) provider note to computed tomography (CT) order requisition, prior to ordering of head CT for emergency department (ED) patients presenting with headache. Methods In this institutional review board-approved retrospective observational study performed between April 1, 2013 and September 30, 2014 at an adult quaternary academic hospital, we reviewed data from 666 consecutive ED encounters for patients with headaches who received head CT. The primary outcome was the number of concept unique identifiers (CUIs) relating to headache extracted via ontology-based natural language processing from the history of present illness (HPI) section in ED notes compared with the number of concepts obtained from the imaging order requisition. Results Our analysis was conducted on cases where the HPI note section was completed prior to image order entry, which occurred in 23.1% (154/666) of encounters. For these 154 encounters, the number of CUIs specific to headache per note extracted from the HPI (median = 3, interquartile range [IQR]: 2–4) was significantly greater than the number of CUIs per encounter obtained from the imaging order requisition (median = 1, IQR: 1–2; Wilcoxon signed rank p < 0.0001). Extracted concepts from notes were distinct from order requisition indications in 92.9% (143/154) of cases. Conclusion EHR provider notes are a valuable source of relevant clinical information at the time of imaging test ordering. Automated extraction of clinical information from notes to prepopulate imaging order requisitions may improve communication between ordering physicians and radiologists, enhance efficiency of ordering process by reducing redundant data entry, and may help improve clinical relevance of clinical decision support at the time of order entry, potentially reducing provider burnout from extraneous alerts.

Reducing medication errors involving antiretroviral therapy with targeted electronic medical record modifications

ABSTRACTMedication errors are common among HIV-infected patients on anti-retroviral therapy (ART), especially when transitioning to the inpatient setting. In previous studies, medication error rates among hospitalized patients on ART have been reported to exceed 50%. When patients receiving ART are admitted to the hospital, medication errors can be prevented through optimization of administration instructions and dosing defaults in order-entry screens in the electronic medical record (EMR). We sought to evaluate the impact of EMR modifications (defaulted doses, frequencies, and administration instructions) implemented to improve the order-entry process and reduce errors. All adult patients admitted between 10/1/2010–3/31/2012 (pre-EMR modification) and 10/1/2013–3/31/2014 (post-EMR modification) that continued on ART upon admission were included. The primary outcome was the overall rate of medication errors identified through review by the antimicrobial stewardship program (ASP). We also characterized the types of medication errors identified during the two time periods. Following EMR modifications, the medication error rate identified through ASP review was reduced from 50.2% to 28.2% (P < 0.01). The number of medication related errors relating to dosage (regimens requiring dose optimization, renal dose adjustment, and dose timing) were reduced by 22% (P < 0.01). Modifications at the anti-retroviral medication order-entry screens in the EMR significantly reduced medication errors, particularly with respect to dosing and dose timing.

193. Duration of Antimicrobial Therapy: The Impact of Defaults

BackgroundDefault durations imbedded in the electronic prescription (e-script) order entry process may be interpreted by providers as duration recommendations. This process could lead to inappropriately long durations of therapy for antibiotics, especially at hospital discharge when patients have received inpatient antibiotics.MethodsDefault durations of 7 or 10 days for fluoroquinolones (FQ) were removed from inpatient and outpatient e-scripts from Duke University Health System (DUHS) hospitals (one academic, two community) and clinics (N = 86) on December 19, 2017. We evaluated the impact on FQ duration by comparing mean duration and percent of 10 day durations in the 12 months pre-default duration removal (DDR) and 3 months post-DDR. All inpatient or outpatient encounters with an FQ e-script with days duration less than 31 days were included. FQ durations were captured in days duration fields or calculated from sig and quantity fields. We used descriptive statistics to compare FQ duration pre- and post-DDR using a chi-squared test.ResultsA total of 35,765 FQ e-scripts and 276,056 FQ e-script days of therapy were included pre-DDR. The post-DDR included 9,526 FQ e-scripts and 71,028 FQ e-script days of therapy. Mean (standard deviation) durations in the pre- and post-periods were 7.78 (4.35) and 7.55 (3.99), respectively (P < 0.001). Common discharge durations in both time periods across all settings were 5, 7, and 10 days. The 10-day default duration was the most common in the pre-DDR with 11,000 e-scripts (31%), and declined by 16% (2,475 e-scripts, 26%) in the post-DDR period. The academic center realized the greatest shift away from 10-day default duration (Table 1).ConclusionRemoval of default e-script durations, a novel and minimally resource intensive strategy, reduced prescribed duration of FQ therapy.Table 1: Ten-day Durations for Fluoroquinolone E-scripts Pre- and Post-DDRPractice SettingPre-DDRN (%) 10 day E-scriptsPost-DDRN (%) 10 day E-scripts% Change Pre–PostAcademic Medical Center771 (20)125 (11)-42Community hospital452 (20)90 (15)-23Community hospital514 (24)126 (21)-16Outpatient9,263 (34)2,134 (30)-12Total11,000 (31)2,475 (26)-16Disclosures All authors: No reported disclosures.

Improving the Inpatient Bowel Preparation

Introduction: Colonoscopy can be a vital tool for the evaluation and management of inpatients. However, bowel preparation in the inpatient setting is challenging, leading to suboptimal rates of adequate preparation. We identified ambiguity in the order entry process for inpatient bowel preparation as a potential target for improvement and deployed a new order set with a goal to improve rates of adequate inpatient bowel preparation. Methods: We developed a new order set that incorporated detailed instructions for inpatient bowel preparation. Within the order set, physicians chose a “standard” prep for patients beginning their prep for a next-day colonoscopy or a “rapid” prep for patients starting after 7pm or who needed an emergent procedure. We recorded demographic and clinical characteristics of patients undergoing non-elective inpatient colonoscopy, including the adequacy of their bowel prep before and after deployment of the new order. The primary outcome was the rate of adequate bowel preparation. Secondary outcomes included length of stay, volume of prep, prep duration, and rate of delayed procedures. Results: Data was recorded for 84 patients prior to implementation of the new order and 81 patients after. Baseline characteristics were similar between groups. There were no differences between the two groups in univariate analysis in LOS, prep duration, total prep, or the proportion of delayed procedures. In multivariate analysis, the OR for an adequate prep was 1.22 for the new order, with patients who were younger, non-delirious, or without baseline constipation more likely to have an adequate prep. Within the intervention group, 65 patients received the “standard” prep and 12 the “rapid” prep. Patients receiving the “rapid” prep employed a similar amount of prep to those in the “standard” subgroup but used it over a shorter period; however, this difference did not reach significance. The number of adequate preps did not differ between the “standard” and “rapid” subgroups in univariate analysis. Conclusion: The rate of adequate bowel preparation improved after deployment of the order set, this result did not reach significance. Patients in the intervention group selected for “rapid” prep were able to prep in less time than those selected for a “standard” prep. Administering all inpatient preps over a shorter period may lead to further improvement in prep quality.

Project to Improve the Transcription of Clinical Order Information into a Radiology Information System

CONTEXTInaccurate and incomplete imaging order information presented to interpreting radiologists is a persistent problem in many radiology settings. Computerized Physician Order Entry processes in clinic-based settings are often inconsistent, and radiology transcription clerks continue to play a critical role in transmitting accurate content and information from referring physician orders to the radiology information system. (RIS) The purpose of this quality improvement project was to a) identify common transcription areas of deficient RIS imaging order information and b) test outcomes from an intervention to improve the content and concordance of transcribed patient information entered into the RIS.METHODSA random convenience sample of 500 outpatient radiographic orders were categorized according to degree and quality of concordance between the transcribed patient information documented in the RIS and the corresponding original imaging order information. During Phase I, the authors used a root-cause analysis to determine the possible etiologies for discordance between the information in original imaging orders and the information transcribed into the RIS. The intervention that was delivered included a short education session with radiology transcription clerks with placement reminder posters at transcription workstations. During Phase 2, a second random sample was obtained following the intervention, with data collection and analyses replicating the process from Phase I. A set of inferential comparisons were conducted using chi-square tests to examine for statistical significance.RESULTSThere was an overall 44% decrease in transcription discordance (p < 0.001), and the number of cases with perfectly concordant RIS order indication documentations increased by 21% (p < 0.001). A total of 34% of transcriptions from Phase I were partially discordant due to an inadequate imaging study indication, compared to 15% during Phase II (p < 0.001). There was also a 22% increase in the number of completely concordant transcriptions free of grammatical errors (p < 0.001).CONCLUSIONSA short education session with radiology transcription clerks along with placement of reminder posters may significantly improve both the concordance and quality of transcribed imaging order information presented to interpreting radiologists using the RIS.

Decrease of Hospital-Onset Clostridium difficile through Enhanced Electronic Decision Support

BackgroundLiterature supports appropriate testing as a key factor affecting hospital onset (HO) Clostridium difficile (CDIF). It was recognized that our institution was a significant outlier in HO CDIF with a standardized infection ratio (SIR) of 2.567 in the second quarter of 2016 compared with a national SIR of 0.997. A February 2015 – April 2015 line list of CDIF LabID events were pulled from the National Healthcare Safety Network (NHSN) and medical records were reviewed for test appropriateness based on CDC/IDSA guidelines. Of these, 50% were related to inappropriate testing. Infection Prevention and Quality identified this as an opportunity for improvement and Executives dedicated resources to reduction efforts.MethodsA report was created using our data warehouse to track specimens that were not collected within 24 hours of an order, as well as patients that had testing done in the previous 7 days. Physician and nurse education was completed on appropriate testing for CDIF, including symptoms and timely specimen collection. An enhanced order set was launched which embedded the testing algorithm into a series of cascading questions and best practice alerts (BPAs) which prompt the provider to reconsider ordering if the patient has less than 3 episodes of diarrhea in a 24 hour period, and/or has alternative explanations for diarrhea, including tube feedings and/or laxatives. Any CDIF test results from the past 30 days appear on the order screen to further guide physician ordering.ResultsBased on our NHSN data, HO CDIF cases were identified from October 2015 – September 2016, resulting in a peak (SIR) of 2.567. Since the interventions in November 2016, we have decreased our SIR to 0.356 in the first quarter of 2017. This shows a 50% overall decrease in HO CDIF. The data warehouse report showed 99% compliance of specimens collected within 24 hours of an order and only 5% of patients with an order in the past 7 days.ConclusionBy implementing targeted education and a sophisticated order entry process that includes decision support, as well as recent results and treatments in the electronic medical record, CDIF cases are being appropriately ordered and collected, ensuring appropriate classification within NHSN and a decrease in overall SIRDisclosures All authors: No reported disclosures.

Introducing Students to Understanding Business Processes and Identifying Data Sources

ABSTRACT The ability to understand, document, and analyse business processes is a key skill for accountants. The lack of business experience makes it difficult for many students to grasp the concept of a business process, to recognize business processes in practice and to prepare the necessary documentation. One of the most problematic areas for these students is the identification of data sources and data flows. This step-by-step in-class exercise utilizes Amazon's order entry process, one with which the students have probably been engaged many times as customers without realizing the complication of the information system behind the website. This exercise allows for active/engaged student learning combined with intense instructor interaction. Additionally, the simple charting notation allows for easy transition to subsequent learning of flowcharting techniques. This exercise also provides an opportunity to touch on many subjects and themes that can be explored later in the semester. Students' feedback pertaining to this exercise was very positive.

Improving geriatric prescribing in the ED: a qualitative study of facilitators and barriers to clinical decision support tool use.

Clinical decision support (CDS) may improve prescribing for older adults in the Emergency Department (ED) if adopted by providers. Existing prescribing order entry processes were mapped at an initial Veterans Administration Medical Center site, demonstrating cognitive burden, effort and safety concerns. Geriatric order sets incorporating 2012 Beers guidelines and including geriatric prescribing advice and prepopulated order options were developed. Geriatric order sets were implemented at two sites as part of the multicomponent 'Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department' quality improvement initiative. Facilitators and barriers to order sets use at the two sites were evaluated. Phone interviews were conducted with two provider groups (n=20), those 'EQUiPPED' with the interventions (n=10, 5 at each site) and Comparison providers who were only exposed to order sets through a clickable option on the ED order menu within the patient's medical record (n=10, 5 at each site). All providers were asked about order set 'use' and 'usefulness'. Users (n=11) were asked about 'usability'. Order set adopters described 'usefulness' in terms of 'safety' and 'efficiency', whereas order set consultants and order set non-users described 'usefulness' in terms of 'information' or 'training'. Provider 'autonomy', 'comfort' level with existing tools, and 'learning curve' were stated as barriers to use. Quantifying efficiency advantages and communicating safety benefit over preexisting practices and tools may improve adoption of CDS in ED and in other settings of care.

Mandatory Assignment of Modified Wells Score Before CT Angiography for Pulmonary Embolism Fails to Improve Utilization or Percentage of Positive Cases.

The objective of our study was to determine the impact of embedding a pretest probability rule that is required during the computerized physician order-entry (CPOE) process on the appropriateness of CT angiography (CTA) of the pulmonary arteries for the diagnosis of pulmonary embolism (PE) in the emergency department (ED). Data were obtained from the electronic medical records of all adults who visited the ED from October 17, 2010, through October 17, 2012 (n = 96,507). The primary outcome was the appropriateness of pulmonary CTA. Logistic regression was used to test whether rates of appropriate use, overuse, and underuse of pulmonary CTA improved significantly after the implementation of the decision support tool when controlling for other patient characteristics. Pulmonary CTA was appropriately used in 67.2% of patients with a modified Wells score of ≥ 4, a positive d-dimer test result, or both. CTA was overused in 19.3% of patients and underused in 13.5% of patients. Each additional month after the start of the intervention was associated with a 4-percentage point increase in the odds that the modified Wells score would indicate CTA had been used appropriately (odds ratio [OR] = 1.04; 95% CI, 1.01-1.07) and significantly lowered the odds of overuse of CTA (OR = 0.93; 95% CI, 0.90-0.96) based on the modified Wells score. These changes were not associated with any significant alteration in the level of CTA utilization or the positivity rate. The addition of a mandatory field in the CPOE record was associated with a significant improvement in the appropriate ordering of pulmonary CTA but did not change the PE positive rate or CTA utilization. It seems likely that physicians gradually inflated the modified Wells scores in spite of the fact that a threshold modified Wells score was not required to perform pulmonary CTA.

Variation in Formulary Management Practices Within the Department of Veterans Affairs Health Care System.

All Department of Veterans Affairs Medical Centers (VAMCs) operate under a single national drug formulary, yet substantial variation in prescribing and spending exists across facilities. Local management of the national formulary may differ across VAMCs and may be one cause of this variation. To characterize variation in the management of nonformulary medication requests and pharmacy and therapeutics (P&T) committee member perceptions of the formulary environment at VAMCs nationwide. We performed an online survey of the chief of pharmacy and an additional staff pharmacist and physician on the P&T committee at all VAMCs. Respondents were asked questions regarding criteria for use for nonformulary medications, specific procedures for ordering nonformulary medications in general and specific lipid-lowering and diabetes agents, the appeals process, and the formulary environment at their VAMCs. We compared responses across facilities and between chiefs of pharmacy, pharmacists, and physicians. A total of 212 chief pharmacists (n = 80), staff pharmacists (n = 78), and physicians (n = 54) responded, for an overall response rate of 49%. In total, 107/143 (75%) different VAMCs were represented. The majority of VAMCs reported adhering to national criteria for use, with 38 (36%) being very adherent and 69 (65%) being mostly adherent. There was substantial variation between VAMCs regarding how nonformulary drugs were ordered, evaluated, and appealed. The nonformulary lipid-lowering drugs ezetimibe, rosuvastatin, and atorvastatin were viewable to providers in the order entry screen at 67 (63%), 67 (63%), and 64 (60%) VAMCs, respectively. The nonformulary diabetes medication pioglitazone was only viewable at 58 (55%) VAMCs. In the remaining VAMCs, providers could not order these nonformulary drugs through the normal order-entry process. For questions about the formulary environment, physician respondent perceptions differed from those of staff pharmacists and chief pharmacists. Compared with pharmacy chiefs and staff pharmacists, physicians were less likely to agree that providers at their VAMC prescribed too many nonformulary medications (47% and 44% vs. 12%, P < 0.001), more likely to agree that providers must jump through too many hoops to prescribe nonformulary medication (5% and 3% vs. 25%, P < 0.001), and more likely to agree that providers make an effort to convert new patients from nonformulary to formulary lipid-lowering (65% and 73% vs. 94%, P <0.02) and diabetic medications (49% and 50% vs. 88%, P < 0.001). Although the Department of Veterans Affairs (VA) operates under a single national formulary, we found significant differences among VAMCs regarding their management of nonformulary medication requests. We also found differences among formulary leaders regarding their perception of the environment in which their VAMC's formulary is managed. These findings have important implications not just for VA, but for any organization that develops, implements, and manages drug formularies across multiple facilities.

Changing Behaviors and Intrinsic Motivation Through Scenario-Based Learning: A Case Study

When training occurs on the job over time, the collective wisdom of the organization becomes the norm. This knowledge or way of doing things is not always the best way and may cause problems elsewhere in the system. This article is a case study that looks at the order entry process of a midsized company and describes the motivational aspects of the performance intervention, as well as the systematic design and development of scenario-based learning.

Cost-of-Quality Optimization via Zero-One Polynomial Programming

In this paper, we consider a Cost-of-Quality (CoQ) optimization problem that finds an optimal allocation of prevention and inspection resources to minimize the expected total quality costs under a prevention-appraisal-failure framework, where the quality costs in the proposed model are involved with prevention, inspection, and correction of internal and external failures. Commencing with a simple structure of the problem, we progressively increase the complexity of the problem by accommodating realistic scenarios regarding preventive, appraisal, and corrective actions. The resulting problem is formulated as a zero-one polynomial program, which can be solved either directly using a mixed-integer nonlinear programming solver such as BARON, or using a more conventional mixed-integer linear programming (MILP) solver such as CPLEX after performing an appropriate linearization step. We examine two case studies from the literature (related to a lamp manufacturing context and an order entry process) to illustrate how the proposed model can be utilized to find optimal inspection and prevention strategies, as well as to analyze sensitivity with respect to different cost parameters. We also provide a comparative numerical study of using the aforementioned solvers to optimize the respective model formulations. The results provide insights into the use of such quantitative methods for optimizing the CoQ, and indicate the efficacy of using the linearized MILP model for this purpose.

Duplicate Laboratory Test Reduction Using a Clinical Decision Support Tool

Duplicate laboratory tests that are unwarranted increase unnecessary phlebotomy, which contributes to iatrogenic anemia, decreased patient satisfaction, and increased health care costs. We employed a clinical decision support tool (CDST) to block unnecessary duplicate test orders during the computerized physician order entry (CPOE) process. We assessed laboratory cost savings after 2 years and searched for untoward patient events associated with this intervention. This CDST blocked 11,790 unnecessary duplicate test orders in these 2 years, which resulted in a cost savings of $183,586. There were no untoward effects reported associated with this intervention. The movement to CPOE affords real-time interaction between the laboratory and the physician through CDSTs that signal duplicate orders. These interactions save health care dollars and should also increase patient satisfaction and well-being.