The impact of computerised physician order entry systmes on pathology services

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The article cited below is a literature review of studies undertaken between 1990 and August 2004 to asses the impact of computerized order entry systems (CPOE) on pathology services. The systematic review yielded a total of 19 studies. 11 studies compared locations with CPOE for pathology with sites that had no CPOE. Of the eleven, 4 studies compared locations that had CPOE’s without decision support to locations that had no CPOE’s at all. The other 8 of the 19 studies compared CPOE’s with decision support to CPOE’s without decision support.

The literature review was performed by researching databases like MEDLINE, CINAHL, EMBASE, SocScience Index, and Cochrane Database of Systematic Reviews. Web-based searches using the search engine Google and manual searches of international health informatics journals were also done. The studies evaluated, spanned a multitude of geographical locations including USA, UK, Canada, Norway, and South Korea. The studies evaluated used a variety of designs which included randomized controlled trials, non-randomized controlled trials, before and after studies, lab based quasi-experimental studies, and interrupted time series studies.

The results of the review were organized based on the different stages of pathology order and reporting process. The stages identified were

1. Test ordering

2. Test processing

3. Application of test results

Test Ordering: The reviewers looked at 16 papers that dealt with the impact of CPOE on the test ordering process (stage 1). Of those 16, 11 papers dealt with impact of CPOE’s on test volume “and /or total average test costs”, 2 dealt with CPOE impact on redundant orders, 3 that dealt with compliance to guidelines, and 3 “assessed clinical work practices.”

· CPOE and test volume – Total of 11 papers reviewed:

o 3 showed no change in test volume due CPOE use

o 1 showed an increase in tests ordered due CPOE use

o 7 showed a decrease in test volume due to CPOE use

· CPOE and test costs – Total of 5 papers reviewed:

o 4 showed significant decreases

o 1 showed no change

· CPOE and redundant test rates – 2 papers reviewed:

o The study at Brigham and Womens hospital found that the effect was limited.

o The second paper Nielson et al. found a decrease in the number of discontinued tests per day after the introduction of the CPOE.

· CPOE and compliance with guidelines – 4 papers reviewed

o All four concluded that CPOE’s with decision support improved compliance with clinical guidelines.

· CPOE and impact on work practices – 3 papers reviewed

o The study at Massachusetts General Hospital and Wishard Memorial Hospital saw the order entry time increase with the implementation of CPOE’s.

o Mutimer et al. saw the ordering time decrease.

Test Processing

Test processing consists of two stages pre-analytical and analytical. In the pre-analytical phase orders (on paper), and associated specimens are delivered to the lab. The analytical test phase consists of performing the test and writing the results of the test on a lab test report.

Studies have found that activities associated with the pre-analytical phase like order request, specimen collection, and transcription account for most laboratory errors.

The article below opines that the a CPOE with mandatory fields during order entry, and interface with lab information system (LIS) should reduce errors relating to order requests and transcription significantly.

· CPOE and physician-laboratory communication – 1 study reviewed

o Study conducted in Central Hospital of Akershus, Norway.

o Study examined telephone activity between intervention wards and the labs.

o After CPOE installation (11 weeks) no change was seen in the number of phone calls from the wards to the lab. But the number of phone calls from the lab to the wards did decrease indicating a decreased need for clarification of orders.

Application of test results

This is the stage of the ordering process where lab results are interpreted and made part of the patient’s treatment regimen. A total of 9 papers were reviewed for this stage of the ordering process. The papers can be classified as follows:

· CPOE and patient management – 3 papers reviewed

o Smith et al. reported a reduction of 1 day for a physician to reach a diagnosis with a “lab advisory system.” They also reported a reduction in venipunctures in addition to physicians arriving at correct diagnosis 100% of the time.

o Kuperman et al. investigated the effect of a CPOE’s “automatic alerting system” (i.e. paging service) function and its effect on detecting critical conditions. The study found a reduction in the median time (1 hour Vs. 1.6 hours) elapsed between a critical result and appropriate medical intervention in 38% of cases. The study also found a reduction in the median and mean time required to resolve the critical result. But this was no judged to be significant.

o Mutimer et al. investigated the link between CPOE and clinician time spent following up on results. The study found a reduction in time junior medical staff spends on specimen enquiries and results (10 min to 4.1 min per day).

· CPOE and patient length of stay – 5 papers reviewed

o Most studies did not find any decrease in length of stay after system implementation. One South Korean study by Hwang et al. did.

· CPOE and adverse events and safety – 4 papers reviewed

o Most studies evaluated found no significant decrease in adverse events due to CPOE usage for critical result alerts. The authors questioned the insufficiency of sample size in some of the results.

Efficiency of information flow between the three stages of the ordering process

The studies evaluated under this category judged the speed at which information flows between the three stages of the ordering process. Turn around time (TAT) was the criterion identified as most effective for this purpose. Most studies found a significant decrease in TAT.

Comment: The discussion section of the article highlights many shortcomings of the studies evaluated. Most studies evaluated for this paper were for homegrown systems rather than commercial systems. Also, many of the studies were narrowly focused on the impact of a CPOE on pathology services ordered form particular area in a hospital. CPOE’s are an important part of the enterprise wide electronic medical record and more studies are probably required to get an overall, organization wide understanding of a CPOE on pathology services.

Most laboratories call (telephone) lab critical results to the health provider as it is required by standard operating procedure in the laboratory. Also, most lab information systems prominently highlight critical results for the technologist performing the test. So it was not a surprise that there was no significant decrease in adverse events with CPOE usage for critical result alerts. Finally, as mentioned in the article an important area future research would be impact of CPOE on work patterns pathology department staff.