Evaluation of outpatient computerized physician medication order entry systems

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Case study: Identifying Potential Problems at the Human/Technical Interface in Complex Clinical Systems

Introduction/Question

This systematic review assessed evaluative studies of CPOE in the outpatient setting to determine impact on safety, cost and efficiency, use of alerts, clinician time, satisfaction, usage and usability.

Data Sources

Papers were identified by searching Ovid MEDLINE and EMBASE and culling additional references from the bibliographies of articles initially selected.

Study Selection and Assessment

Thirty studies met the criteria for inclusion, being either randomized clinical trials (RCTs), non-randomized clinical trials, or observational studies.

reporting original data from a study in an outpatient setting with a main goal of either evaluating:

  1. a CPOE system for medication ordering
  2. a DSS used during medication ordering

Outcomes

The review assessed study results with regard to six major outcome groups: medication safety; cost and (organizational) efficiency; compliance with guidelines; alerts and alert appropriateness; clinician time; and satisfaction, usage, and usability. Most of the papers covered multiple outcome areas.

Main Results

Only a small number of the studies evaluated safety, with three of four papers failing to demonstrate significant reduction in numbers of ADE’s. The majority of the studies examining costs did not show savings attributable to CPOE use. Papers evaluating alerts indicated that physicians largely ignore them, which is not necessarily indicative a decline in patient safety, since many alerts are not patient specific. Six of eleven studies showed CPOE having a positive effect on adherence to guidelines, while three of four studies indicated that clinician patient care time increased following the introduction of CPOE.

Conclusion

Despite reported benefits of CPOE in the areas of safety and costs [1, 2], studies reviewed here do not demonstrate significant improvements in these factors in the outpatient setting. There is more evidence indicating that CPOE leads to increased guideline adherence, which could positively impact costs and safety. The authors advocate for development of standardized study methods to facilitate comparisons, and recommend more attention to elucidating standards for CPOE system requirements in order to improve future implementations.

Comments

As the authors indicate, this appears to be the first comprehensive review of studies evaluating outpatient, rather than inpatient, CPOE systems. The positive impact on guideline adherence is encouraging, while other areas (costs, safety) showing mixed results may be indicative of a need for alerting clinicians to equivalent, but less costly drugs, and more evidence-based and patient-specific messages. Clearly, there is a need for more studies and systematic reviews of CPOE use in the outpatient setting.

References

  1. Bates, D.W., et al., The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc, 1999. 6(4): p. 313-21.
  2. Tierney, W.M., et al., Physician inpatient order writing on microcomputer workstations. Effects on resource utilization. JAMA, 1993. 269(3): p. 379-83.