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Cohen SM, Kashyap N, Steel TL, Edelman EJ, Fiellin DA, Joudrey PJ. Guideline concordance of electronic health record order sets for hospital-based treatment of alcohol withdrawal syndrome. J Hosp Med 2024. [PMID: 39580659 DOI: 10.1002/jhm.13556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 10/31/2024] [Accepted: 11/05/2024] [Indexed: 11/26/2024]
Abstract
BACKGROUND Treatment of alcohol withdrawal syndrome (AWS) in hospitals is inconsistent. Electronic health record (EHR) order sets protocolize care. OBJECTIVE We examined variation in AWS order sets across hospital organizations and their concordance with AWS guidelines. METHODS We conducted a cross-sectional study of hospital organization user-created EHR order sets for AWS extracted from the December 2021 Epic® userweb community library. Hospital organizations with an acute care hospital and≥ $\ge $ 1 AWS order set were included. We measured the proportion of guideline-concordant care practices within four categories: (1) laboratory assessment, (2) risk assessment for severe AWS and associated management changes, (3) symptom assessment and treatment of AWS, and identification and management of complications and (4) screening, diagnosis, and treatment of unhealthy alcohol use and AUD including medications for alcohol use disorder (MAUD). RESULTS Ninety-five organizations with 289 order sets were included. The proportion of organizations with guideline-concordant laboratory assessments included testing of electrolytes (83%), hepatic function (75%), substance use (83%), and screening for infections (33%). Guidance for assessing risk of severe AWS (34%) and indications for care escalation (63%) used inconsistent definitions. Use of guideline-concordant medications for AWS (99%) and AWS symptom scores (91%) were nearly universal. MAUD was included by two organizations (2%). A common templated order set was used by 26% of organizations in EHR order sets. CONCLUSIONS We observed frequent organizational inclusion of guideline-concordant medications and symptom scores but rare and/or poorly defined guidance for evaluating risk of severe AWS, escalation of care, and MAUD.
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Affiliation(s)
- Shawn M Cohen
- Program in Addiction Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nitu Kashyap
- Department of Internal Medicine, Emory University, Atlanta, Georgia, USA
| | - Tessa L Steel
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - E Jennifer Edelman
- Program in Addiction Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Social and Behavioral Science, Yale School of Public Health, New Haven, Connecticut, USA
| | - David A Fiellin
- Program in Addiction Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
| | - Paul J Joudrey
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Manchego PA, Krouss M, Alaiev D, Talledo J, Tsega S, Chandra K, Zaurova M, Shin D, Cohen V, Cho HJ. Using a Built-in Clinical Decision Support to Improve Phosphate Repletion Practice: A Quasi-Experimental Study. Jt Comm J Qual Patient Saf 2024; 50:801-808. [PMID: 39304371 DOI: 10.1016/j.jcjq.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 07/26/2024] [Accepted: 07/29/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Inpatient serum phosphate replacement is common, but there is great variability in replacement practice, which leads to overuse. Electronic health record (EHR) interventions with clinical decision support (CDS) can be effective tools to guide clinicians toward best clinical practices. The authors' objective was to use CDS tools to reduce overuse of hypophosphatemia corrections at a large safety-net health care system. METHODS The first intervention involved enhancing an existing order set for phosphate repletion by incorporating CDS to guide appropriate repletion orders based on deficit severity and simplifying ordering. The second intervention was a Best Practice Advisory (BPA) that triggered when an intravenous (IV) phosphate repletion was ordered for a patient with mild to moderate phosphate deficiency without an existing nil per os (NPO) order. The primary outcome measure was the number of patients with mild and moderate hypophosphatemia receiving IV replacement without NPO orders per 1,000 patient-days. RESULTS Across all hospitals, rate of IV replacement in patients with mild to moderate hypophosphatemia (1.0 to 1.9 mg/dL) without NPO orders decreased from 7.22 to 3.40 per 1,000 patient-days (53.0% reduction, p < 0.001), while the oral replacements in this population increased from 6.39 to 8.87 (38.8% increase, p < 0.001). For patients with phosphate levels ≥ 2.0, IV replacements decreased from 10.66 to 5.36 (49.8% reduction, p < 0.001), and oral replacements from decreased 19.78 to 16.69 (15.6% reduction, p < 0.01). CONCLUSION This intervention successfully reduced inpatient IV phosphate replacements by 53.0% in patients with mild to moderate hypophosphatemia using a two-pronged EHR intervention across a large safety-net setting.
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Hillyer M, Fundora M, Williams F, Gleason M, Lukacs M, Hamrick S, Meisel J, Clarke S, Korcinsky-Tillman N, Chanani N. Standardizing the diagnosis of necrotizing enterocolitis in infants with congenital heart disease. J Perinatol 2024:10.1038/s41372-024-02112-0. [PMID: 39266665 DOI: 10.1038/s41372-024-02112-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 08/27/2024] [Accepted: 09/04/2024] [Indexed: 09/14/2024]
Abstract
OBJECTIVE This quality improvement initiative aimed to standardize the diagnosis of necrotizing enterocolitis (NEC) in infants with congenital heart disease (CHD). STUDY DESIGN A multidisciplinary team developed clinical practice guidelines for the diagnosis and treatment of NEC within the Cardiac Intensive Care Unit (CICU). The diagnosis rate of NEC per 100 at-risk admissions was the primary outcome measure. NEC order set usage was employed as a process measure, and the balancing measures monitored were CICU length of stay (LOS) and mortality. RESULT After guideline development and implementation, the diagnosis rate of NEC decreased from 3% to 1%, sustained over three years. The EMR order set enabled guideline integration into daily workflow. No change was noted in CICU LOS or mortality. CONCLUSION Guideline implementation standardized the diagnosis of NEC in infants with CHD. Establishing a standardized definition and subsequent treatment regimen has enabled us to provide more consistent and appropriate care.
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Affiliation(s)
- Margot Hillyer
- Emory University School of Medicine, Department of Pediatrics, Division of Critical Care Medicine, Atlanta, GA, USA.
| | - Michael Fundora
- Emory University School of Medicine, Department of Pediatrics, Division of Cardiology, Atlanta, GA, USA
- The Heart Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Feifei Williams
- Emory University School of Medicine, Department of Pediatrics, Division of Cardiology, Atlanta, GA, USA
- AdventHealth Medical Group, Division of Pediatric Critical Care Medicine, AdventHealth for Children, Orlando, FL, USA
| | - Michelle Gleason
- The Heart Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Mary Lukacs
- The Heart Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Shannon Hamrick
- Emory University School of Medicine, Department of Pediatrics, Division of Neonatology, Atlanta, GA, USA
| | - Jonathan Meisel
- Emory University School of Medicine, Department of Pediatrics, Division of General Surgery, Atlanta, GA, USA
| | - Shanelle Clarke
- Emory University School of Medicine, Department of Pediatrics, Division of Cardiology, Atlanta, GA, USA
- The Heart Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Natalie Korcinsky-Tillman
- The Heart Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
- Children's Healthcare of Atlanta Quality Department, Atlanta, GA, USA
| | - Nikhil Chanani
- Emory University School of Medicine, Department of Pediatrics, Division of Cardiology, Atlanta, GA, USA
- The Heart Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Hodgson T, Burton-Jones A, Donovan R, Sullivan C. The Role of Electronic Medical Records in Reducing Unwarranted Clinical Variation in Acute Health Care: Systematic Review. JMIR Med Inform 2021; 9:e30432. [PMID: 34787585 PMCID: PMC8663492 DOI: 10.2196/30432] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/22/2021] [Accepted: 09/19/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The use of electronic medical records (EMRs)/electronic health records (EHRs) provides potential to reduce unwarranted clinical variation and thereby improve patient health care outcomes. Minimization of unwarranted clinical variation may raise and refine the standard of patient care provided and satisfy the quadruple aim of health care. OBJECTIVE A systematic review of the impact of EMRs and specific subcomponents (PowerPlans/SmartSets) on variation in clinical care processes in hospital settings was undertaken to summarize the existing literature on the effects of EMRs on clinical variation and patient outcomes. METHODS Articles from January 2000 to November 2020 were identified through a comprehensive search that examined EMRs/EHRs and clinical variation or PowerPlans/SmartSets. Thirty-six articles met the inclusion criteria. Articles were examined for evidence for EMR-induced changes in variation and effects on health care outcomes and mapped to the quadruple aim of health care. RESULTS Most of the studies reported positive effects of EMR-related interventions (30/36, 83%). All of the 36 included studies discussed clinical variation, but only half measured it (18/36, 50%). Those studies that measured variation generally examined how changes to variation affected individual patient care (11/36, 31%) or costs (9/36, 25%), while other outcomes (population health and clinician experience) were seldom studied. High-quality study designs were rare. CONCLUSIONS The literature provides some evidence that EMRs can help reduce unwarranted clinical variation and thereby improve health care outcomes. However, the evidence is surprisingly thin because of insufficient attention to the measurement of clinical variation, and to the chain of evidence from EMRs to variation in clinical practices to health care outcomes.
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Affiliation(s)
- Tobias Hodgson
- The University of Queensland Business School, The University of Queensland, St Lucia, Australia
| | - Andrew Burton-Jones
- The University of Queensland Business School, The University of Queensland, St Lucia, Australia
| | - Raelene Donovan
- Princess Alexandra Hospital, Metro South Health, Woolloongabba, Australia
| | - Clair Sullivan
- The University of Queensland Centre for Health Services Research, The University of Queensland, Herston, Australia
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McCulloh RJ, Commers T, Williams DD, Michael J, Mann K, Newland JG. Effect of Combined Clinical Practice Guideline and Electronic Order Set Implementation on Febrile Infant Evaluation and Management. Pediatr Emerg Care 2021; 37:e25-e31. [PMID: 32221058 DOI: 10.1097/pec.0000000000002012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Management of febrile infants 60 days and younger for suspected serious infection varies widely. Clinical practice guidelines (CPGs) are intended to improve clinician adherence to evidence-based practices. In 2011, a CPG for managing febrile infants was implemented in an urban children's hospital with simultaneous release of an electronic order set and algorithm to guide clinician decisions for managing infants for suspected serious bacterial infection. The objective of the present study was to determine the association of CPG implementation with order set use, clinical practices, and clinical outcomes. METHODS Records of febrile infants 60 days and younger from February 1, 2009, to January 31, 2013, were retrospectively reviewed. Clinical documentation, order set use, clinical management practices, and outcomes were compared pre-CPG and post-CPG release. RESULTS In total, 1037 infants pre-CPG and 930 infants post-CPG implementation were identified. After CPG release, more infants 29 to 60 days old underwent lumbar puncture (56% vs 62%, P = 0.02). Overall antibiotic use and duration of antibiotic use decreased for infants 29 to 60 days (57% vs 51%, P = 0.02). Blood culture and urine culture obtainment remained unchanged for older infants. Diagnosed infections, hospital readmissions, and length of stay were unchanged. Electronic order sets were used in 80% of patient encounters. CONCLUSIONS Antibiotic use and lumbar puncture performance modestly changed in accordance with CPG recommendations provided in the electronic order set and algorithm, suggesting that the presence of embedded prompts may affect clinician decision-making. Our results highlight the potential usefulness of these decision aids to improve adherence to CPG recommendations.
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Affiliation(s)
| | | | - David D Williams
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City
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Muniga ET, Walroth TA, Washburn NC. The Impact of Changes to an Electronic Admission Order Set on Prescribing and Clinical Outcomes in the Intensive Care Unit. Appl Clin Inform 2020; 11:182-189. [PMID: 32162288 DOI: 10.1055/s-0040-1702215] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Implementation of disease-specific order sets has improved compliance with standards of care for a variety of diseases. Evidence of the impact admission order sets can have on care is limited. OBJECTIVE The main purpose of this article is to evaluate the impact of changes made to an electronic critical care admission order set on provider prescribing patterns and clinical outcomes. METHODS A retrospective, observational before-and-after exploratory study was performed on adult patients admitted to the medical intensive care unit using the Inpatient Critical Care Admission Order Set. The primary outcome measure was the percentage change in the number of orders for scheduled acetaminophen, a histamine-2 receptor antagonist (H2RA), and lactated ringers at admission before implementation of the revised order set compared with after implementation. Secondary outcomes assessed clinical impact of changes made to the order set. RESULTS The addition of a different dosing strategy for a medication already available on the order set (scheduled acetaminophen vs. as needed acetaminophen) had no impact on physician prescribing (0 vs. 0%, p = 1.000). The addition of a new medication class (an H2RA) to the order set significantly increased the number of patients prescribed an H2RA for stress ulcer prophylaxis (0 vs. 20%, p < 0.001). Rearranging the list of maintenance intravenous fluids to make lactated ringers the first fluid option in place of normal saline significantly decreased the number of orders for lactated ringers (17 vs. 4%, p = 0.005). The order set changes had no significant impact on clinical outcomes such as incidence of transaminitis, gastrointestinal bleed, and acute kidney injury. CONCLUSION Making changes to an admission order set can impact provider prescribing patterns. The type of change made to the order set, in addition to the specific medication changed, may have an effect on how influential the changes are on prescribing patterns.
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Affiliation(s)
- Ellen T Muniga
- Department of Pharmacy, Bronson Methodist Hospital, Kalamazoo, Michigan, United States
| | - Todd A Walroth
- Department of Pharmacy, Eskenazi Health, Indianapolis, Indiana, United States
| | - Natalie C Washburn
- Department of Pharmacy, Bronson Methodist Hospital, Kalamazoo, Michigan, United States
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Lee B, Hershey D, Patel A, Pierce H, Rhee KE, Fisher E. Reducing Unnecessary Testing in Uncomplicated Skin and Soft Tissue Infections: A Quality Improvement Approach. Hosp Pediatr 2020; 10:129-137. [PMID: 31941651 DOI: 10.1542/hpeds.2019-0179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Skin and soft tissue infections are common pediatric diagnoses with substantial costs. Recent studies suggest blood cultures are not useful in management of uncomplicated skin and soft tissue infections (uSSTIs). Complete blood cell count, erythrocyte sedimentation rate, and C-reactive protein are also of questionable value. We aimed to decrease these tests by 25% for patients with uSSTIs admitted to the pediatric hospital medicine service within 3 months. METHODS An interdisciplinary team led a quality improvement (QI) project. Baseline assessment included review of the literature and 12 months of medical records. Key stakeholders identified drivers that informed the creation of an electronic order set and development of a pediatric hospital medicine-emergency department collaborative QI project. The primary outcome measure was mean number of tests per patient encounter. Balancing measures included unplanned readmissions and missed diagnoses. RESULTS Our baseline-year rate was 3.4 tests per patient encounter (573 tests and 169 patient encounters). During the intervention year, the rate decreased by 35% to 2.2 tests per patient encounter (286 tests and 130 patient encounters) and was sustained for 14 months postintervention. There were no unplanned readmissions or missed diagnoses for the study period. Order set adherence was 80% (83 out of 104) during the intervention period and sustained at 87% postintervention. CONCLUSIONS Our interdisciplinary team achieved our aim, reducing unnecessary laboratory testing in patients with an uSSTI without patient harm. Awareness of local culture, creation of an order set, defining appropriate patient selection and testing indications, and implementation of a collaborative QI project helped us achieve our aim.
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Affiliation(s)
- Begem Lee
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Daniel Hershey
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Aarti Patel
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Heather Pierce
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Kyung E Rhee
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Erin Fisher
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
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8
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Lander B, Balka E. Balancing quality improvement and unintended effects: The impact of implementing admission order sets for chronic obstructive pulmonary disease and heart failure at two teaching hospitals. J Eval Clin Pract 2019; 25:469-475. [PMID: 30511470 DOI: 10.1111/jep.13080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 09/29/2018] [Accepted: 11/02/2018] [Indexed: 11/26/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Local health administrators implemented chronic obstructive pulmonary disease and heart failure admission order sets to increase guideline adherence. We explored the impact of these order sets on workflows and guideline adherence in the internal medicine specialty in two Canadian teaching hospitals. METHODS A mixed methods study combined shadowing care providers (250 h), meeting observation and interviews (11 h), and patient medical chart audits for heart failure (n = 120) and chronic obstructive pulmonary disease (n = 120) patients. The chart audits analysed details of the admission process and 14 guideline elements associated with heart failure (nine) and chronic obstructive pulmonary disease (five). RESULTS A subset (10/14) of the evaluated guideline elements were included in the heart failure or chronic obstructive pulmonary disease order sets. Order set use significantly increased adherence to some (4/10) of these elements. However, our qualitative work uncovered a perception that use of these two order sets increased order duplication. Our chart audits supported this perception. Order set use increased order duplication for heart failure (92% vs 43%) and chronic obstructive pulmonary disease (75% vs 43%). CONCLUSION It is unclear whether, for these two hospitals, the gains brought by implementation of chronic obstructive pulmonary disease and heart failure admission order sets were worth their associated organisational shortcomings. Problems with order set implementation appeared to stem from poor integration with pre-existing complex organisational systems. Health administrators and clinicians interested in implementing order sets within their own hospitals need to remain cognizant of how these tools will fit into existing systems and practices.
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Affiliation(s)
- Bryn Lander
- School of Communication, Simon Fraser University, Burnaby, BC, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Ellen Balka
- School of Communication, Simon Fraser University, Burnaby, BC, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
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9
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Gellert GA, Davenport CM, Minard CG, Castano C, Bruner K, Hobbs D. Reducing pediatric asthma hospital length of stay through evidence-based quality improvement and deployment of computerized provider order entry. J Asthma 2019; 57:123-135. [PMID: 30678502 DOI: 10.1080/02770903.2018.1553053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: Evaluate the impact of multi-component quality improvement for pediatric asthma care focusing on serial use of an evidence-based clinical pathway via paper order sets, pathway integration into computerized provider order entry (CPOE), use of a clinical respiratory score (CRS) and a discharge checklist. Methods: Outcomes were assessed over three intervention periods and 50 months on: time to beta-agonist and steroid first administration, frequency of readmissions and hospital length of stay. A general linear model estimated mean log(LOS) over time and between study periods. Time to discharge was transformed using the natural logarithm. Results: No improvements in time to first beta-agonist or steroid administration were observed. There was a reduction in 100-day readmissions (p = 0.008): decreasing from 7.4 to 2.1% after introduction of paper order sets and CRS (adjusted p = 0.04); to 3.9% after CPOE implementation (adjusted p = 0.53) and to 2.2% when a discharge checklist was added (adjusted p = 0.01). There was a statistically significant reduction in LOS between study periods (p = 0.015). The geometric mean LOS in hours during study periods 1-4 were: 34.8 (95% CI: 32.2, 37.6), 29.3 (95% CI: 27.5, 31.3), 29.0 (95% CI: 27.0, 31.3) and 23.1 (95% CI: 22.1, 24.2). Pair-wise comparisons between periods were statistically significant (adjusted p ≤ 0.003), except for Periods 2 and 3 (adjusted p = 0.83). Conclusions: Hospital length of stay and 100-day readmissions rate in a predominantly Hispanic, Medicaid patient population were reduced by utilization of an evidence-based best practices asthma management pathway and CRS within CPOE, combined with a checklist to expedite discharge.
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Affiliation(s)
- George A Gellert
- Department of Health Informatics, CHRISTUS Health Santa Rosa, San Antonio, TX, USA
| | - Crystal M Davenport
- CHRISTUS Health Santa Rosa and Baylor College of Medicine, Department of Pediatrics, Children's Hospital of San Antonio, San Antonio, TX, USA
| | - Charles G Minard
- Baylor College of Medicine, Dan L. Duncan Institute for Clinical and Translational Research, Houston, TX, USA
| | - Claudia Castano
- CHRISTUS Health Santa Rosa and Baylor College of Medicine, Department of Pediatrics, Children's Hospital of San Antonio, San Antonio, TX, USA
| | - Kylynn Bruner
- Department of Health Informatics, CHRISTUS Health Santa Rosa, San Antonio, TX, USA
| | - Deon Hobbs
- CHRISTUS Health Santa Rosa and Baylor College of Medicine, Department of Pediatrics, Children's Hospital of San Antonio, San Antonio, TX, USA
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Stultz JS, Taylor P, McKenna S. Assessment of Different Methods for Pediatric Meningitis Dosing Clinical Decision Support. Ann Pharmacother 2019; 53:35-42. [DOI: 10.1177/1060028018788688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Indication-specific medication dosing support is needed to improve pediatric dosing support. Objective: To compare the sensitivity and positive predictive value (PPV) of different meningitis dosing alert triggers and dosing error rates between antimicrobials with and without meningitis order sentences. Methods: We retrospectively analyzed 4-months of pediatric orders for antimicrobials with meningitis-specific dosing. At the time of the order, it was determined if the antimicrobial was for meningitis management, if a cerebrospinal fluid (CSF) culture was ordered, and if a natural language processing (NLP) system could detect “meningitis” in clinical notes. Results: Of 1383 orders, 243 were for the management of meningitis. A CSF culture or NLP combination trigger searching the electronic health record since admission yielded the greatest sensitivity for detecting meningitis management (67.5%, P < 0.01 vs others), but dosing error detection was similar if the trigger only searched 48 hours preceding the order (68.8% vs 62.5%, P = 0.125). Using a CSF culture alone and a 48-hour time frame had a higher PPV versus a combination with a 48-hour time frame (97.1% vs 80.9%, P < 0.001), and both triggers had a higher PPV than others ( P < 0.001). Antimicrobials with meningitis order sentences had fewer dosing errors (19.8% vs 43.2%, P < 0.01). Conclusion and Relevance: A meningitis dosing alert triggered by a combination of a CSF culture or NLP system and a 48-hour triggering time frame could provide reasonable sensitivity and PPV for meningitis dosing errors. Order sentences with indication-specific recommendations may provide additional dosing support, but additional studies are needed.
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Affiliation(s)
- Jeremy S. Stultz
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Perry Taylor
- Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Sean McKenna
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
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11
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A Quality Improvement Bundle Including Pay for Performance for the Standardization of Order Set Use in Moderate Asthma. Pediatr Emerg Care 2018; 34:740-742. [PMID: 30281577 DOI: 10.1097/pec.0000000000001627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE In order to standardize use of our hospital's computerized asthma order set, which was developed based on an asthma clinical practice guideline, for moderately ill children presenting for care of asthma, we developed a quality improvement bundle, including a time-limited pay-for-performance component, for pediatric emergency department and pediatric urgent care faculty members. METHODS Following baseline measurement, we used a run-in period for education, feedback, and improvement of the asthma order set. Then, faculty members earned 0.1% of salary during each of 10 successive months (evaluation period) in which the asthma order set was used in managing 90% or more of eligible patients. RESULTS At baseline, the asthma order set was used in managing 60.5% of eligible patients. Order set use rose sharply during the run-in period. During the 10-month evaluation period, use of the asthma order set was significantly above baseline, with a mean of 91.6%; faculty earned pay-for-performance bonuses during 8 of 10 possible months. Following completion of the evaluation period, asthma order set use remained high. CONCLUSIONS A quality improvement bundle, including a time-limited pay-for-performance component, was associated with a sustained increase in the use of a computerized asthma order set for managing moderately ill asthmatic children.
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Ansari S, Fung K, MacNeil S, Nichols A, Yoo J, Sowerby L. The use of standardized order sets to improve adherence to evidence-based postoperative management in major head and neck surgery. Eur Ann Otorhinolaryngol Head Neck Dis 2018; 135:S107-S111. [DOI: 10.1016/j.anorl.2018.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 08/09/2018] [Accepted: 08/13/2018] [Indexed: 11/28/2022]
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Order Set to Improve the Care of Patients Hospitalized for an Exacerbation of Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2018; 13:811-5. [PMID: 27058777 DOI: 10.1513/annalsats.201507-466oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Physicians' adherence to prescribing evidence-based inpatient and outpatient therapies for chronic obstructive pulmonary disease (COPD) is low, and there is a paucity of information about the utility of admission order sets for patients with COPD exacerbations. OBJECTIVES To determine if implementation of a locally designed, evidence-based, multidisciplinary computer physician order entry set in the electronic health record improves the quality of physician pharmacologic prescribing for patients hospitalized for COPD exacerbations. METHODS This study was performed before and after implementation of a computerized order set for patients hospitalized for COPD exacerbations. The primary outcome was the rate of zero prescribing errors by physicians for inpatient and discharge drugs for COPD over a 1-year period before implementation and for 6 months after implementation. Errors were defined as no therapy or inappropriate therapy in the following categories: antibiotic, systemic corticosteroid, short-acting bronchodilator, long-acting bronchodilator, and inhaled corticosteroid. Secondary outcomes included mean physician pharmaceutical prescribing error rate; types of errors; hospital lengths of stay; and unscheduled physician visits, emergency department visits, rehospitalizations, and deaths within 30 days from discharge. MEASUREMENTS AND MAIN RESULTS There were 194 COPD exacerbation admissions during the 1-year preimplementation period and 81 admissions during the 6-month postimplementation period. Compared with the preimplementation period, the percentage of patients receiving all recommended pharmacologic therapies for the 6 months after implementation increased from 18.6% to 54.3% (P < 0.001). The mean number of errors decreased from 1.76 to 0.65 (P < 0.001). Antibiotic and systemic corticosteroid errors decreased from 39% to 16% (P < 0.001) and from 58% to 28% (P < 0.001), respectively. Fewer patients were discharged without a short-acting bronchodilator (13.9% vs. 2.5%; P = 0.005), a long-acting bronchodilator (16.5% vs. 7.4%; P = 0.047), or inhaled corticosteroid (18% vs. 9.9%; P = 0.089). Improvements were sustained over the 6-month postimplementation period. Hospital length of stay decreased from 4 (±3) days preimplementation to 2.9 (±1.9) days postimplementation (P = 0.002). There were no significant differences in 30-day clinical outcomes, including the rates of unscheduled physician or emergency department visits, rehospitalizations, or deaths. CONCLUSIONS Computerized multidisciplinary admission order set implementation for patients hospitalized for a COPD exacerbation improved physicians' adherence to evidence-based pharmacologic treatment, and they were associated with reductions in length of hospital stay.
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Dayal A, Alvarez F. The Effect of Implementation of Standardized, Evidence-Based Order Sets on Efficiency and Quality Measures for Pediatric Respiratory Illnesses in a Community Hospital. Hosp Pediatr 2016; 5:624-9. [PMID: 26596964 DOI: 10.1542/hpeds.2015-0140] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Standardization of evidence-based care, resource utilization, and cost efficiency are commonly used metrics to measure inpatient clinical care delivery. The aim of our project was to evaluate the effect of pediatric respiratory order sets and an asthma pathway on the efficiency and quality measures of pediatric patients treated with respiratory illnesses in an adult community hospital setting. METHODS We used a pre-post study to review pediatric patients admitted to the inpatient setting with the primary diagnoses of asthma, bronchiolitis, or pneumonia. Patients with concomitant chronic respiratory illnesses were excluded. After implementation of order sets and asthma pathway, we examined changes in respiratory medication use, hospital utilization cost, length of stay (LOS), and 30-day readmission rate. Statistical significance was measured via 2-tailed t-test and Fisher test. RESULTS After implementation of evidence-based order sets and asthma pathway, utilization of bronchodilators decreased and the hospital utilization cost of patients with asthma was reduced from $2010 per patient in 2009 to $1174 per patient in 2011 (P < .05). Asthma LOS decreased from 1.90 days to 1.45 days (P < .05), bronchiolitis LOS decreased from 2.37 days to 2.04 days (P < .05), and pneumonia LOS decreased from 2.3 days to 2.1 days (P = .083). Readmission rates were unchanged. CONCLUSION The use of order sets and an asthma pathway was associated with a reduction in respiratory treatment use as well as hospitalization utilization costs. Statistically significant decrease in LOS was achieved within the asthma and bronchiolitis populations but not in the pneumonia population. No statistically significant effect was found on the 30-day readmission rates.
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Affiliation(s)
- Anuradha Dayal
- Division of Hospitalist Medicine, Children's National Medical Center, Washington, District of Columbia; George Washington University School of Medicine Department of Pediatrics, Washington, District of Columbia; and Mary Washington Hospital, Department of Pediatric Hospitalist Medicine, Fredericksburg, Virginia
| | - Francisco Alvarez
- Division of Hospitalist Medicine, Children's National Medical Center, Washington, District of Columbia; George Washington University School of Medicine Department of Pediatrics, Washington, District of Columbia; and Mary Washington Hospital, Department of Pediatric Hospitalist Medicine, Fredericksburg, Virginia
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15
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Effectiveness of Evidence-based Pneumonia CPOE Order Sets Measured by Health Outcomes. Online J Public Health Inform 2015; 7:e211. [PMID: 26392842 PMCID: PMC4576442 DOI: 10.5210/ojphi.v7i2.5527] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective Evidence-based sets of medical orders for the treatment of patients with
common conditions have the potential to induce greater efficiency and
convenience across the system, along with more consistent health outcomes.
Despite ongoing utilization of order sets, quantitative evidence of their
effectiveness is lacking. In this study, conducted at Advocate Health Care
in Illinois, we quantitatively analyzed the benefits of community acquired
pneumonia order sets as measured by mortality, readmission, and length of
stay (LOS) outcomes. Methods In this study, we examined five years (2007–2011) of computerized
physician order entry (CPOE) data from two city and two suburban community
care hospitals. Mortality and readmissions benefits were analyzed by
comparing “order set” and “no order set” groups
of adult patients using logistic regression, Pearson’s chi-squared,
and Fisher’s exact methods. LOS was calculated by applying one-way
ANOVA and the Mann-Whitney U test, supplemented by analysis of comorbidity
via the Charlson Comorbidity Index. Results The results indicate that patient treatment orders placed via electronic sets
were effective in reducing mortality [OR=1.787; 95% CF 1.170-2.730;
P=.061], readmissions [OR=1.362; 95% CF 1.015-1.827;
P=.039], and LOS [F (1,5087)=6.885,
P=.009, 4.79 days (no order set group) vs. 4.32 days (order
set group)]. Conclusion Evidence-based ordering practices have the potential to improve pneumonia
outcomes through reduction of mortality, hospital readmissions, and cost of
care. However, the practice must be part of a larger strategic effort to
reduce variability in patient care processes. Further experimental and/or
observational studies are required to reduce the barriers to retrospective
patient care analyses.
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Kitchlu A, Abdelshaheed T, Tullis E, Gupta S. Gaps in the inpatient management of chronic obstructive pulmonary disease exacerbation and impact of an evidence-based order set. Can Respir J 2015; 22:157-62. [PMID: 25886627 PMCID: PMC4470549 DOI: 10.1155/2015/587026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Evidence-based, guideline-recommended practices improve multiple outcomes in patients admitted with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), but are incompletely implemented in actual practice. Admission order sets with evidence-based diagnostic and therapeutic guidance have enabled quality improvement and guideline implementation in other conditions. OBJECTIVE To characterize the magnitude of care gaps and the effect of order sets on quality of care in patients with AECOPD. METHODS The authors prospectively designed a standardized chart review protocol to document process of care and health care utilization before and after implementation of AECOPD order sets at an academic hospital in Toronto, Ontario. RESULTS A total of 243 total AECOPD admissions and multiple important care gaps were identified. There were 74 admissions in the pre-order set period (January to June 2009) and 169 in the order set period (October 2009 to September 2010). The order set was used in 78 of 169 (46.2%) admissions. In the order set period, we observed improvements in respiratory therapy educational referrals (five of 74 [6.8%] versus 48 of 169 [28.4%]; P<0.01); venous thromboembolism prophylaxis prescriptions (when indicated) (15 of 68 [22.1%] versus 100 of 134 [74.6%]; P<0.01); systemic steroid prescriptions (55 of 74 (74.3%) versus 151 of 169 [89.4%]; P<0.01]); and appropriate antibiotic prescriptions (nine of 24 [37.5%] versus 61 of 88 [69.3%]; P<0.01). The mean (± SD) length of stay also decreased from 6.5 ± 7.7 days before order sets to 4.1 ± 5.0 days with order sets (P=0.017). CONCLUSIONS Care gaps in inpatient AECOPD management were large and evidence-based order sets may improve guideline adherence at the point of care. Randomized trials including patient outcomes are required to further evaluate this knowledge translation intervention.
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Affiliation(s)
- Abhijat Kitchlu
- Department of Medicine, Core Internal Medicine Training Program, University of Toronto, Toronto
| | - Tamer Abdelshaheed
- Department of Medicine, Division of Respirology, McMaster University, Hamilton
| | - Elizabeth Tullis
- Department of Medicine, Division of Respirology, University of Toronto
- The Keenan Research Centre in the Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario
| | - Samir Gupta
- Department of Medicine, Division of Respirology, University of Toronto
- The Keenan Research Centre in the Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario
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Mudd SS, Leu K, Sloand ED, Ngo TL. Pediatric asthma and the use of metered dose inhalers with valve holding chambers: barriers to the implementation of evidence-based practice. J Emerg Nurs 2014; 41:13-8. [PMID: 25219951 DOI: 10.1016/j.jen.2014.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 06/23/2014] [Accepted: 06/24/2014] [Indexed: 10/24/2022]
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Weizman AV, Nguyen GC. Interventions and targets aimed at improving quality in inflammatory bowel disease ambulatory care. World J Gastroenterol 2013; 19:6375-6382. [PMID: 24151356 PMCID: PMC3801308 DOI: 10.3748/wjg.v19.i38.6375] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/15/2013] [Accepted: 08/20/2013] [Indexed: 02/06/2023] Open
Abstract
Over the past decade, there has been increasing focus on improving the quality of healthcare delivered to patients with chronic diseases, including inflammatory bowel disease. Inflammatory bowel disease is a complex, chronic condition with associated morbidity, health care costs, and reductions in quality of life. The condition is managed primarily in the outpatient setting. The delivery of high quality of care is suboptimal in several ambulatory inflammatory bowel disease domains including objective assessments of disease activity, the use of steroid-sparing agents, screening prior to anti-tumor necrosis factor therapy, and monitoring thiopurine therapy. This review outlines these gaps in performance and provides potential initiatives aimed at improvement including reimbursement programs, quality improvement frameworks, collaborative efforts in quality improvement, and the use of healthcare information technology.
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Strauss J. Behavioral health order sets in a hybrid information environment. Open Med Inform J 2013; 7:30-3. [PMID: 24039642 PMCID: PMC3771227 DOI: 10.2174/1874431120130607002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 05/15/2013] [Accepted: 05/25/2013] [Indexed: 11/25/2022] Open
Abstract
Introduction: The Centre for Addiction and Mental Health (CAMH) is a 500 bed freestanding psychiatric hospital in Canada. We are in the process of preparing for an integrated commercial clinical information system, which will have computerized physician order entry (CPOE) functionality. Methods: As a preparation for CPOE, we developed inpatient order sets (OSs). Development teams from individual clinical programs created and sent their OSs to an OS Working Group for initial endorsement, and then to Pharmacy & Therapeutics and Medical Advisory committees subsequent approvals. Results: In twelve months we created and introduced 22 behavioral health OSs across eight clinical programs in our hybrid information system with an excellent adoption rate (>97%) by clinicians. Discussion: The development and implementation temporarily contributed to a multifactorial flow problem in the emergency department (ED), which was addressed by substantially simplifying the General Admission via the ED OS. Also, as the OSs were developed and sent for approval the project identified areas where local clinical practice can improve. Our electronic-paper hybrid set of clinical systems was a major factor impacting the effort.
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Affiliation(s)
- John Strauss
- Centre for Addiction and Mental Health, 1001 Queen St. W., Toronto, ON, M6J 1H4, Canada
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20
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Lee Y, Mourad O, Panisko D, Sargeant R, Cavalcanti RB. Evaluation of standardized doctor's orders as an educational tool for undergraduate medical students: a prospective cohort study. BMC MEDICAL EDUCATION 2013; 13:97. [PMID: 23842504 PMCID: PMC3710495 DOI: 10.1186/1472-6920-13-97] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 06/19/2013] [Indexed: 06/02/2023]
Abstract
BACKGROUND Standardized doctor's orders are replacing traditional order writing in teaching hospitals. The impact of this shift in practice on medical education is unknown. It is possible that preprinted orders interfere with knowledge acquisition and retention by not requiring active decision-making. The objective of the study was to evaluate the impact of standardized admission orders on disease-specific knowledge among undergraduate medical trainees. METHODS This prospective cohort study enrolled Year 3 (n = 121) and Year 4 (n = 54) medical students at two academic hospitals in Toronto (Ontario, Canada) during their general internal medicine rotation. We used standardized orders for patient admissions for alcohol withdrawal (AW) and for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) as the intervention and manual order writing as the control. Educational outcomes were assessed through end-of-rotation questionnaires assessing disease-specific knowledge of AW and AECOPD. RESULTS AND DISCUSSIONS Of 175 students, 105 had exposure to patients with alcohol withdrawal during their rotation, and 68 students wrote admission orders. Among these 68 students, 48 used standardized orders (intervention, n = 48) and 20 used manual order writing (control, n = 20). Only 3 students used standardized orders for AECOPD, precluding analysis. There was no significant difference found in mean total score of questionnaires between those who used AW standardized orders and those who did not (11.8 vs. 11.0, p = 0.4). Students who had direct clinical experience had significantly higher mean total scores (11.6 vs. 9.0, p < 0.0001 for AW; 13.8 vs. 12.6, p = 0.02 for AECOPD) compared to students who did not. When corrected for overall knowledge, this difference only persisted for AW. CONCLUSIONS No significant differences were found in total scores between students who used standardized admission orders and traditional manual order writing. Clinical exposure was associated with increase in disease-specific knowledge.
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Affiliation(s)
- Yuna Lee
- St. Michael’s Hospital, 4 CCW 149 30 bond st, Toronto, Ontario M5B 1W8, Canada
| | - Ophyr Mourad
- St. Michael’s Hospital, 30 bond st, Toronto, Ontario M5B 1W8, Canada
| | - Daniel Panisko
- Toronto Western Hospital, 399 Bathurst st, Toronto, Ontario M5T 2S8, Canada
| | - Robert Sargeant
- St. Michael’s Hospital, 30 bond st, Toronto, Ontario M5B 1W8, Canada
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Nakamura MM, Harper MB, Jha AK. Change in adoption of electronic health records by US children's hospitals. Pediatrics 2013; 131:e1563-75. [PMID: 23589808 DOI: 10.1542/peds.2012-2904] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED OBJECTIVES To assess electronic health record (EHR) adoption and meaningful use among US children's hospitals through 2011 and compare these outcomes with adult hospitals and among subgroups of children's hospitals. We hypothesized that children's hospitals would show progress since our initial evaluation of health information technology (HIT) implementation in 2008. METHODS We identified children's hospitals using the membership directory of the Children's Hospital Association and analyzed their responses from 2008 to 2011 to the American Hospital Association's annual HIT survey. EHR adoption rates were determined by using previously specified definitions of the essential functionalities comprising an EHR. Achievement of meaningful use was evaluated based on hospitals' ability to fulfill 12 core meaningful use criteria. We compared these outcomes in 2011 between children's and adult hospitals and among subgroups of children's hospitals. RESULTS Of 162 children's hospitals, 126 (78%) responded to the survey in 2011. The proportion of children's hospitals with an EHR increased from 21% (in 2008) to 59% (in 2011). In 2011, 29% of children's hospitals met the 12 core criteria in our meaningful use proxy measure. EHR adoption rates and meaningful use were significantly higher for children's hospitals than for adult hospitals as a whole but similar for children's and adult major teaching hospitals. Among children's hospitals, major teaching hospitals were significantly more likely to have an EHR. CONCLUSIONS Children's hospitals have achieved substantial gains in HIT implementation although minor teaching and nonteaching institutions are not keeping pace.
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Affiliation(s)
- Mari M Nakamura
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, USA.
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Abstract
Electronic health record (EHR) order sets are common. Order sets represent one clinical decision support (CDS) tool within computerized provider order entry systems that may promote safe, efficient, and evidence-based patient care. A small number of order sets account for the vast majority of use, suggesting that some order sets have a higher value to clinicians than others. While EHR order sets can save time and improve processes of care, it remains less clear that EHR order sets have shown definite patient outcome benefits. There are general guidelines on CDS and usability that can be applied to the development of EHR order sets. Order set success requires leadership, planning, and resources as well as ongoing maintenance and evaluation. This article describes one academic medical center's experience in developing an EHR order set embedded with evidence-based principles and lessons learned for future order set development.
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Affiliation(s)
- John D McGreevey
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, and Office of the Chief Medical Information Officer, University of Pennsylvania Health System, Philadelphia, PA.
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Abstract
OBJECTIVES Order sets are widely used in hospitals to enter diagnosis and treatment orders. To determine the effectiveness of order sets in improving guideline adherence, treatment outcomes, processes of care, efficiency, and cost, we conducted a systematic review of the literature. METHODS A comprehensive literature search was performed in various databases for studies published between January 1, 1990, and April 18, 2009. A total of eighteen studies met inclusion criteria. No randomized controlled trials were found. RESULTS Outcomes of the included studies were summarized qualitatively due to variations in study population, intervention type, and outcome measures. There were no important inconsistencies between the results reported by studies involving different types of order sets. While the studies generally suggested positive outcomes, they were typically of low quality, with simple before-after designs and other methodological limitations. CONCLUSIONS The benefits of order sets remain eminently plausible, but given the paucity of high quality evidence, further investigations to formally evaluate the effectiveness of order sets would be highly valuable.
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Impact of a Computerized Order Set on Adherence to Centers for Disease Control Guidelines for the Treatment of Victims of Sexual Assault. J Emerg Med 2013; 44:528-35. [DOI: 10.1016/j.jemermed.2012.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 01/09/2012] [Accepted: 06/28/2012] [Indexed: 01/22/2023]
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Changing patient care orders from paper to computerized provider order entry-based process. Comput Inform Nurs 2013; 30:417-25. [PMID: 22466865 DOI: 10.1097/nxn.0b013e318251076e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to describe the extent of change in patient care orders primarily for six diagnoses, procedures, or conditions in a not-for-profit Midwestern rural referral hospital. A descriptive method was used to analyze changes in the order sets over time for chest pain with acute myocardial infarction, degenerative osteoarthritis with hip joint replacement and degenerative osteoarthritis with knee joint replacement procedures, coronary artery bypass graft procedures, congestive heart failure, and pneumonia. Ten items about service-specific order sets were abstracted during pre- and post-EHR implementation and a year later. We then examined use 5 years later. The findings illustrate how the order sets evolved with multiple nested order sets to facilitate computerized provider order entry with a rate greater than 70% by physicians. The total number of available patient care orders within the order sets increased primarily because of linked nested order sets related to medications and diagnostic tests. Five years later, 50% of the orders were medication orders. In conclusion, this was important to deploy the order sets within smaller critical-access hospital facilities to train providers in adopting order sets internally.
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Stultz JS, Nahata MC. Computerized clinical decision support for medication prescribing and utilization in pediatrics. J Am Med Inform Assoc 2012; 19:942-53. [PMID: 22813761 PMCID: PMC3534459 DOI: 10.1136/amiajnl-2011-000798] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 06/26/2012] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Accurate and informed prescribing is essential to ensure the safe and effective use of medications in pediatric patients. Computerized clinical decision support (CCDS) functionalities have been embedded into computerized physician order entry systems with the aim of ensuring accurate and informed medication prescribing. Owing to a lack of comprehensive analysis of the existing literature, this review was undertaken to analyze the effect of CCDS implementation on medication prescribing and use in pediatrics. MATERIALS AND METHODS A literature search was performed using keywords in PubMed to identify research studies with outcomes related to the implementation of medication-related CCDS functionalities. RESULTS AND DISCUSSION Various CCDS functionalities have been implemented in pediatric patients leading to different results. Medication dosing calculators have decreased calculation errors. Alert-based CCDS functionalities, such as duplicate therapy and medication allergy checking, may generate excessive alerts. Medication interaction CCDS has been minimally studied in pediatrics. Medication dosing support has decreased adverse drug events, but has also been associated with high override rates. Use of medication order sets have improved guideline adherence. Guideline-based treatment recommendations generated by CCDS functionalities have had variable influence on appropriate medication use, with few studies available demonstrating improved patient outcomes due to CCDS use. CONCLUSION Although certain medication-related CCDS functionalities have shown benefit in medication prescribing for pediatric patients, others have resulted in high override rates and inconsistent or unknown impact on patient care. Further studies analyzing the effect of individual CCDS functionalities on safe and effective prescribing and medication use are required.
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Affiliation(s)
- Jeremy S Stultz
- Ohio State University College of Pharmacy, Columbus, Ohio, USA
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Abrahamyan L, Austin PC, Donovan LR, Tu JV. Standard admission orders can improve the management of acute myocardial infarction. Int J Qual Health Care 2012; 24:425-32. [DOI: 10.1093/intqhc/mzs022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Prevedello LM, Raja AS, Zane RD, Sodickson A, Lipsitz S, Schneider L, Hanson R, Mukundan S, Khorasani R. Variation in use of head computed tomography by emergency physicians. Am J Med 2012; 125:356-64. [PMID: 22325235 DOI: 10.1016/j.amjmed.2011.06.023] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 06/23/2011] [Accepted: 06/24/2011] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Variation in emergency department head computed tomography (CT) use in patients with atraumatic headaches between hospitals is being measured nationwide. However, the magnitude of interphysician variation within a hospital is currently unknown. We hypothesized that there was significant variation in the rates of physician head CT use, both overall and for patients diagnosed with atraumatic headaches. METHODS This cross-sectional study was conducted in the emergency department of a large urban academic hospital, and institutional review board approval was obtained. All emergency department visits from 2009 were analyzed, and the primary outcome measure was whether or not head CT was performed. Logistic regression was used to control for patient, physician, and visit characteristics potentially associated with head CT ordering. The degree of interphysician variability was tested, both before and after controlling for these variables. RESULTS Of 55,286 emergency department patient encounters, 4919 (8.9%) involved head CT examinations. Unadjusted head CT ordering rates per physician ranged from 4.4% to 16.9% overall and from 15.2% to 61.7% in patients diagnosed with atraumatic headaches, with both rates varying significantly between physicians. Two-fold variation in head CT ordering overall (6.5%-13.5%) and approximately 3-fold variation in head CT ordering for atraumatic headaches (21.2%-60.1%) persisted even after controlling for pertinent variables. CONCLUSION Emergency physicians vary significantly in their use of head CT both overall and in patients with atraumatic headaches. Further studies are needed to identify strategies to reduce interphysician variation in head CT use.
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Affiliation(s)
- Luciano M Prevedello
- Center for Evidence-Based Imaging, Brigham and Women's Hospital, Boston, Mass., USA.
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Jacobs BR, Hart KW, Rucker DW. Reduction in Clinical Variance Using Targeted Design Changes in Computerized Provider Order Entry (CPOE) Order Sets: Impact on Hospitalized Children with Acute Asthma Exacerbation. Appl Clin Inform 2012; 3:52-63. [PMID: 23616900 DOI: 10.4338/aci-2011-01-ra-0002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 01/22/2012] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES Unwarranted variance in healthcare has been associated with prolonged length of stay, diminished health and increased cost. Practice variance in the management of asthma can be significant and few investigators have evaluated strategies to reduce this variance. We hypothesized that selective redesign of order sets using different ways to frame the order and physician decision-making in a computerized provider order entry system could increase adherence to evidence-based care and reduce population-specific variance. PATIENTS AND METHODS The study focused on the use of an evidence-based asthma exacerbation order set in the electronic health record (EHR) before and after order set redesign. In the Baseline period, the EHR was queried for frequency of use of an asthma exacerbation order set and its individual orders. Important individual orders with suboptimal use were targeted for redesign. Data from a Post-Intervention period were then analyzed. RESULTS In the Baseline period there were 245 patient visits in which the acute asthma exacerbation order set was selected. The utilization frequency of most orders in the order set during this period exceeded 90%. Three care items were targeted for intervention due to suboptimal utilization: admission weight, activity center use and peak flow measurements. In the Post-Intervention period there were 213 patient visits. Order set redesign using different default order content resulted in significant improvement in the utilization of orders for all 3 items: admission weight (79.2% to 94.8% utilization, p<0.001), activity center (84.1% to 95.3% utilization, p<0.001) and peak flow (18.8% to 55.9% utilization, p<0.001). Utilization of peak flow orders for children ≥8 years of age increased from 42.7% to 94.1% (p<0.001). CONCLUSIONS Details of order set design greatly influence clinician prescribing behavior. Queries of the EHR reveal variance associated with ordering frequencies. Targeting and changing order set design elements in a CPOE system results in improved selection of evidence-based care.
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Affiliation(s)
- B R Jacobs
- Children's National Medical Center , Washington, DC
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Gagnon MP, Desmartis M, Labrecque M, Car J, Pagliari C, Pluye P, Frémont P, Gagnon J, Tremblay N, Légaré F. Systematic review of factors influencing the adoption of information and communication technologies by healthcare professionals. J Med Syst 2012; 36:241-77. [PMID: 20703721 PMCID: PMC4011799 DOI: 10.1007/s10916-010-9473-4] [Citation(s) in RCA: 314] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 03/08/2010] [Indexed: 01/18/2023]
Abstract
This systematic review of mixed methods studies focuses on factors that can facilitate or limit the implementation of information and communication technologies (ICTs) in clinical settings. Systematic searches of relevant bibliographic databases identified studies about interventions promoting ICT adoption by healthcare professionals. Content analysis was performed by two reviewers using a specific grid. One hundred and one (101) studies were included in the review. Perception of the benefits of the innovation (system usefulness) was the most common facilitating factor, followed by ease of use. Issues regarding design, technical concerns, familiarity with ICT, and time were the most frequent limiting factors identified. Our results suggest strategies that could effectively promote the successful adoption of ICT in healthcare professional practices.
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O'Reilly D, Tarride JE, Goeree R, Lokker C, McKibbon KA. The economics of health information technology in medication management: a systematic review of economic evaluations. J Am Med Inform Assoc 2011; 19:423-38. [PMID: 21984590 DOI: 10.1136/amiajnl-2011-000310] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To conduct a systematic review and synthesis of the evidence surrounding the cost-effectiveness of health information technology (HIT) in the medication process. MATERIALS AND METHODS Peer-reviewed electronic databases and gray literature were searched to identify studies on HIT used to assist in the medication management process. Articles including an economic component were reviewed for further screening. For this review, full cost-effectiveness analyses, cost-utility analyses and cost-benefit analyses, as well as cost analyses, were eligible for inclusion and synthesis. RESULTS The 31 studies included were heterogeneous with respect to the HIT evaluated, setting, and economic methods used. Thus the data could not be synthesized, and a narrative review was conducted. Most studies evaluated computer decision support systems in hospital settings in the USA, and only five of the studied performed full economic evaluations. DISCUSSION Most studies merely provided cost data; however, useful economic data involves far more input. A full economic evaluation includes a full enumeration of the costs, synthesized with the outcomes of the intervention. CONCLUSION The quality of the economic literature in this area is poor. A few studies found that HIT may offer cost advantages despite their increased acquisition costs. However, given the uncertainty that surrounds the costs and outcomes data, and limited study designs, it is difficult to reach any definitive conclusion as to whether the additional costs and benefits represent value for money. Sophisticated concurrent prospective economic evaluations need to be conducted to address whether HIT interventions in the medication management process are cost-effective.
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Affiliation(s)
- Daria O'Reilly
- Programs for Assessment of Technology in Health-PATH, Research Institute-St Joseph's Healthcare, Hamilton, Ontario, Canada.
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O'Connor C, Adhikari NKJ, DeCaire K, Friedrich JO. Medical admission order sets to improve deep vein thrombosis prophylaxis rates and other outcomes. J Hosp Med 2009; 4:81-9. [PMID: 19219912 DOI: 10.1002/jhm.399] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The value of order sets for clinical decision support has not been established. OBJECTIVE To determine whether introduction of admission order sets increases the proportion of inpatients receiving deep venous thrombosis (DVT) prophylaxis. DESIGN Before-after study. SETTING Community hospital. PATIENTS General medical patients admitted to hospital. INTERVENTION Paper-based admission order sets (instead of free-text orders) for voluntary use by internists, without any education or behavior change interventions. MEASUREMENTS Primary outcome was proportion of medical admissions ordered DVT prophylaxis. Secondary outcomes included overall utilization of DVT prophylaxis in medical inpatients and other admission order care quality measures. RESULTS Prior to introduction of order sets, DVT prophylaxis was ordered in 10.9% of patients. Patients admitted with order sets were more likely to be ordered DVT prophylaxis than patients admitted with free-text orders (44.0% versus 20.6%, by months 14 and 15, P<0.0001). Hospital-wide DVT prophylaxis in medical inpatients increased from 12.8% to 25.8% of patient-days (P<0.0001). Order set use improved many other secondary outcomes (P<0.05 for all), including allied health consultations (62.8% versus 12.7%), use of standardized diabetic diet (17.0% versus 5.1%), insulin sliding scale (19.1% versus 7.6%), potassium replacement protocol (63.8% versus 0.51%), documentation of allergies (54.3% versus 9.6%) and resuscitation status (57.4% versus 10.2%), and reduced orders for inappropriate laboratory tests such as blood urea nitrogen (39.4% versus 59.0%). CONCLUSIONS The broad impact of order sets and minimal organizational resources required for their implementation suggests that order sets may have wide applicability as a clinical decision support tool.
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Affiliation(s)
- Chris O'Connor
- Department of Medicine, Trillium Health Centre, Mississauga, Ontario, Canada
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Eslami S, de Keizer NF, Abu-Hanna A. The impact of computerized physician medication order entry in hospitalized patients—A systematic review. Int J Med Inform 2008; 77:365-76. [PMID: 18023611 DOI: 10.1016/j.ijmedinf.2007.10.001] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 09/26/2007] [Accepted: 10/03/2007] [Indexed: 11/19/2022]
Affiliation(s)
- Saeid Eslami
- Department of Medical Informatics, Academic Medical Center, Universiteit van Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands.
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