Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010)
Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010)
Description
This project sought to identify whether computerised pathology order entry (CPOE) systems with varying levels of electronic decision support (EDS) can enhance the efficiency of pathology services and lead to more effective and rational pathology ordering and improved patient outcomes. While research has shown that CPOE has the potential to support more efficient pathology services, it is the EDS component which holds the promise for making substantial improvements in delivering more rational pathology ordering and improvements in patients outcomes.
A major limiting factor in deriving benefit from CPOE with EDS is the lack of research evidence regarding which level of EDS is useful and which specific EDS features will improve pathology practice and patient outcomes. This project targeted this large knowledge gap by undertaking a detailed analysis of three levels of EDS.
Grant Recipient
University of Sydney
Aims and Objectives
to identify how computerised pathology order systems with varying levels of electronic decision support can enhance the efficiency of pathology services and lead to more effective and rational pathology ordering which improves patient outcomes
to undertake a multi-site study which will:
undertake a global assessment of the impact of CPOE on pathology practice measuring a broad range of effectiveness (e.g. length of stay) and efficiency (e.g. turnaround time) indicators
measure the impact of different levels of EDS (basic, intermediate and advanced) on quality of information provided to laboratories, rational pathology ordering and patient outcomes.
These aims and objectives appeared to be partially achieved by this project as the report did not articulate the level of EDS for each outcome/finding, nor did it articulate the 39 measures across the spectrum of the pathology test processes (see outcomes).
Outcomes
The reported noted the review identified 39 measures classified into 10 impact areas across the spectrum of pathology test processes (ordering, processing and reporting). These included measures of:
turnaround time (TAT)
test volumes
redundant tests
costs
guideline compliance
work practices
communication
patient management
length of stay
adverse events/safety.
This project resulted in 13 peer-reviewed papers including a number in high impact international journals and conference proceedings.
This project also resulted in 19 presentations including invited and keynote presentations at major national and international fora.
The project’s researchers also received an invitation by the American College of Pathologists to contribute a chapter on electronic medical records to the College textbook, and an invitation to outline their work in the founding issue of the Journal of Pathology Informatics.
Findings
Turnaround time, test volumes, redundant tests (tests reordered within an inappropriate time frame providing no additional information) and length of stay (the number of days a patient remains in hospital from admission to discharge) can provide valuable information to monitor the implementation of CPOE and drive benefits realisation.
There is value in using a standardised record linkage technique to generate a quality dataset with enriched information. Analyses applied to these enriched datasets can provide valuable information to health system planners, clinicians and pathology managers for use in managing and evaluating new CPOE systems.
The various measures of CPOE performance and impact provide a framework to assess:
efficiency – test volumes, communication
effectiveness – test costs, redundant test rates, TAT, work practices
quality – patient safety, compliance with guidelines, patient management, length of stay, patient safety.
The study found the CPOE system produced sustained and continuing improvements in laboratory efficiency over a two-year period.
A regression analysis demonstrated that TAT was a significant factor contributing to patient’s length of stay in the emergency department. This provided evidence that reducing TATs via the introduction of a CPOE may produce improvements in these patients’ outcomes in terms of reduced lengths of stay.
The rates of missed test results were lower than those from studies where paper ordering and reporting systems were used. This suggests the availability of CPOE systems may reduce the risk of these events. Electronic result delivery, with electronic endorsement to allow documentation of follow-up test results, may provide additional efficiency benefits and further reduce the risk of test results which are not followed up.
There was a positive impact of using the CPOE for notifying the haematology laboratory about patients on heparin or warfarin treatment when ordering activated Partial Thromboplastin Time (aPTT) or Prothrombin (PT)/International Normalised Ratio (INR). The median TAT also decreased from 28 to 21 minutes for aPTT and from 34 to 23 minutes for PT/INR. Decreases were also shown for TAT in normal test results (30 to 22 minutes) and abnormal rest results (33 to 23 minutes).
Recommendations
Associations between increased mortality rates and the introduction of a computerised provider order entry system should be investigated carefully to ascertain any likely association.
Conduct research into the change in lengths of stay in emergency departments following the introduction of CPOE.
Follow on Initiatives and Projects
Continued development as stage 2 in the project The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions
