A Statistical Approach for the Learning Curve of Physicians in Utilization of Electronic Order Sets

2019 ◽  
Vol 58 (04/05) ◽  
pp. 160-166
Author(s):  
Jaehoon Lee ◽  
Nathan C. Hulse
Keyword(s):  
Learning Curve ◽  
Utilization Rate ◽  
New Order ◽  
Inpatient Setting ◽  
Standard Order ◽  
Order Sets ◽  
Initial Hypothesis ◽  
Localized Patterns ◽  
Physician Order Entry ◽  
Order Set

Abstract Background Understanding a physician's behavior toward learning order sets is important as it is a key information to design order sets with optimized contents. Objective The objective of this article is to test a hypothesis: for a physician using a new order set repeatedly, the utilization rate of order set contents has a pattern of either increase or decrease. Methods To test the hypothesis, we retrieved empirical data of order set usage in local hospitals that adopted a new computerized physician order entry (CPOE) system and enterprise wide standard order sets. We extracted 4-year data including 63,583 orders made by 600 physicians in the inpatient setting and analyzed patterns of the learning curve at several aggregation levels. Result The analysis results demonstrated that content modification rates over time were relatively flat except for a few localized patterns. Conclusion Based on our finding, we reject our initial hypothesis.

scholarly journals MP011: Using GRADE-based recommendations for analgesia and antiemetics in electronic order sets to influence physician behaviour towards best practice and cost-savings

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S69-S70
Author(s):  
R.J. Hartmann ◽  
E. Lang ◽  
T. Rich ◽  
B. Ford ◽  
K. Lonergan ◽  
...  
Keyword(s):  
Best Practices ◽  
Working Group ◽  
Cost Savings ◽  
Sufficient Evidence ◽  
New Order ◽  
Order Entry ◽  
Physician Behaviour ◽  
Order Sets ◽  
Electronic Order ◽  
Order Set

Introduction: The addition of computerized physician order entry (CPOE) to Emergency Departments in recent years has led to speculation over potential benefits and pitfalls. Recent studies have shown benefits to CPOE, though there lacks sufficient evidence on how it could change physician behaviour. Physician practices are known to be difficult to change, with getting evidence into daily practice being the main challenge of knowledge translation. Our study aims were to determine if well-designed electronic order sets for CPOE improved MD practices. Methods: The Calgary Zone Pain Management in the Emergency Department Working Group relied on a GRADE-based literature review for identifying best practices for analgesia and antiemetics, resulting in soft changes to the dedicated analgesia and antiemetic electronic order set noting working group preference, and emphasizing hydromorphone over morphine, as well as 4 mg ondansetron over 8 mg. The new electronic order set was started in the only Calgary Region order entry system on December 11th, 2014. Data was collected from July 2014 - May 2015. A Yates chi-squared analysis was completed on all orders in a category, as well as the subgroups of ED staff and residents, and orders placed using the new order set. Results: A total of 100460 orders were analyzed. The use of hydromorphone increased significantly across all 4 EDs. IV hydromorphone use increased (5.82% of all opioid orders up to 26.93%, P<0.0001) with a reciprocal decline in IV morphine (67.81% of all opioid orders down to 46.56%, P<0.0001). Similar effects were observed with ondansetron 4 mg IV orders increasing (1.37% of all ondansetron orders to 18.64%, P<0.0001) with a decrease in 8 mg dosing (15.75% of all ondansetron orders to 7.23%, P<0.0001). These results were replicated to a lesser degree in the non-ED staff and non-order set subgroups. Implementation of the new order set resulted in an increase of its use (37.64% of all opioid orders up to 49.29%, P<0.0001). Finally, a cost-savings analysis was completed showing a projected annual savings of $185,676.52 on medications alone. Conclusion: This data supports the manipulation of electronic order sets to help shape physician behaviour towards best practices. This provides another strong argument towards the benefits of CPOE, and can help maintain best practices in Emergency Medicine.

scholarly journals Effectiveness of Evidence-based Pneumonia CPOE Order Sets Measured by Health Outcomes

2015 ◽  
Vol 7 (2) ◽  
Author(s):  
Jacob Krive ◽  
Joel S. Shoolin ◽  
Steven D. Zink
Keyword(s):  
Health Outcomes ◽  
Patient Care ◽  
Cost Of Care ◽  
Patient Treatment ◽  
Computerized Physician Order Entry ◽  
Evidence Based ◽  
Order Entry ◽  
Order Sets ◽  
Physician Order Entry ◽  
Order Set

ObjectiveEvidence-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.MethodsIn 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.ResultsThe 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)].ConclusionEvidence-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.Keywords: evidence-based medicine, medication order sets, health outcomes research, pneumonia, computerized physician order entry (CPOE).

scholarly journals Implementation of disease-based standard order sets in emergency department of tertiary care hospital, Pakistan- a novel approach for enhancing patient care

2020 ◽  
pp. 1-13
Author(s):  
Feroza Parveen ◽  
Asif Khaliq ◽  
Nadeem Ullah Khan ◽  
Zainab Mazhar ◽  
Aisha Akram ◽  
...  
Keyword(s):  
Emergency Department ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
Care Hospital ◽  
Order Entry ◽  
Post Intervention ◽  
Order Processing ◽  
Standard Order ◽  
Order Sets ◽  
Order Set

Abstract Objectives: To evaluate the efficacy of disease-based standard order sets in reducing time of order entry, order processing and medication dispensation in emergency department of a tertiary care hospital. Methods: The pilot study was conducted as part of a retrospective clinical audit using pre- and post-intervention design comprising data from July to September 2013 of the emergency department of a tertiary care hospital in Karachi. Data collected related to the reduction in medicine order entry, processing and dispensing time of eight common emergency conditions with standard order set.  Subsequently, standard medication orders for the selected medical conditions were developed together with physicians of emergency and other specialties. Post-intervention data was collected and the two data sets were compared using SPSS version 23.0. Results: Mean medication order entry and processing time from the physician end improved from 67.7±22.7 seconds to 20.5±7.1 seconds.  Mean order processing and medication processing and dispensing time at pharmacist end reduced from 70.0±22.4 to 20.6±8.8 seconds. The difference between pre- and post-intervention values was significant (p<0.001). Conclusion: Implementation of disease-based standard order set significantly improved efficiency. Key Words: Standard, Order sets, Emergency department, Disease, Time management. Continuous...

scholarly journals Duplicate Orders: An Unintended Consequence of Computerized provider/physician order entry (CPOE) Implementation

2012 ◽  
Vol 03 (04) ◽  
pp. 377-391 ◽  
Author(s):  
C. Forrer ◽  
S. Shaha ◽  
S. Magid
Keyword(s):  
Time Series ◽  
Improve Patient Safety ◽  
Clinical Decision ◽  
Unintended Consequences ◽  
Unintended Consequence ◽  
Mitigation Strategies ◽  
Order Entry ◽  
Order Sets ◽  
Physician Order Entry ◽  
Order Set

SummaryObjective: Computerized provider/physician order entry (CPOE) with clinical decision support (CDS) is designed to improve patient safety. However, a number of unintended consequences which include duplicate ordering have been reported. The objective of this time-series study was to characterize duplicate orders and devise strategies to minimize them.Methods: Time series design with systematic weekly sampling for 84 weeks. Each week we queried the CPOE database, downloaded all active orders onto a spreadsheet, and highlighted duplicate orders. We noted the following details for each duplicate order: time, order details (e.g. drug, dose, route and frequency), ordering prescriber, including position and role, and whether the orders originated from a single order or from an order set (and the name of the order set). This analysis led to a number of interventions, including changes in: order sets, workflow, prescriber training, pharmacy procedures, and duplicate alerts.Results: Duplicates were more likely to originate from different prescribers than from same prescribers; and from order sets than from single orders. After interventions, there was an 84.8% decrease in the duplication rate from weeks 1 to 84 and a 94.6% decrease from the highest (1) to the lowest week (75). Currently, we have negligible duplicate orders.Conclusions: Duplicate orders can be a significant unintended consequence of CPOE. By analyzing these orders, we were able to devise and implement generalizable strategies that significantly reduced them. The incidence of duplicate orders before CPOE implementation is unknown, and our data originate from a weekly snapshot of active orders, which serves as a sample of total active orders. Thus, it should be noted that this methodology likely under-reports duplicate orders.Citation: Magid S, Forrer C, Shaha S. Duplicate Orders: An unintended consequence of computerized provider/physician order entry (CPOE) implementation. Analysis and mitigation strategies. Appl Clin Inf 2012; 3: 377–391http://dx.doi.org/10.4338/ACI-2012-01-RA-0002

scholarly journals Implementing a Protocol to Reduce Opioid Prescriptions in Military Otolaryngology: A Quality Improvement Initiative

2021 ◽  
Author(s):  
CindyLee P Neighbors ◽  
Michael W Noller ◽  
Michael P Avillion ◽  
John W Neighbors ◽  
Mark C Spaw ◽  
...  
Keyword(s):  
Retrospective Chart Review ◽  
Outcome Variable ◽  
Quality Improvement Initiative ◽  
New Order ◽  
Opioid Prescription ◽  
Medication Refill ◽  
Before And After ◽  
Patient Pain ◽  
Prescription Rates ◽  
Order Set

ABSTRACT Introduction To compare pain medication refill rates for adult septoplasty and rhinoplasty patients before and after initiating a multimodal analgesic protocol for reducing opioid prescriptions (PROP). Materials and Methods Data from 58 adult patients were retrieved by retrospective chart review (19 septoplasties and 10 rhinoplasties before initiating PROP in September 2018 and 21 septoplasties and 8 rhinoplasties after PROP). We selected consecutive septoplasties and rhinoplasties, at which time a new discharge order set was implemented. The new order set consisted of 10 oxycodone tabs (5 mg), 100 acetaminophen tabs (325 mg), and 28 celecoxib tabs (200 mg). The primary outcome variable was the number of initial opioid prescriptions and refills filled by any provider. Results Among the septoplasties, there was a 46% decrease in total morphine milligram equivalent (MME) prescribed, from a mean of 202.0 mg in the non-PROP group (95% CI, 235.4, 174.6) to 108.6 mg in the PROP group (95% CI, 135.8, 81.4), with no difference in refill rates. Among the rhinoplasties, there was a 51% decrease in total MME prescribed, from a mean of 258.8 mg in the non-PROP group (95% CI, 333.4, 184.1) to 126.6 mg in the PROP group (95% CI, 168.1, 85.0) with no difference in refill rates. Conclusions The outcomes after PROP implementation for septoplasty and rhinoplasty at our institution suggest that opioid prescription rates can be significantly decreased to manage postoperative pain, with no difference in opioid refill rates. The results also warrant further investigation into patient pain, satisfaction, provider efficiency, and healthcare costs.

scholarly journals Clinical decision support improves the appropriateness of laboratory test ordering in primary care without increasing diagnostic error: the ELMO cluster randomized trial

2020 ◽  
Author(s):  
Nicolas Delvaux ◽  
Veerle Piessens ◽  
Tine De Burghgraeve ◽  
Pavlos Mamouris ◽  
Bert Vaes ◽  
...  
Keyword(s):  
Primary Care ◽  
Decision Support ◽  
Laboratory Test ◽  
Clinical Decision Support ◽  
Clinical Decision ◽  
Diagnostic Error ◽  
Order Sets ◽  
Cluster Randomized ◽  
Physician Order Entry ◽  
Test Ordering

Abstract Background Inappropriate laboratory test ordering poses an important burden for healthcare. Clinical decision support systems (CDSS) have been cited as promising tools to improve laboratory test ordering behavior. The objectives of this study were to evaluate the effects of an intervention that integrated a clinical decision support service into a computerized physician order entry (CPOE) on the appropriateness and volume of laboratory test ordering, and on diagnostic error in primary care.Methods This study was a pragmatic, cluster randomized, open label, controlled clinical trial. Setting 280 general practitioners (GPs) from 72 primary care practices in Belgium. Patients Patients aged ≥18 years with a laboratory test order for at least one of 17 indications; cardiovascular disease management, hypertension, check-up, chronic kidney disease (CKD), thyroid disease, type 2 diabetes mellitus, fatigue, anemia, liver disease, gout, suspicion of acute coronary syndrome (ACS), suspicion of lung embolism, rheumatoid arthritis, sexually transmitted infections (STI), acute diarrhea, chronic diarrhea, and follow-up of medication. Interventions The CDSS was integrated into a computerized physician order entry (CPOE) in the form of evidence-based order sets that suggested appropriate tests based on the indication provided by the general physician. Measurements The primary outcome of the ELMO study was the proportion of appropriate tests over the total number of ordered tests and inappropriately not-requested tests. Secondary outcomes of the ELMO study included diagnostic error, test volume and cascade activities.Results CDSS increased the proportion of appropriate tests by 0.21 (95% CI 0.16 - 0.26, p<.0001) for all tests included in the study. GPs in the CDSS arm ordered 7 (7.15 (95% CI 3.37 - 10.93, p=.0002)) tests fewer per panel. CDSS did not increase diagnostic error. The absolute difference in proportions was a decrease of 0.66% (95% CI 1.4% decrease - 0.05% increase) in possible diagnostic error.Conclusions A CDSS in the form of order sets, integrated within the CPOE improved appropriateness and decreased volume of laboratory test ordering without increasing diagnostic error. Trial Registration Clinicaltrials.gov Identifier: NCT02950142, registered on October 25, 2016Funding source This study was funded through the Belgian Health Care Knowledge Centre (KCE) Trials Programme agreement KCE16011.

Altering standard admission order sets to promote clinical laboratory stewardship: a cohort quality improvement study

2019 ◽  
Vol 28 (10) ◽  
pp. 846-852 ◽  
Author(s):  
Benjamin Leis ◽  
Andrew Frost ◽  
Rhonda Bryce ◽  
Andrew W Lyon ◽  
Kelly Coverett
Keyword(s):  
Clinical Decision Making ◽  
Clinical Laboratory ◽  
Clinical Decision ◽  
Thyroid Stimulating Hormone ◽  
Clinical Indication ◽  
Medical Overuse ◽  
Order Sets ◽  
Cohort Quality ◽  
Careful Design ◽  
Order Set

BackgroundCareful design of preprinted order sets is needed to prevent medical overuse. Recent work suggests that removing a single checkbox from an order set changes physicians’ clinical decision-making.Local problemDuring a 2-month period, our coronary care unit (CCU) ordered almost eight times as many serum thyroid-stimulating hormone (TSH) tests as our neighbouring intensive care unit, many without a reasonable clinical basis. We postulated that we could reduce inappropriate testing and improve clinical laboratory stewardship by removing the TSH checkbox from the CCU admission order set.MethodsAfter we retrospectively evaluated CCU TSH ordering before intervention, the checkbox was removed from the CCU admission order set. Twelve weeks later, we commenced a prospective 2-month assessment of TSH testing and clinical sequelae of thyroid disease among all CCU admissions. If clinical indications were absent or testing had occurred within 6 weeks, TSH requests were labelled as ‘inappropriate’.ResultsPhysician ordering and, specifically, inappropriate ordering decreased substantially after the intervention. In 2016 among physician-ordered TSH tests, 60.6% (66/109) were inappropriate; in 2017 this decreased to 20% (2/10, p=0.01). Overall, the net effect of checkbox removal saw the decrease in TSH testing without clinical indication outweigh an increase in missed testing where indications appear to exist.ConclusionsProvision of an optional checkbox for a laboratory test in an admission order set can promote overuse of laboratory resources. Simple removal of a checkbox may dramatically change test ordering patterns and promote clinical laboratory stewardship. Given our reliance on order sets, particularly by trainees, changes to order sets must be cautious to assure guideline-directed care is maintained.

scholarly journals Clinical decision support improves the appropriateness of laboratory test ordering in primary care without increasing diagnostic error: the ELMO cluster randomized trial

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Nicolas Delvaux ◽  
Veerle Piessens ◽  
Tine De Burghgraeve ◽  
Pavlos Mamouris ◽  
Bert Vaes ◽  
...  
Keyword(s):  
Primary Care ◽  
Decision Support ◽  
Laboratory Test ◽  
Clinical Decision Support ◽  
Clinical Decision ◽  
Diagnostic Error ◽  
Order Sets ◽  
Cluster Randomized ◽  
Physician Order Entry ◽  
Test Ordering

Abstract Background Inappropriate laboratory test ordering poses an important burden for healthcare. Clinical decision support systems (CDSS) have been cited as promising tools to improve laboratory test ordering behavior. The objectives of this study were to evaluate the effects of an intervention that integrated a clinical decision support service into a computerized physician order entry (CPOE) on the appropriateness and volume of laboratory test ordering, and on diagnostic error in primary care. Methods This study was a pragmatic, cluster randomized, open-label, controlled clinical trial. Setting Two hundred eighty general practitioners (GPs) from 72 primary care practices in Belgium. Patients Patients aged ≥ 18 years with a laboratory test order for at least one of 17 indications: cardiovascular disease management, hypertension, check-up, chronic kidney disease (CKD), thyroid disease, type 2 diabetes mellitus, fatigue, anemia, liver disease, gout, suspicion of acute coronary syndrome (ACS), suspicion of lung embolism, rheumatoid arthritis, sexually transmitted infections (STI), acute diarrhea, chronic diarrhea, and follow-up of medication. Interventions The CDSS was integrated into a computerized physician order entry (CPOE) in the form of evidence-based order sets that suggested appropriate tests based on the indication provided by the general physician. Measurements The primary outcome of the ELMO study was the proportion of appropriate tests over the total number of ordered tests and inappropriately not-requested tests. Secondary outcomes of the ELMO study included diagnostic error, test volume, and cascade activities. Results CDSS increased the proportion of appropriate tests by 0.21 (95% CI 0.16–0.26, p < 0.0001) for all tests included in the study. GPs in the CDSS arm ordered 7 (7.15 (95% CI 3.37–10.93, p = 0.0002)) tests fewer per panel. CDSS did not increase diagnostic error. The absolute difference in proportions was a decrease of 0.66% (95% CI 1.4% decrease–0.05% increase) in possible diagnostic error. Conclusions A CDSS in the form of order sets, integrated within the CPOE improved appropriateness and decreased volume of laboratory test ordering without increasing diagnostic error. Trial registration ClinicalTrials.gov Identifier: NCT02950142, registered on October 25, 2016

scholarly journals When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record

2019 ◽  
pp. bmjqs-2018-008968 ◽  
Author(s):  
Ron C Li ◽  
Jason K Wang ◽  
Christopher Sharp ◽  
Jonathan H Chen
Keyword(s):  
Electronic Health Record ◽  
Point Of Care ◽  
Set Design ◽  
Health Record ◽  
Additional Item ◽  
Order Sets ◽  
Usage Patterns ◽  
Electronic Health ◽  
Order Set ◽  
A La Carte

BackgroundOrder sets are widely used tools in the electronic health record (EHR) for improving healthcare quality. However, there is limited insight into how well they facilitate clinician workflow. We assessed four indicators based on order set usage patterns in the EHR that reflect potential misalignment between order set design and clinician workflow needs.MethodsWe used data from the EHR on all orders of medication, laboratory, imaging and blood product items at an academic hospital and an itemset mining approach to extract orders that frequently co-occurred with order set use. We identified the following four indicators: infrequent ordering of order set items, rapid retraction of medication orders from order sets, additional a la carte ordering of items not included in order sets and a la carte ordering of items despite being listed in the order set.ResultsThere was significant variability in workflow alignment across the 11 762 order set items used in the 77 421 inpatient encounters from 2014 to 2017. The median ordering rate was 4.1% (IQR 0.6%–18%) and median medication retraction rate was 4% (IQR 2%–10%). 143 (5%) medications were significantly less likely while 68 (3%) were significantly more likely to be retracted than if the same medication was ordered a la carte. 214 (39%) order sets were associated with least one additional item frequently ordered a la carte and 243 (45%) order sets contained at least one item that was instead more often ordered a la carte.ConclusionOrder sets often do not align with what clinicians need at the point of care. Quantitative insights from EHRs may inform how order sets can be optimised to facilitate clinician workflow.

Sign in / Sign up

Export Citation Format

Share Document