scholarly journals P019: The path of least resistance: how computerized provider order entry can lead to (and reduce) wasteful practices

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S63-S63
Author(s):  
J. Choi
Keyword(s):  
Complete Blood Count ◽  
Clinical Care ◽  
Cost Savings ◽  
Quality Improvement Initiative ◽  
Order Entry ◽  
Clinical Value ◽  
Post Intervention ◽  
Computerized Provider Order Entry ◽  
Order Sets ◽  
Before And After

Introduction: Background Computerized provider order entry (CPOE) is rapidly becoming the mainstay in clinical care and has the potential to improve provider efficiency and accuracy. However, this hinges on careful planning and implementation. Poorly planned CPOE order sets can lead to undetected errors and waste. In our emergency department (ED), lactate dehydrogenase (LDH) was bundled into various blood work panels, but had little clinical value. Aim Statement This quality improvement initiative aimed to reduce unnecessary LDH testing in the ED. Methods: Methods A group of ED physicians reviewed CPOE blood work panels and uncoupled LDH in conditions where it was deemed not to provide any clinically useful information. We measured the daily number of LDH tests performed before and after its removal. We tracked the frequency of other serum tests as controls. We also analyzed the number of add-on LDH (i.e. to add LDH to samples already sent to the lab) as a balancing measure, since this can disrupt work flow and delay care. Results: Results Through this intervention, we reduced the number of LDH tests performed by 69%, from an average of 75.1 tests per day to 23.2 (p<0.0005). The baseline controls did not differ after the intervention (e.g. a complete blood count was performed 197.7 and 196.1 times per day pre- and post-intervention, respectively [p=0.7663]). There was less than 1 add-on LDH per day on average. This translates to a cost savings of $33,340.65 at our institution. Conclusion: Conclusions CPOE care templates can be powerful in shaping behaviours and reducing variability. However, close oversight of these panels is necessary to prevent errors and waste.

scholarly journals Path of least resistance: how computerised provider order entry can lead to (and reduce) wasteful practices

2018 ◽  
Vol 7 (2) ◽  
pp. e000345 ◽  
Author(s):  
Joseph Choi ◽  
Cori Rebecca Atlin
Keyword(s):  
Blood Count ◽  
Complete Blood Count ◽  
Clinical Care ◽  
Work Flow ◽  
Quality Improvement Initiative ◽  
Order Entry ◽  
Clinical Value ◽  
Careful Planning ◽  
Order Sets ◽  
Before And After

BackgroundComputerised provider order entry (CPOE) is rapidly becoming the mainstay in clinical care and has the potential to improve provider efficiency and accuracy. However, this hinges on careful planning and implementation. Poorly planned CPOE order sets can lead to undetected errors and waste. In our emergency department (ED), lactate dehydrogenase (LDH) was bundled into various blood work panels but had little clinical value.ObjectivesThis quality improvement initiative aimed to reduce unnecessary LDH testing in the ED.MethodsA group of ED physicians reviewed CPOE blood work panels and uncoupled LDH in conditions where it was deemed not to provide any clinically useful information. We measured the daily number of LDH tests performed before and after its removal. We tracked the frequency of other serum tests as controls. We also analysed the number of add-on LDH (ie, to add LDH to samples already sent to the lab) as a balancing measure, since this can disrupt work flow and delay care.ResultsThrough this intervention, we reduced the number of LDH tests performed by 69%, from an average of 75.1 tests per day to 23.2 (P<0.0005). The baseline controls did not differ after the intervention (eg, a complete blood count was performed 197.7 and 196.1 times per day preintervention and postintervention, respectively (P=0.7663)). There was less than one add-on LDH per day on average.ConclusionsCPOE care templates can be powerful in shaping behaviours and reducing variability. However, close oversight of these panels is necessary to prevent errors and waste.

scholarly journals Optimized Computerized Order Entry can Reduce Errors in Electronic Prescriptions and Associated Pharmacy Calls to Clarify (CTC)

2016 ◽  
Vol 07 (02) ◽  
pp. 587-595 ◽  
Author(s):  
Richard Ogletree ◽  
Allison Sutterfield ◽  
John Pace ◽  
Laurene Lahr ◽  
Jaimin Patel
Keyword(s):  
Error Rate ◽  
Secondary Analysis ◽  
Cost Savings ◽  
Electronic Prescribing ◽  
Free Text ◽  
Order Entry ◽  
Computerized Provider Order Entry ◽  
Before And After ◽  
Physician Time ◽  
The Cost

SummaryAfter implementation of a system-wide EMR within our university system, e-prescribing is now commonplace.The authors conducted a study to assess whether optimization of computerized provider order entry (CPOE) can reduce errors in these electronically transmitted prescriptions and would require less frequent interventions from pharmacists, in particular the need for them to “call to clarify” (CTC) details of particular prescriptions. Secondary analysis based on cost assumptions was preformed to presume cost differences before and after optimization changes.In order to generate complete, error-free prescriptions, optimization changes were implemented in the form of in line validation messages. These messages were generated if (1) an order did not specify a provider or pharmacy; (2) the DEA requirements were not met; (3) character limits were exceeded in patient sig or demographics or (4) administration instructions had breaks or had both discrete and free text elements. Retrospectively, prescriptions were randomly selected from a nine month period before and after implementing changes. These prescriptions were analyzed by a pharmacist and a nurse to identify types of errors that would require a CTC to a prescribing provider. Errors were compared statistically to determine effectiveness of changes pre and post optimization.A total of 602 prescriptions were analyzed; 301 before changes and 301 after changes. Of these prescriptions, 20.27% had errors before changes and 12.96% had errors after changes. The decline in the error rate was considered statistically significant for p<0.05. The cost savings were estimated at $76 per 100 prescriptions for pharmacist and physician time-cost estimates combined.Implementing optimization changes to the CPOE resulted in a reduction in error rate requiring pharmacist CTC. This study identifies effective optimization changes for electronic prescribing that can reduce prescribing errors and may result in cost saving.

scholarly journals Reducing redundant creatine kinase testing in cardiac injury

2020 ◽  
Vol 9 (4) ◽  
pp. e001182
Author(s):  
Sheharyar Raza ◽  
Andre C Amaral ◽  
Jeffrey Pang ◽  
Fuad Moussa ◽  
Dominick Shelton ◽  
...  
Keyword(s):  
Creatine Kinase ◽  
Low Cost ◽  
Cardiac Injury ◽  
Cost Savings ◽  
High Volume ◽  
Quality Improvement Initiative ◽  
Successful Implementation ◽  
Clinical Value ◽  
Root Cause ◽  
Order Sets

BackgroundCreatine kinase (CK) testing in the setting of suspected cardiac injury is commonly performed yet rarely provides clinical value beyond troponin testing. We sought to evaluate and reduce CK testing coupled with troponin testing by 50% or greater.MethodsWe performed root cause analysis to study prevailing processes and patterns of CK testing. We developed new institutional guidelines, removed CK from high-volume paper and electronic order bundles and conducted academic detailing for departments with highest ordering frequency. We evaluated consecutive patients at Sunnybrook Health Sciences Centre between 1 January 2018 and 31 March 2020 who had either a CK or troponin level measured. We prespecified successful implementation as a reduction of 50% in total CK orders and a decrease in the ratio of CK-to-troponin tests to one-third or less. We retained additional data beyond our study period to assess for sustained reductions in testing.ResultsTotal CK tests decreased over the study period from 3963 to 2111 per month, amounting to a 46.7% reduction (95% CI 33.2 to 60.2; p<0.001) equalling 61 fewer tests per hospital day. Troponin testing did not significantly change during the intervention. Ratio of CK-to-troponin tests decreased from 0.91 to 0.49 (p<0.001). The reduction coincided with changes to order-sets, was observed across all clinical units and was sustained during additional months beyond the study period. These reductions in testing resulted in a projected annual cost savings of C$28 446.ConclusionsWe demonstrate that a low-cost and feasible quality improvement initiative may lead to significant reduction in unnecessary CK testing and substantial savings in healthcare costs for patients with suspected cardiac injury.

scholarly journals Impact of Computerized Provider Order Entry on Total Parenteral Nutrition in the Neonatal Intensive Care Unit

2016 ◽  
Vol 21 (4) ◽  
pp. 339-345 ◽  
Author(s):  
Kyle A. Franco ◽  
Keliana O'Mara
Keyword(s):  
Parenteral Nutrition ◽  
Neonatal Intensive Care ◽  
Intervention Group ◽  
Preterm Neonates ◽  
Control Group ◽  
Order Entry ◽  
Serum Electrolyte ◽  
Computerized Provider Order Entry ◽  
Electrolyte Disturbances ◽  
Before And After

OBJECTIVES: To determine if computerized provider order entry (CPOE) implementation impacts the time it takes for preterm neonates to reach their parenteral macronutrient goals. METHODS: Retrospective review of neonates &lt;1750 g receiving parenteral nutrition (PN) before and after the implementation of CPOE. Primary outcome was the attainment of parenteral macronutrient goals. Secondary outcomes included time to attainment, the frequency of electrolyte abnormalities, and the incidence of required adjustments made to PN orders by verification pharmacists. RESULTS: Goal PN was achieved by 12/47 (25.5%) intervention vs. 2/44 (4.5%) control group infants (p &lt; 0.05). This goal was attained in 10.8 ± 7.5 days in the intervention group and 10 ± 4.2 days in the control group (p = 0.90). Goal protein was reached by 74.5% of CPOE patients vs. 36.4% of controls, p &lt; 0.05. Lipid goals were achieved by 98% vs. 100% (p = 0.33) of patients and were attained at an average of 1.5 ± 0.8 days vs. 2.0 ± 1.1 days (p &lt; 0.05). Abnormal serum electrolyte values occurred more frequently in the control group (0.79 vs. 1.12/day PN). Adjustments by a verification pharmacist were required in 5.6% of CPOE compared with 30.4% of control group orders (p &lt; 0.05). CONCLUSIONS: CPOE parenteral nutrition increased the proportion of preterm neonates attaining overall macronutrient goals. With CPOE, protein goals were reached by more patients and goal lipids were achieved faster. This system also decreased the number of pharmacist interventions during verification of PN orders and appeared to positively impact the incidence of serum electrolyte disturbances.

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.

Improving clinic utilization and workload capture for clinical pharmacy specialists

2020 ◽  
Vol 77 (7) ◽  
pp. 552-559
Author(s):  
Allison Steen ◽  
Jessica Bovio Franck
Keyword(s):  
Clinical Pharmacy ◽  
Clinical Care ◽  
Quality Care ◽  
Clinical Pharmacy Service ◽  
Quality Improvement Initiative ◽  
Pharmacy Services ◽  
Veterans Health ◽  
Health Administration ◽  
Post Intervention ◽  
Clinical Pharmacy Services

Abstract Purpose To assess a quality improvement initiative aimed at improving clinic utilization and encounter and intervention workload capture for clinical pharmacy specialists. This initiative aided in justification of clinical pharmacy services, identification of clinical areas for intervention, and incorporation of all modalities to appropriately document clinical care. Methods In order to objectively demonstrate clinical pharmacy service value to stakeholders, pharmacy administrators and clinical pharmacy specialists at the North Florida/South Georgia Veterans Health System performed clinic scheduling and profile reviews using data extracted from the Veterans Health Administration electronic health record and analytic software. Outpatient clinical pharmacy specialty practice areas were primarily investigated; the specialty areas included are as follows: cardiology, infectious disease, mental health, oncology, pain management/palliative care, and specialty clinics (a collection of medical and surgical subspecialties). The first intervention entailed completing a worksheet and assessing clinic utilization data. Then, an evaluation was performed to assess the number of encounters, clinical interventions, clinic modalities, and coding for each clinic. Next, a meeting was arranged with each like clinical pharmacy specialist practice group to discuss this collected data. During these meetings, the delineation of where workload was generated and the activities taking place in an average workday were discussed. Finally, clinics were adjusted to reflect appropriate clinic coding and mapping of the average workday. Metrics were evaluated pre intervention (October through December 2017) and post intervention (July through September 2018). Results After intervention, there were statistically significant increases in clinic utilization, total encounters completed, and total interventions recorded in the composite group of clinical pharmacy specialists. Conclusion The increases in clinic utilization, total encounters, and interventions observed for the clinical pharmacy specialists suggest the beneficial role of pharmacy administrators’ collaboration with clinical pharmacy specialists to improve workload capture and access to quality care, to justify clinical pharmacy services, and to identify opportunities for pharmacy clinical intervention.

scholarly journals Cost Savings Analysis of Individualized Exercise Oncology Programs

2019 ◽  
Vol 18 ◽  
pp. 153473541983946 ◽  
Author(s):  
Karen Y. Wonders ◽  
Rob Wise ◽  
Danielle Ondreka ◽  
Josh Gratsch
Keyword(s):  
Cancer Care ◽  
Cost Savings ◽  
Length Of Hospital Stay ◽  
Standard Of Care ◽  
National Standard ◽  
Cost Burden ◽  
Post Intervention ◽  
Before And After ◽  
The Impact ◽  
Exercise Oncology

Background: The physical and economic toll of cancer make it a high health priority. The rising cost of cancer care is now a primary focus for patients, payers, and providers. Escalating costs of clinical trials and national drug regulations have led the median monthly costs of cancer drugs to rise from less than $100 in 1965 to 1969, to more than $5000 in 2005 to 2009, stressing the importance of finding innovative ways to reduce cost burden. In the present study, we report the economic evaluation of an individualized exercise oncology program beginning early after diagnosis. Methods: An independent research group, ASCEND Innovations, retrospectively analyzed patient records to statistically demonstrate the impact of exercise oncology during cancer treatment. All patients completed 12 weeks of prescribed, individualized exercise that included cardiovascular, strength training, and flexibility components. The 3 primary hospital measures leveraged for statistical comparison before and after supportive care enrollment were number of encounters, number of readmissions, and average total charges, as well as emergency room visits and length of hospital stay ( P < .05). Results: The resulting dataset consisted of 1493 total hospital encounters for 147 unique patients. The results statistically demonstrate a positive effect of exercise oncology during cancer care, in terms of reductions in overall cost per patient pre- to post-intervention. Conclusions: Individualized exercise oncology programs should be employed as part of the national standard of care for individuals battling cancer, in order to improve patient outcome and reduce cost burden.

scholarly journals The impact of computerized provider order entry on emergency department flow

CJEM ◽  
2016 ◽  
Vol 18 (4) ◽  
pp. 264-269 ◽  
Author(s):  
Andrew Gray ◽  
Christopher M.B. Fernandes ◽  
Kristine Van Aarsen ◽  
Melanie Columbus
Keyword(s):  
Emergency Department ◽  
Patient Safety ◽  
Improve Patient Safety ◽  
Patient Flow ◽  
Wait Time ◽  
Order Entry ◽  
Computerized Provider Order Entry ◽  
Left Without Being Seen ◽  
Before And After ◽  
The Impact

AbstractObjectivesComputerized provider order entry (CPOE) has been established as a method to improve patient safety by avoiding medication errors; however, its effect on emergency department (ED) flow remains undefined. We examined the impact of CPOE implementation on three measures of ED throughput: wait time (WT), length of stay (LOS), and the proportion of patients that left without being seen (LWBS).MethodsWe conducted a retrospective cohort study of all ED patients of 18 years and older presenting to London Health Sciences Centre during July and August 2013 and 2014, before and after implementation of a CPOE system. The three primary variables were compared between time periods. Subgroup analyses were also conducted within each Canadian Triage and Acuity Scale (CTAS) level (1–5) individually, as well as for admitted patients only.ResultsA significant increase in WT of 5 minutes (p=0.036) and LOS of 10 minutes (p=0.001), and an increase in LWBS from 7.2% to 8.1% (p=0.002) was seen after CPOE implementation. Admitted patients’ LOS increased by 63 minutes (p<0.001), the WT of CTAS 3 and 5 patients increased by 6 minutes (p=0.001) and 39 minutes (p=0.005), and LWBS proportion increased significantly for CTAS 3–5 patients, from 24.3% to 42.0% (p<0.001) for CTAS 5 patients specifically.ConclusionsCPOE implementation detrimentally impacted all patient flow throughput measures that we examined. The most striking clinically relevant result was the increase in LOS of 63 minutes for admitted patients. This raises the question as to whether the potential detrimental effects to patient safety of CPOE implementation outweigh its benefits.

scholarly journals Healthcare Quality Improvement Analytics: An Example Using Computerized Provider Order Entry

Healthcare ◽  
2021 ◽  
Vol 9 (9) ◽  
pp. 1187
Author(s):  
Jungwon Cho ◽  
Sangmi Shin ◽  
Youngmi Jeong ◽  
Eunsook Lee ◽  
Soyeon Ahn ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Control Chart ◽  
Healthcare Professionals ◽  
Segmented Regression ◽  
Long Term Effects ◽  
Order Entry ◽  
Post Intervention ◽  
Computerized Provider Order Entry ◽  
Healthcare Settings ◽  
The Impact

Evaluation of sustainability after quality improvement (QI) projects in healthcare settings is an essential part of monitoring and future QI planning. With limitations in adopting quasi-experimental study design in real-world practice, healthcare professionals find it challenging to present the sustained effect of QI changes effectively. To provide quantitative methodological approaches for demonstrating the sustainability of QI projects for healthcare professionals, we conducted data analyses based on a QI project to improve the computerized provider order entry system to reduce patients’ dosing frequencies in Korea. Data were collected for 5 years: 24-month pre-intervention, 12-month intervention, and 24-month post-intervention. Then, analytic approaches including control chart, Analysis of Variance (ANOVA), and segmented regression were performed. The control chart intuitively displayed how the outcomes changed over the entire period, and ANOVA was used to test whether the outcomes differed between groups. Last, segmented regression analysis was conducted to evaluate longitudinal effects of interventions over time. We found that the impact of QI projects in healthcare settings should be initiated following the Plan–Do–Study–Act cycle and evaluated long-term effects while widening the scope of QI evaluation with sustainability. This study can serve as a guide for healthcare professionals to use a number of statistical methodologies in their QI evaluations.

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