The impact of computerised physician order entry systems on pathology services: A systematic review

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Abstract

Purpose

Computerised physician order entry (CPOE) systems hold the promise of significant improvements to health care delivery and patient care. The implementation of such systems is costly and complex. The purpose of this paper is to review current evidence of the impact of CPOE on hospital pathology services.

Methods

This paper presents a review of the literature (1990–August 2004) about CPOE systems and identifies indicators for measuring the impact of CPOE on pathology services.

Results

Nineteen studies which contained some form of ‘control’ group, were identified. They featured a variety of designs including randomised controlled trials, quasi-experimental and before and after studies. We categorised these into three groups: studies comparing pathology CPOE systems (with no decision support) to paper systems; pathology CPOE systems (with decision support) to paper systems; and pathology CPOE systems with specific pathology features compared to systems without those features. We identified 10 areas of impact assessment and 39 indicators used to measure the impact of CPOE on different stages of the pathology test ordering and reporting process.

Conclusion

We conclude that while some data suggest that CPOE systems are beneficial for clinical and laboratory work processes, these data are limited, and further research is needed. Few data are available regarding the impact of CPOE on patient outcomes.

Introduction

Many potential benefits of computerised physician order entry (CPOE) in hospitals have been identified. These include improvements to physician ordering patterns, increased compliance with guidelines, optimisation of clinical time, and facilitation of communication processes in health care [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]. If realised, these benefits would logically lead to improvements in patient outcomes, as well as major cost efficiencies. CPOE systems are an integral part of hospital information systems and constitute an important building block for the establishment of the electronic medical record [2], [7], [15]. For these reasons, CPOE systems have been strongly promoted in the United States, Europe and Australia as a means of improving the quality of care, reducing errors and increasing efficiency in health care delivery [16], [17], [18], [19], [20], [21], [22].

Pathology order entry allows physicians (or other authorised staff) to enter laboratory orders directly into a computer [4], [11], [14], [23]. Such systems may include decision support mechanisms such as defined order sets for particular conditions in order to support the selection and appropriate use of tests and treatment; parameter checks to ensure that orders are within agreed test time frames, frequency or dose limits; and more complex rule based alerts that prompt clinicians with information about previous test results, patient characteristics and available test choices [16], [17], [24], [25], [26], [27], [28], [29].

CPOE systems remain costly and complex to design and implement [9], [13]. Despite the potential benefits, there are very few evaluations of the effect of CPOE on clinical outcomes [1], and evidence of the effectiveness of CPOE has focused predominantly on medication order systems in hospital settings [9]. One of the reasons for this may be the limited funding available for such studies. Outside of medication orders a large proportion of orders processed through a CPOE system relate to pathology and imaging services that can have a potentially significant impact on clinicians’ test ordering decisions and pose a new set of challenges and opportunities for pathology managers.

Relatively little research has focused specifically on the impact of CPOE on hospital pathology services, order patterns or patient outcomes. The purpose of this paper is to review current evidence of the impact of CPOE on hospital pathology services and to identify the indicators, which have been used to measure impact.

Section snippets

Methods

A literature review was undertaken to identify all evaluation studies of computerised pathology order entry systems published between 1990 and August 2004. The following databases were searched: MEDLINE, CINAHL, EMBASE, SocScience Index and Cochrane Database of Systematic Reviews. Web-based searches using Google and hand searches of international health informatics journals were completed. The reference lists from relevant articles and additional articles by key authors were also reviewed [30].

Results

The review identified 19 studies of the impact of CPOE systems on pathology. Eleven studies compared CPOE for pathology orders (with and without decision support) to no CPOE (Table 2, Table 3). Of these, four studies compared CPOE without defined decision support mechanisms to settings where there was no CPOE. Eight studies compared CPOE with specific decision support features to CPOE without these features (Table 4). The studies comparing CPOE with no CPOE were conducted in the USA (5), United

Discussion

There is a growing body of research which has examined either the impact on pathology services of CPOE alone, or with decision support mechanisms. We identified 19 empirical studies published between 1990 and August 2004. The geographical scope of the research spread from the USA and Canada, to South Korea, Norway and England, reflecting international interest in this area. Six hospitals (five from the USA and one from England) featured in more than one study. The hospital where most studies

Acknowledgements

The study is part of an Australian Research Council Linkage Grant funded project in partnership with the Centre for Clinical Governance Research in Health from the University of New South Wales, and the New South Wales Health Department.

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