CPOEs prompt better communication in the ED

Dec 25, 2007

When using a computerized provider order entry (CPOE) system, emergency department (ED) physicians tend to provide more details on a patient's medical history and on clinical questions for ED radiologists. That enhanced communication leads to better interpretation and results in ED studies.

Those conclusions come from a study conducted at Massachusetts General Hospital (MGH) in Boston.

While CPOE systems are implemented into more healthcare and ED settings to increase efficiency, their effect on the amount of relevant information provided to radiologists by ordering physicians has been somewhat unclear. To determine what impact the technology may or may not have, researchers in MGH's radiology department reviewed physician requisitions for abdominal CT scans from its ED before and after implementation of a new CPOE system. Prior to the CPOE, the ED used paper-based, handwritten communication between physicians and radiologists.

"It was an interesting opportunity to see how the workflow was going in the ER, and see what different kinds of information we would be told and how it mattered," said Dr. Tarik Alkasab, a resident in MGH's department of radiology. Alkasab presented the results of the study at the 2007 RSNA meeting in Chicago.

With emergency room events often changing very quickly, the need for rapid patient turnover and treatment further magnifies the critical communication points between ordering physicians and radiologists.

'Skimpy' information

"Radiologists know that sometimes when ordering physicians are in a hurry, information they provide on the requisitions can be skimpy, but that information can be incredibly valuable," Alkasab said. "We wanted to see if there were ways to improve the information that we are given when working in the emergency room."

The study reviewed consecutive requisitions for abdominal CT scans from MGH's ED 10 days before and 10 days after implementation of the new CPOE. The amount of clinical history on each requisition from an ordering physician was rated as none, some, and detailed. Patient information also was segmented into four categories: signs/symptoms, medical history, abnormal test results, and clinical question.

Clinical histories were examined for 135 CPOE-generated requisitions and 141 handwritten requisitions. The study found significant differences in clinical questions and prior medical histories in the two study samples. A detailed clinical question was asked in three of the handwritten and 25 of the CPOE requisitions; some clinical question was found in 46 requisitions from each sample.

In addition, a detailed medical history was given in 14 of the handwritten requisitions and 16 of the CPOE requisitions, while some prior history was presented on 58 and 80 histories, respectively.

Detailed information on a patient's signs and symptoms were included in 57 handwritten requisitions, compared with 36 CPOE requisitions. Some data was noted on 65 and 68, respectively. Detailed abnormal results were described in three of the handwritten and four of the CPOE requisitions, while some results were provided on 21 and 14 requisitions, respectively.

Noteworthy results

Alkasab cited three significant findings from the research. The most important note was how ordering physicians more often entered meaningful patient data using the CPOE's free-form text box. "They were much more likely to describe the clinical question," he said. "That is especially important in emergency radiology where we need to know exactly what they (physicians) are trying to figure out when they order the abdominal CT. Are they looking for kidney stones? Are they worried about obstructions? Do they think there may be some sort of interabdominal hemorrhage?"

The study also found that radiologists received more information on a patient's past medical history, which again can be critical in an ER where many patients have not been seen previously in the healthcare system. "We have access to electronic medical records, but if the patient hasn't been seen before, there isn't anything there," Alkasab said. "The only place where the past medical history may be recorded and a radiologist can get to it is in the requisition."

In addition, ordering physicians were much more inclined to provide more information by way of the CPOE than the antiquated handwritten method. As noted above, the CPOE's free-form text box was credited as the catalyst.

While the research did not investigate whether the CPOE system shortened the time from patient review to treatment, Alkasab noted that the ED physicians "have been happy" with the new technology. "They didn't like the old paper system," he added. "Because it was paper, it had to be carried from one place to another; they didn't like how that affected their workload."

Homegrown CPOE

The CPOE system used in the study is a homegrown technology developed by MGH and works much like other commercially available CPOEs. While, in this case, the study looked at abdominal CT scans, the CPOE is not geared specifically toward radiology exam ordering and can be used with other imaging modalities and under other medical scenarios, Alkasab said.

"At MGH outpatient imaging -- not in the ED -- there is a system that tries to guide ordering physicians to the correct study and most useful information," he said. "That kind of design where the information that is requested is even more specific to the modality will be important to make it as easy as possible for ordering physicians to provide the most useful information to the radiologist with the least amount of effort."

As for the next step, MGH plans to incorporate other imaging modalities in the new CPOE and eventually publish results on its effect on workflow.

"One of the key things we hope happens with the CPOE in the future is that designers think about and exam how the interface they provide impacts communication," Alkasab said. "I think they should be systematic about testing how information should be communicated, making changes to improve it, and testing to prove those changes worked."

By Wayne Forrest
AuntMinnie.com staff writer
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