Evaluation of Outpatient Computerized Physician Medication Order Entry Systems: A Systematic Review

Academic Medical Center, Universiteit van Amsterdam, Department of Medical Informatics, J1b-124, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands.
Journal of the American Medical Informatics Association (Impact Factor: 3.5). 04/2007; 14(4):400-6. DOI: 10.1197/jamia.M2238
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ABSTRACT This paper provides a systematic literature review of CPOE evaluation studies in the outpatient setting on: safety; cost and efficiency; adherence to guideline; alerts; time; and satisfaction, usage, and usability. Thirty articles with original data (randomized clinical trial, non-randomized clinical trial, or observational study designs) met the inclusion criteria. Only four studies assessed the effect of CPOE on safety. The effect was not significant on the number of adverse drug events. Only one study showed a significant reduction of the number of medication errors. Three studies showed significant reductions in medication costs; five other studies could not support this. Most studies on adherence to guidelines showed a significant positive effect. The relatively small number of evaluation studies published to date do not provide adequate evidence that CPOE systems enhance safety and reduce cost in the outpatient settings. There is however evidence for (a) increasing adherence to guidelines, (b) increasing total prescribing time, and (c) high frequency of ignored alerts.

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Available from: Nicolette F de Keizer, Sep 26, 2015
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    • "This model allowed us to relate the observed impacts on the various stakeholders involved in the medication management process, without limiting the impacts to one stakeholder in particular. The studies' methodologies were described using a classification scheme developed by the University of California San Francisco Stanford Evidence-Based Practice Center that has been used before in two systematic reviews (Kaushal et al. [11] and Eslami et al. [6]). "
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    ABSTRACT: The objective of this study was to identify physicians' and pharmacists' perceptions of the challenges and benefits to implementing a nationwide electronic prescribing network linking medical clinics and community pharmacies in Quebec, Canada. Forty-nine people (12 general practitioners, 2 managers, 33 community pharmacists, and 2 pharmacy staff members) from 40 points of care (10 primary care clinics (42% of all the connected sites) and 30 community pharmacies (44%)) were interviewed in 2013. Verbatim transcripts were analyzed using thematic analysis. A low level of network use was observed. Most pharmacists processed e-prescriptions by manual entry instead of importing electronically. They reported concerns about potential errors generated by importing e-prescriptions, mainly due to the instruction field. Paper prescriptions were still perceived as the best means for safe and effective processing of prescriptions in pharmacies. Speed issues when validating e-prescription messages were seen as an irritant by physicians, and resulted in several of them abandoning transmission. Displaying the medications based on the dispensing data was identified as the main obstacle to meaningful use of medication histories. Numerous challenges impeded realization of the benefits of this network. Standards for e-prescription messages, as well as rules for message validation, need to be improved to increase the potential benefits of e-prescriptions. Standard drug terminology including the concept of clinical medication should be developed, and the implementation of rules in local applications to allow for the classification and reconciliation of medication lists from dispensing data should be made a priority. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email:
    Journal of the American Medical Informatics Association 04/2015; 22(4). DOI:10.1093/jamia/ocv026 · 3.50 Impact Factor
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    • "Our scoping literature search did not identify systematic reviews or randomized studies in the field that might substantiate these assertions. One review that classified outcome type found only four of 30 included studies (1950 to March 31, 2006) that assessed safety [22]. Another [23] lists adverse drug events (ADEs) and deaths as patient outcomes and identifies the studies in which AEs and monitoring for AEs were specified à priori. "
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    ABSTRACT: The objective was to find evidence to substantiate assertions that electronic applications for medication management in ambulatory care (electronic prescribing, clinical decision support (CDSS), electronic health record, and computer generated paper prescriptions), while intended to reduce prescribing errors, can themselves result in errors that might harm patients or increase risks to patient safety. Because a scoping search for adverse events in randomized controlled trials (RCTs) yielded few relevant results, we systematically searched nine databases, including MEDLINE, EMBASE, and The Cochrane Database of Systematic Reviews for systematic reviews and studies of a wide variety of designs that reported on implementation of the interventions. Studies that had safety and adverse events as outcomes, monitored for them, reported anecdotally adverse events or other events that might indicate a threat to patient safety were included. We found no systematic reviews that examined adverse events or patient harm caused by organizational interventions. Of the 4056 titles and abstracts screened, 176 full-text articles were assessed for inclusion. Sixty-one studies with appropriate interventions, settings and participants but without patient safety, adverse event outcomes or monitoring for risks were excluded, along with 77 other non-eligible studies. Eighteen randomised controlled trials (RCTs), 5 non-randomised controlled trials (non-R, CTs) and 15 observational studies were included. The most common electronic intervention studied was CDSS and the most frequent clinical area was cardio-vascular, including anti-coagulants. No RCTS or non-R,CTS reported adverse event. Adverse events reported in observational studies occurred less frequently after implementation of CDSS. One RCT and one observational study reported an increase in problematic prescriptions with electronic prescribing CONCLUSIONS: The safety implications of electronic medication management in ambulatory care have not been established with results from studies found in this systematic review. Only a minority of studies that investigated these interventions included threats to patients' safety as outcomes or monitored for adverse events. It is therefore not surprising that we found little evidence to substantiate fears of new risks to patient safety with their implementation. More research is needed to focus on the draw-backs and negative outcomes that implementation of these interventions might introduce.
    BMC Medical Informatics and Decision Making 12/2013; 13(1):133. DOI:10.1186/1472-6947-13-133 · 1.83 Impact Factor
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    • "This model allowed us to relate the observed impacts on the various stakeholders involved in the medication management process, without limiting the impacts to one stakeholder in particular. The studies' methodologies were described using a classification scheme developed by the University of California San Francisco Stanford Evidence-Based Practice Center that has been used before in two systematic reviews (Kaushal et al. [11] and Eslami et al. [6]). "
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    ABSTRACT: Objective: To describe second-generation electronic prescription (eRx) technologies and identify their impacts on the medication management process in primary care. Second-generation eRx technologies have focused on networking various stakeholders so that they can communicate electronically. Method: Using key words, a search was conducted of the relevant databases up to January 2011. A manual search was conducted of the bibliographies of the studies as well as the prior systematic reviews found. The tables of contents of the major periodicals in the field were also searched. This included studies of the impacts of eRx technologies that allow electronic circulation of information between prescription sites and dispensing sites, independent of the methodology used. A structured form was used to extract the data. The studies' impacts were classified by stage in the medication management process (prescription, transmission of the prescription, execution of the prescription and use of the medication). Results: Nineteen observational studies were included in this review. Most of them (10/19) have evaluated users' perceptions using interviews, focus groups or questionnaires. Two technology models stand out: the push model, under which the prescriber directs the prescription toward a specific pharmacy, and the pull model, under which any authorized pharmacy can download a given prescription into its system. The push model is the most widely used, particularly in the United States. Communication between prescribers and dispensers is usually unidirectional, and communications standards have to be refined. The only demonstrated impacts of second-generation eRx technologies were found at two levels: positive impacts on the quality of the pharmacological profile available to professionals, and negative impacts on the execution of prescriptions in pharmacies. Stakeholders' perceptions were mixed and reflected considerable differences according to context, the type of technology used, the intensity of its use and its maturity. Electronic transmission of prescriptions provides a new way to monitor patient compliance. Conclusion: There is little empirical data demonstrating benefits to second-generation eRx technologies, even if it is a highly promoted model for improving primary care quality. More research is required, with studies that measure the impacts of second-generation technologies using empirical data and conducted in the context of actual use. Future studies should also employ the same terminology and provide full descriptions of context, type of technology and intensity of use.
    International Journal of Medical Informatics 02/2013; 82(6). DOI:10.1016/j.ijmedinf.2013.01.012 · 2.00 Impact Factor
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