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
Source: DBLP


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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    • "A systematic review proved that reminders are more effective than feedback in modifying physician behavior related to medication management[2]. Systematic reviews have also demonstrated that the use of CDSSs for prescribing can reduce toxic drug levels and time to therapeutic control345, increase the adherence of clinicians to guideline-or protocol-based care[6,7], decrease the rate of medication errors789, enhance preventive health care deliv- ery[7], and, ultimately, they may improve health care process measures across diverse settings[10]. EBMeDS (Evidence-Based Medicine electronic Decision Support) is a CDSS created by Duodecim Medical Publications in Finland ([11], Table 1). "
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    ABSTRACT: Although a number of studies have evaluated the effectiveness of computerized decision-support systems (CDSS), there is lack of data on user perspectives, barriers, and facilitators to the implementation of CDSSs in real-life surroundings. The aim of this study was to assess individually perceived barriers, facilitators and ideas influencing the CDSS implementation and usability. In this qualitative study, five focus groups were carried out with physicians and nurses separately at the Tampere City Health Center, Finland. The participants were end-users of the EBMeDS computerized decision support system. An explorative data content analysis was applied. The most important barrier to benefitting from CDSS was the lack of structured and coded diagnosis documentation and outdated medication information in the electronic health records. This led to false alerts and distrust towards the system. Among the major facilitators found were e.g. the beneficial reminders that helped practitioners take into account matters otherwise ignored; automatic glomerular filtration rate (GFR) calculations; medication safety checks; and the summaries in the single medication review at a glance. Physicians’ and nurses’ are keen to use the CDSS and it may enhance their inter-professional collaboration. Documenting patient information in a structured, uniform and easy manner is the essential starting point for electronic decision support. When implementing CDSS, managers need to focus on common practices in documenting structured data in their organizations in order to prevent undermining trust in the system.
    Preview · Article · Dec 2015 · BMC Medical Informatics and Decision Making
    • "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:
    No preview · Article · Apr 2015 · Journal of the American Medical Informatics Association
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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.
    Full-text · Article · Dec 2013 · BMC Medical Informatics and Decision Making
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