AIM: CPOE improves documentationbut how much?

Image courtesy of HealthEast Care System, St. Paul, Minn.

Computerized physician order entry (CPOE) can significantly improve the documentation of indications for imaging studies, but more is needed to address overall poor communication of radiology order indications, according to preliminary research published June 13 in the Archives of Internal Medicine.  

Order documentation and appropriateness for imaging studies vary widely across institutions. One study concluded that 91 percent of paper orders assessed lacked appropriate indications, while another found 31 percent were missing acceptable indications, explained Erika Schneider, PhD, and colleagues from the Cleveland Clinic in Cleveland.

As part of an effort to improve the communication of radiologic exam indications, Cleveland Clinic implemented CPOE for imaging orders in the spring of 2008. Indications were required in two free-text fields (one for signs and symptoms, the other for presumed diagnoses), to be approved by the attending physician.

The researchers observed a significant improvement in the proportion of orders with “reasonable” or “excellent” quality indications, from 6 percent of orders prior to CPOE to 22 percent after implementation. All 20 specialties except plastic surgery experienced double-digit improvements in acceptable documentation for exam indications.

“While statistically significant and in agreement with other studies, the overall level of 22 percent was unacceptably low,” argued Schneider and co-authors. Although they acknowledged the feasibility and benefit of switching from paper requisitions to CPOE, the authors noted that systems should utilize discrete indication choices instead of free-text explanations.

“Poor radiologic examination order indications are analogous to poor patient hand-offs and include performance of incorrect or incomplete examinations, overlooking patient-specific issues, general examination interpretations (not addressing the clinical question), safety and compliance issues, billing delays and rejections,” Schneider and colleagues wrote.

The authors admitted that even with the institution of discrete indication fields as well as improved monitoring of physician orders and educational programs, “work-arounds are possible using any system."

“With the pivotal role radiologic examinations play in healthcare decision making, improving the quality of order indications for radiologic examinations should improve the quality of patient care,” Schneider and co-authors concluded.