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Can automated alerts within computerized physician order entry improve compliance with laboratory practice guidelines for ordering Pap tests?

BACKGROUND: The electronic health record (EHR) provides opportunity to improve health and enhance appropriate test utilization through decision support. Electronic alerts in the order entry system can guide test use. Few published reports have assessed the impact of automated alerts on compliance of...

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Autores principales: Howell, Lydia Pleotis, MacDonald, Scott, Jones, Jacqueline, Tancredi, Daniel J., Melnikow, Joy
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Medknow Publications & Media Pvt Ltd 2014
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4204299/
https://www.ncbi.nlm.nih.gov/pubmed/25337434
http://dx.doi.org/10.4103/2153-3539.141994
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author Howell, Lydia Pleotis
MacDonald, Scott
Jones, Jacqueline
Tancredi, Daniel J.
Melnikow, Joy
author_facet Howell, Lydia Pleotis
MacDonald, Scott
Jones, Jacqueline
Tancredi, Daniel J.
Melnikow, Joy
author_sort Howell, Lydia Pleotis
collection PubMed
description BACKGROUND: The electronic health record (EHR) provides opportunity to improve health and enhance appropriate test utilization through decision support. Electronic alerts in the order entry system can guide test use. Few published reports have assessed the impact of automated alerts on compliance of Pap ordering with published screening guidelines. METHODS: Programming rules for Pap test ordering were developed within the EHR (Epic, Madison, WI) of the University of California, Davis Health System using American College of Obstetrics and Gynecology's 2009 guidelines and implemented in primary care clinics in 2010. Alerts discouraged Pap orders in women <21 and >71 years and displayed when an order was initiated. Providers were not prevented from placing an order. Results were measured during four calendar periods: (1) pre-alert (baseline) (July 2010 to June 2011), (2) post alert (alerts on) (July 2011 to December 2011), (3) inadvertent alert turn-off (“glitch”) (January 2012 to December 2012), (5) post-glitch (alerts re-instated) (1/2013-7/2013). Metrics used to measure alert impact were between time and period seasonally adjusted relative frequency ratios. RESULTS: Alerts were most effective in the <21 year old age group. During the baseline period 2.7 Pap tests were order in patients less than age 21 for every 100 Paps in those 21-71 years of age. This relative frequency decreased to 1.7 in the post-alert period and 1.4 during the glitch, with an even greater decline to 0.8 post-glitch when alerts were reinstated. Less impact was observed in the >70 year old group where the baseline relative frequency was 2.4 and declined to 2.1 post-alert, remained stable at 2.0 during the glitch period, and declined again to 1.7 post-glitch when alerts were reinstated. This likely reflects inclusion of women with a history of abnormal Pap tests for whom continued Pap testing is indicated, as well as reluctance by providers and patients to accept discontinuation of Pap testing for women with a history of normal Pap results. In both age groups, decreases in ordering were greatest when the alerts were functioning, indicating that the alerts had an effect beyond the influences of the environment. CONCLUSIONS: Discouraging alerts can impact ordering of Pap tests and improve compliance with established guidelines, thus avoiding unnecessary follow-up tests that can create potential patient harm and unnecessary expense. Alerts represent a potential model to address utilization of other lab tests. Longer study intervals are necessary to determine if provider compliance is maintained.
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spelling pubmed-42042992014-10-21 Can automated alerts within computerized physician order entry improve compliance with laboratory practice guidelines for ordering Pap tests? Howell, Lydia Pleotis MacDonald, Scott Jones, Jacqueline Tancredi, Daniel J. Melnikow, Joy J Pathol Inform Original Article BACKGROUND: The electronic health record (EHR) provides opportunity to improve health and enhance appropriate test utilization through decision support. Electronic alerts in the order entry system can guide test use. Few published reports have assessed the impact of automated alerts on compliance of Pap ordering with published screening guidelines. METHODS: Programming rules for Pap test ordering were developed within the EHR (Epic, Madison, WI) of the University of California, Davis Health System using American College of Obstetrics and Gynecology's 2009 guidelines and implemented in primary care clinics in 2010. Alerts discouraged Pap orders in women <21 and >71 years and displayed when an order was initiated. Providers were not prevented from placing an order. Results were measured during four calendar periods: (1) pre-alert (baseline) (July 2010 to June 2011), (2) post alert (alerts on) (July 2011 to December 2011), (3) inadvertent alert turn-off (“glitch”) (January 2012 to December 2012), (5) post-glitch (alerts re-instated) (1/2013-7/2013). Metrics used to measure alert impact were between time and period seasonally adjusted relative frequency ratios. RESULTS: Alerts were most effective in the <21 year old age group. During the baseline period 2.7 Pap tests were order in patients less than age 21 for every 100 Paps in those 21-71 years of age. This relative frequency decreased to 1.7 in the post-alert period and 1.4 during the glitch, with an even greater decline to 0.8 post-glitch when alerts were reinstated. Less impact was observed in the >70 year old group where the baseline relative frequency was 2.4 and declined to 2.1 post-alert, remained stable at 2.0 during the glitch period, and declined again to 1.7 post-glitch when alerts were reinstated. This likely reflects inclusion of women with a history of abnormal Pap tests for whom continued Pap testing is indicated, as well as reluctance by providers and patients to accept discontinuation of Pap testing for women with a history of normal Pap results. In both age groups, decreases in ordering were greatest when the alerts were functioning, indicating that the alerts had an effect beyond the influences of the environment. CONCLUSIONS: Discouraging alerts can impact ordering of Pap tests and improve compliance with established guidelines, thus avoiding unnecessary follow-up tests that can create potential patient harm and unnecessary expense. Alerts represent a potential model to address utilization of other lab tests. Longer study intervals are necessary to determine if provider compliance is maintained. Medknow Publications & Media Pvt Ltd 2014-09-30 /pmc/articles/PMC4204299/ /pubmed/25337434 http://dx.doi.org/10.4103/2153-3539.141994 Text en Copyright: © 2014 Howell LP. http://creativecommons.org/licenses/by-nc-sa/3.0 This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
spellingShingle Original Article
Howell, Lydia Pleotis
MacDonald, Scott
Jones, Jacqueline
Tancredi, Daniel J.
Melnikow, Joy
Can automated alerts within computerized physician order entry improve compliance with laboratory practice guidelines for ordering Pap tests?
title Can automated alerts within computerized physician order entry improve compliance with laboratory practice guidelines for ordering Pap tests?
title_full Can automated alerts within computerized physician order entry improve compliance with laboratory practice guidelines for ordering Pap tests?
title_fullStr Can automated alerts within computerized physician order entry improve compliance with laboratory practice guidelines for ordering Pap tests?
title_full_unstemmed Can automated alerts within computerized physician order entry improve compliance with laboratory practice guidelines for ordering Pap tests?
title_short Can automated alerts within computerized physician order entry improve compliance with laboratory practice guidelines for ordering Pap tests?
title_sort can automated alerts within computerized physician order entry improve compliance with laboratory practice guidelines for ordering pap tests?
topic Original Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4204299/
https://www.ncbi.nlm.nih.gov/pubmed/25337434
http://dx.doi.org/10.4103/2153-3539.141994
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