Improvements in the efficiency and effectiveness of pathology services using electronic ordering - research findings from a 2-year project

Objective: This paper reports on the overall findings of a comprehensive two-year research program investigating computerised pathology order entry systems (CPOE) with different levels of electronic decision support (EDS) and their impact on the efficiency and effectiveness of pathology services. Background: Electronic ordering systems allow clinicians to order diagnostic tests directly via a computer thus eliminating the need for cumbersome handwritten orders which have a huge potential for error. Despite the enormous potential of electronic systems, their diffusion across healthcare settings remains poor. Implementation of health information and communication systems is difficult, involving a number of organisational and professional issues beyond the ever present technical challenges. Methods: The project centred on a pathology service which employs over 300 staff and is located at a major metropolitan tertiary referral hospital in Sydney, Australia. The pathology service is responsible for a suburban network made up of seven major hospitals. In 2005 the pathology service's Laboratory Information System was replaced by the Cerner Corporation (Kansas City, USA) Pathnet system which automates clinical and managerial pathology data process. In 2006 this was integrated into a hospital-wide PowerChart (version 2004.01) system. Ethics approval for the study was obtained from the relevant Area Health Service Research Ethics Committee. Results: The first stage of the project defined key evidence-based performance indicators and used record linkage techniques to generate an enriched dataset for the study of electronic ordering systems. The various measures of CPOE performance and impact provided a framework with which to assess the efficiency, effectiveness and quality of the system. Measurements of the effect of key efficiency indicators and their impact on patient care indicators revealed improvements in turnaround time achieved in the first 12 months and were sustained at 24 months post-implementation, with no change in average number of tests per patient. Regression analysis using turnaround time data and emergency department data before the implementation of CPOE produced a model that accounted for 25.4 percent of the variance in patient length of stay (Adj. R2=0.254) amongst emergency department patients and demonstrating that TAT was a significant contributor to emergency department length of stay. Discussion and conclusion: The results from this extensive program of research represent significant advances on what was previously known. The findings from this project are comparative examining a number of hospital sites (of different sizes, make up and serving different populations) using robustly defined indicators, which contribute to providing greater confidence in the generalisability of the results. There remains a lot more to learn and understand about how decision support systems can be used to improve the quality of patient care. One of the key lessons of this project is the key role that robust quantitative measures of performance can play in effectively monitoring and improving the performance of CPOE systems.