Integrating “Best of Care” Protocols into Clinicians' Workflow via Care Provider Order Entry: Impact on Quality-of-Care Indicators for Acute Myocardial Infarction
- Affiliations of the authors: Department of Biomedical Informatics (AO, LRW, RAM), Department of Medicine, Center for Health Services Research (TS), Division of Cardiology, Department of Medicine (JB), Section of Surgical Sciences (AO), Vanderbilt University, Nashville, TN, Center for Health Services Research, VA Tennessee Valley Healthcare System, Nashville, TN (TS, JB). Institute of Medicine, the National Academies, Washington, DC (JO). Note: JO's participation in this research occurred while she was a faculty member at Vanderbilt University
- Correspondence and reprints: Asli Ozdas, PhD, 2209 Garland Avenue, Nashville, TN 37232; e-mail: <asli.ozdas{at}vanderbilt.edu>
- Received 20 July 2004
- Accepted 7 December 2005
Abstract
Objective In the context of an inpatient care provider order entry (CPOE) system, to evaluate the impact of a decision support tool on integration of cardiology “best of care” order sets into clinicians' admission workflow, and on quality measures for the management of acute myocardial infarction (AMI) patients.
Design A before-and-after study of physician orders evaluated (1) per-patient use rates of standardized acute coronary syndrome (ACS) order set and (2) patient-level compliance with two individual recommendations: early aspirin ordering and beta-blocker ordering.
Measurements The effectiveness of the intervention was evaluated for (1) all patients with ACS (suspected for AMI at the time of admission) (N = 540) and (2) the subset of the ACS patients with confirmed discharge diagnosis of AMI (n = 180) who comprise the recommended target population who should receive aspirin and/or beta-blockers. Compliance rates for use of the ACS order set, aspirin ordering, and beta-blocker ordering were calculated as the percentages of patients who had each action performed within 24 hours of admission.
Results For all ACS admissions, the decision support tool significantly increased use of the ACS order set (p = 0.009). Use of the ACS order set led, within the first 24 hours of hospitalization, to a significant increase in the number of patients who received aspirin (p = 0.001) and a nonsignificant increase in the number of patients who received beta-blockers (p = 0.07). Results for confirmed AMI cases demonstrated similar increases, but did not reach statistical significance.
Conclusion The decision support tool increased optional use of the ACS order set, but room for additional improvement exists.
Footnotes
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This research was supported by VUMC, Agency for Healthcare Research and Quality, Centers for Education and Research in Therapeutics cooperative agreement (grant no. HS 1-0384), and National Library of Medicine (grant nos. R01LM06920 and R01LM LM07995.
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The authors acknowledge the technical assistance provided by Ty Webb, Grace Brennan, Martha Newton, Rick Stotler, and Dario Guise. They thank Irene Feurer, Rafe Donahue, and Dominik Aronsky for their insightful suggestions for data analyses and are also grateful to Penny Vaughan, Jeannie Byrd, and Janis Smith for their assistance with the implementation.
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Disclosure: The WizOrder Care Provider Order Entry (CPOE) system described in this manuscript was developed by Vanderbilt University Medical Center faculty and staff within the School of Medicine and Informatics Center beginning in 1994. In May 2001, Vanderbilt University licensed the product to a commercial vendor who is modifying the software. Drs. Miller and Waitman have been recognized by Vanderbilt as contributing to the authorship of the WizOrder software and have received and will continue to receive royalties from Vanderbilt under the University's intellectual property policies. While these involvements could potentially be viewed as conflict of interest with respect to the submitted manuscript, the authors have taken a number of concerted steps to avoid an actual conflict, and those steps have been disclosed to the Journal during the editorial review.
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↵1 Acute Coronary Syndrome (ACS) is the clinical term that covers a group of clinical conditions associated with acute myocardial ischemia (substernal chest pain suggestive of insufficient blood supply to the heart muscle). The spectrum of clinical conditions covered under ACS range from unstable angina to AMI. Initial presentation of both is similar, and additional tests are required to determine which patients had AMI.
