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Systematic review

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Journal Cochrane Database of Systematic Reviews
Year 2013
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BACKGROUND: Maintaining therapeutic concentrations of drugs with a narrow therapeutic window is a complex task. Several computer systems have been designed to help doctors determine optimum drug dosage. Significant improvements in health care could be achieved if computer advice improved health outcomes and could be implemented in routine practice in a cost-effective fashion. This is an updated version of an earlier Cochrane systematic review, first published in 2001 and updated in 2008. OBJECTIVES: To assess whether computerized advice on drug dosage has beneficial effects on patient outcomes compared with routine care (empiric dosing without computer assistance). SEARCH METHODS: The following databases were searched from 1996 to January 2012: EPOC Group Specialized Register, Reference Manager; Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Ovid; EMBASE, Ovid; and CINAHL, EbscoHost. A "top up" search was conducted for the period January 2012 to January 2013; these results were screened by the authors and potentially relevant studies are listed in Studies Awaiting Classification. The review authors also searched reference lists of relevant studies and related reviews. SELECTION CRITERIA: We included randomized controlled trials, non-randomized controlled trials, controlled before-and-after studies and interrupted time series analyses of computerized advice on drug dosage. The participants were healthcare professionals responsible for patient care. The outcomes were any objectively measured change in the health of patients resulting from computerized advice (such as therapeutic drug control, clinical improvement, adverse reactions). DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed study quality. We grouped the results from the included studies by drug used and the effect aimed at for aminoglycoside antibiotics, amitriptyline, anaesthetics, insulin, anticoagulants, ovarian stimulation, anti-rejection drugs and theophylline. We combined the effect sizes to give an overall effect for each subgroup of studies, using a random-effects model. We further grouped studies by type of outcome when appropriate (i.e. no evidence of heterogeneity). MAIN RESULTS: Forty-six comparisons (from 42 trials) were included (as compared with 26 comparisons in the last update) including a wide range of drugs in inpatient and outpatient settings. All were randomized controlled trials except two studies. Interventions usually targeted doctors, although some studies attempted to influence prescriptions by pharmacists and nurses. Drugs evaluated were anticoagulants, insulin, aminoglycoside antibiotics, theophylline, anti-rejection drugs, anaesthetic agents, antidepressants and gonadotropins. Although all studies used reliable outcome measures, their quality was generally low. This update found similar results to the previous update and managed to identify specific therapeutic areas where the computerized advice on drug dosage was beneficial compared with routine care: 1. it increased target peak serum concentrations (standardized mean difference (SMD) 0.79, 95% CI 0.46 to 1.13) and the proportion of people with plasma drug concentrations within the therapeutic range after two days (pooled risk ratio (RR) 4.44, 95% CI 1.94 to 10.13) for aminoglycoside antibiotics; 2. it led to a physiological parameter more often within the desired range for oral anticoagulants (SMD for percentage of time spent in target international normalized ratio +0.19, 95% CI 0.06 to 0.33) and insulin (SMD for percentage of time in target glucose range: +1.27, 95% CI 0.56 to 1.98); 3. it decreased the time to achieve stabilization for oral anticoagulants (SMD -0.56, 95% CI -1.07 to -0.04); 4. it decreased the thromboembolism events (rate ratio 0.68, 95% CI 0.49 to 0.94) and tended to decrease bleeding events for anticoagulants although the difference was not significant (rate ratio 0.81, 95% CI 0.60 to 1.08). It tended to decrease unwanted effects for aminoglycoside antibiotics (nephrotoxicity: RR 0.67, 95% CI 0.42 to 1.06) and anti-rejection drugs (cytomegalovirus infections: RR 0.90, 95% CI 0.58 to 1.40); 5. it tended to reduce the length of time spent in the hospital although the difference was not significant (SMD -0.15, 95% CI -0.33 to 0.02) and to achieve comparable or better cost-effectiveness ratios than usual care; 6. there was no evidence of differences in mortality or other clinical adverse events for insulin (hypoglycaemia), anaesthetic agents, anti-rejection drugs and antidepressants. For all outcomes, statistical heterogeneity quantified by I2 statistics was moderate to high. AUTHORS' CONCLUSIONS: This review update suggests that computerized advice for drug dosage has some benefits: it increases the serum concentrations for aminoglycoside antibiotics and improves the proportion of people for which the plasma drug is within the therapeutic range for aminoglycoside antibiotics. It leads to a physiological parameter more often within the desired range for oral anticoagulants and insulin. It decreases the time to achieve stabilization for oral anticoagulants. It tends to decrease unwanted effects for aminoglycoside antibiotics and anti-rejection drugs, and it significantly decreases thromboembolism events for anticoagulants. It tends to reduce the length of hospital stay compared with routine care while comparable or better cost-effectiveness ratios were achieved. However, there was no evidence that decision support had an effect on mortality or other clinical adverse events for insulin (hypoglycaemia), anaesthetic agents, anti-rejection drugs and antidepressants. In addition, there was no evidence to suggest that some decision support technical features (such as its integration into a computer physician order entry system) or aspects of organization of care (such as the setting) could optimize the effect of computerized advice. Taking into account the high risk of bias of, and high heterogeneity between, studies, these results must be interpreted with caution.

Systematic review

Unclassified

Authors Bassi J , Lau F , Bardal S
Journal The Annals of pharmacotherapy
Year 2010
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OBJECTIVE: To identify studies involving information technology (IT) in medication reconciliation (MedRec) and determine how IT is used to facilitate the MedRec process. DATA SOURCES: The search strategy included a database search of MEDLINE and Cumulative Index of Nursing and Allied Health Literature (CINAHL), hand-searching of collected material, and references from articles retrieved. The database search was limited to English-language papers. MEDLINE includes publications dating back to 1950 and CINAHL includes those dating back to 1982. The search included articles in both databases up to March 2009. Boolean queries were constructed using combinations of search terms for medication reconciliation, IT, and electronic records. STUDY SELECTION AND DATA EXTRACTION: Three inclusion criteria were used. The study had to (1) involve the MedRec process, (2) be a primary study, and (3) involve the use of IT. Selection was performed by 2 reviewers through consensus. Data related to study characteristics, focus, and IT use were extracted. DATA SYNTHESIS: The included studies described a range of IT used throughout the MedRec process, from basic email and databases to specialized MedRec tools. A generic MedRec workflow was created and types of IT found in the studies were mapped to the workflow activities as well as to a set of functionalities based on the Institute of Medicine's Key Capabilities of an Electronic Health Record System. In the studies reviewed, IT was mainly used to obtain medication information. Although there were only a few MedRec tools in the studies, those that did exist supported the central activities for MedRec: comparison of medications and clarification of discrepancies. CONCLUSIONS: MedRec is an important process to ensure patient medication safety. Evidence was found that IT can and has been used to facilitate some MedRec activities and new applications are being developed to support the entire MedRec process.

Systematic review

Unclassified

Journal BMC health services research
Year 2010
BACKGROUND: Clinical practice guidelines have been developed aiming to improve the quality of care. The implementation of the computerized clinical guidelines (CCG) has been supported by the development of computerized clinical decision support systems.This systematic review assesses the impact of CCG on the process of care compared with non-computerized clinical guidelines. METHODS: Specific features of CCG were studied through an extensive search of scientific literature, querying electronic databases: Pubmed/Medline, Embase and Cochrane Controlled Trials Register. A multivariable logistic regression was carried out to evaluate the association of CCG's features with positive effect on the process of care. RESULTS: Forty-five articles were selected. The logistic model showed that Automatic provision of recommendation in electronic version as part of clinician workflow (Odds Ratio [OR]= 17.5; 95% confidence interval [CI]: 1.6-193.7) and Publication Year (OR = 6.7; 95%CI: 1.3-34.3) were statistically significant predictors. CONCLUSIONS: From the research that has been carried out, we can conclude that after implementation of CCG significant improvements in process of care are shown. Our findings also suggest clinicians, managers and other health care decision makers which features of CCG might improve the structure of computerized system.

Systematic review

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Journal Health technology assessment (Winchester, England)
Year 2010
Background: Order communication systems (OCS) are computer applications used to enter diagnostic and therapeutic patient care orders and to view test results. Many potential benefits of OCS have been identified including improvements in clinician ordering patterns, optimisation of clinical time, and aiding communication processes between clinicians and different departments. Many OCS now include computerised decision support systems (CDSS), which are information systems designed to improve clinical decision-making. CDSS match individual patient characteristics to a computerised knowledge base, and software algorithms generate patient-specific recommendations. Objectives: To investigate which CDSS in OCS are in use within the UK and the impact of CDSS in OCS for diagnostic, screening or monitoring test ordering compared to OCS without CDSS. To determine what features of CDSS are associated with clinician or patient acceptance of CDSS in OCS and what is known about the cost-effectiveness of CDSS in diagnostic, screening or monitoring test OCS compared to OCS without CDSS. Data sources: A generic search to identify potentially relevant studies for inclusion was conducted using MEDLINE, EMBASE, Cochrane Controlled Trials Register (CCTR), CINAHL (Cumulative Index to Nursing and Allied Health Literature), DARE (Database of Abstracts of Reviews of Effects), Health Technology Assessment (HTA) database, IEEE (Institute of Electrical and Electronic Engineers) Xplore digital library, NHS Economic Evaluation Database (NHS EED) and EconLit, searched between 1974 and 2009 with a total of 22,109 titles and abstracts screened for inclusion. Review methods: CDSS for diagnostic, screening and monitoring test ordering OCS in use in the UK were identified through contact with the 24 manufacturers/ suppliers currently contracted by the National Project for Information Technology (NpfIT) to provide either national or specialist decision support. A generic search to identify potentially relevant studies for inclusion in the review was conducted on a range of medical, social science and economic databases. The review was undertaken using standard systematic review methods, with studies being screened for inclusion, data extracted and quality assessed by two reviewers. Results were broadly grouped according to the type of CDSS intervention and study design where possible. These were then combined using a narrative synthesis with relevant quantitative results tabulated. Results: Results of the studies included in review were highly mixed and equivocal, often both within and between studies, but broadly showed a beneficial impact of the use of CDSS in conjunction with OCS over and above OCS alone. Overall, if the findings of both primary and secondary outcomes are taken into account, then CDSS significantly improved practitioner performance in 15 out of 24 studies (62.5%). Only two studies covered the cost-effectiveness of CDSS: a Dutch study reported a mean cost decrease of 3% for blood tests orders (€ 639) in each of the intervention clinics compared with a 2% (€ 208) increase in control clinics in test costs; and a Spanish study reported a significant increase in the cost of laboratory tests from € 41.8 per patient per annum to € 47.2 after Limitations: The response rate from the survey of manufacturers and suppliers was extremely low at only 17% and much of the feedback was classified as being commercial-in-confidence (CIC). No studies were identified which assessed the features of CDSS that are associated with clinician or patient acceptance of CDSS in OCS in the test ordering process and only limited data was available on the cost-effectiveness of CDSS plus OCS compared with OCS alone and the findings highly specific. Although CDSS appears to have a potentially small positive impact on diagnostic, screening or monitoring test ordering, the majority of studies come from a limited number of institutions in the USA. Conclusions: If the findings of both primary and secondary outcomes are taken into account then CDSS showed a statistically significant benefit on either process or practitioner performance outcomes in nearly two-thirds of the studies. Furthermore, in four studies that assessed adverse effects of either test cancellation or delay, no significant detrimental effects in terms of additional utilisation of health-care resources or adverse events were observed. We believe the key current need is for a well designed and comprehensive survey, and on the basis of the results of this potentially for evaluation studies in the form of cluster randomised controlled trials or randomised controlled trials which incorporate process, and patient outcomes, as well as full economic evaluations alongside the trials to assess the impact of CDSS in conjunction with OCS versus OCS alone for diagnostic, screening or monitoring test ordering in the NHS. The economic evaluation should incorporate the full costs of potentially developing, testing, and installing the system, including staff training costs. Study registration: Study registration 61. © Queen's Printer and Controller of HMSO. All rights reserved.

Systematic review

Unclassified

Journal CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne
Year 2010
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BACKGROUND: The opportunity to improve care using computer reminders is one of the main incentives for implementing sophisticated clinical information systems. We conducted a systematic review to quantify the expected magnitude of improvements in processes of care from computer reminders delivered to clinicians during their routine activities. METHODS: We searched the MEDLINE, Embase and CINAHL databases (to July 2008) and scanned the bibliographies of retrieved articles. We included studies in our review if they used a randomized or quasi-randomized design to evaluate improvements in processes or outcomes of care from computer reminders delivered to physicians during routine electronic ordering or charting activities. RESULTS: Among the 28 trials (reporting 32 comparisons) included in our study, we found that computer reminders improved adherence to processes of care by a median of 4.2% (interquartile range [IQR] 0.8%-18.8%). Using the best outcome from each study, we found that the median improvement was 5.6% (IQR 2.0%-19.2%). A minority of studies reported larger effects; however, no study characteristic or reminder feature significantly predicted the magnitude of effect except in one institution, where a well-developed, "homegrown" clinical information system achieved larger improvements than in all other studies (median 16.8% [IQR 8.7%-26.0%] v. 3.0% [IQR 0.5%-11.5%]; p = 0.04). A trend toward larger improvements was seen for reminders that required users to enter a response (median 12.9% [IQR 2.7%-22.8%] v. 2.7% [IQR 0.6%-5.6%]; p = 0.09). INTERPRETATION: Computer reminders produced much smaller improvements than those generally expected from the implementation of computerized order entry and electronic medical record systems. Further research is required to identify features of reminder systems consistently associated with clinically worthwhile improvements.

Systematic review

Unclassified

Authors Khajouei R , Jaspers MW
Journal Methods of information in medicine
Year 2010
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OBJECTIVES: To examine the impact of design aspects of computerized physician order entry (CPOE) systems for medication ordering on usability, physicians' workflow and on medication orders. METHODS: We systematically searched PubMed, EMBASE and Ovid MEDLINE for articles published from 1986 to 2007. We also evaluated reference lists of reviews and relevant articles captured by our search strategy, and the web-based inventory of evaluation studies in medical informatics 1982-2005. Data about design aspects were extracted from the relevant articles. Identified design aspects were categorized in groups derived from principles for computer screen and dialogue design and user guidance from the International Standard Organization, and if CPOE-specific, from the collected data. RESULTS: A total of 19 papers met our inclusion criteria. Sixteen studies used qualitative evaluation methods and the rest both qualitative and quantitative. In total 42 CPOE design aspects were identified and categorized in seven groups: 1) documentation and data entry components, 2) alerting, 3) visual clues and icons, 4) drop-down lists and menus, 5) safeguards, 6) screen displays, and 7) auxiliary functions. CONCLUSIONS: Beside the range of functionalities provided by a CPOE system, their subtle design is important to increase physicians' adoption and to reduce medication errors. This requires continuous evaluations to investigate whether interfaces of CPOE systems follow normal flow of actions in the ordering process and if they are cognitively easy to understand and use for physicians. This paper provides general recommendations for CPOE (re)design based on the characteristics of CPOE design aspects found.

Systematic review

Unclassified

Authors Jamal A , McKenzie K , Clark M
Journal The HIM journal
Year 2009
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The aim of this study was to systematically review the published evidence of the impact of health information technology (HIT) or health information systems (HIS) on the quality of healthcare, focusing on clinicians's; adherence to evidence-based guidelines and the corresponding impact this had on patient clinical outcomes. The review covered the use of health information technologies and systems in both medical care (i.e. clinical and surgical) and other areas such as allied health and preventive services. Studies were included in the review if they examined the impact of Electronic Health Record (EHR), Computerised Provider Order-Entry (CPOE), or Decision Support System (DS); and if the primary outcomes of the studies were focused on the level of compliance with evidence-based guidelines among clinicians. Measurements considered relevant to the review were either of changes in clinical processes resulting from a change of the providers' behaviour, or of specific patient outcomes that demonstrated the effectiveness of a particular treatment given by providers. Of 23 studies included in the current review, 17 assessed the impact of HIT/HIS on health care practitioners' performance. A positive improvement, in relation to their compliance with evidence-based guidelines, was seen in 14 studies. Studies that included an assessment of patient outcomes, however, showed insufficient evidence of either clinically or statistically important improvements. Although the number of studies reviewed was relatively small, the findings demonstrated consistency with similar previous reviews of this nature in that wide scale use of HIT has been shown to increase clinician's adherence to guidelines.

Systematic review

Unclassified

Authors Hayward GL , Parnes AJ , Simon SR
Journal Pharmacoepidemiology and drug safety
Year 2009
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Purpose: To conduct a systematic review of current evidence regarding the use of health information technology (HIT) interventions to improve drug monitoring in ambulatory care. Methods: We searched PubMed, CINAHL, the Cochrane Library, and other computerized databases from 1 January 1998 to 30 June 2008 using the key words "drug monitoring," "medical records systems, computerized," "ambulatory care," and "outpatients." We manually reviewed reference lists of articles identified through computer searches and asked experts in the field to review our search strategy and results for completeness. Results: Seven relevant studies were identified. Four of these studies assessed real-time interventions that used alerts to physicians at the time of medication ordering to ensure adequate monitoring, only one of which showed an improvement in monitoring. Of three studies using HIT outside the physician encounter, two suggested some improvement in monitoring rates. Methodological limitations were apparent in all studies identified. Conclusions: Few studies have assessed the effectiveness of HIT interventions to improve drug monitoring, and among them, there is no clear consensus regarding the most consistently effective approaches to reducing drug monitoring errors. There is a clear need for well designed randomized trials to evaluate possible interventions to reduce drug monitoring errors. Such studies should incorporate health outcomes and detailed cost analyses to further characterize the feasibility of successful interventions. Copyright © 2009 John Wiley & Sons, Ltd.

Systematic review

Unclassified

Journal Pediatrics
Year 2009
CONTEXT: Pediatric and intensive care patients are particularly at risk for medication errors. Computerized physician order entry systems could be effective in reducing medication errors and improving outcome. Effectiveness of computerized physician order entry systems has been shown in adult medical care. However, in critically ill patients and/or children, medication prescribing is a more complex process, and usefulness of computerized physician order entry systems has yet to be established. OBJECTIVE: To evaluate the effects of computerized physician order entry systems on medication prescription errors, adverse drug events, and mortality in inpatient pediatric care and neonatal, pediatric or adult intensive care settings. METHODS: PubMed, the Cochrane library, and Embase up to November 2007 were used as our data sources. Inclusion criteria were studies of (1) children 0 to 18 years old and/or ICU patients (including adults), (2) computerized physician order entry versus no computerized physician order entry as intervention, and (3) randomized trial or observational study design. All studies were validated, and data were analyzed. RESULTS: Twelve studies, all observational, met our inclusion criteria. Eight studies took place at an ICU: 4 were adult ICUs, and 4 were PICUs and/or NICUs. Four studies were pediatric inpatient studies. Meta-analysis showed a significant decreased risk of medication prescription errors with use of computerized physician order entry. However, there was no significant reduction in adverse drug events or mortality rates. A qualitative assessment of studies revealed the implementation process of computerized physician order entry software as a critical factor for outcome. CONCLUSIONS: Introduction of computerized physician order entry systems clearly reduces medication prescription errors; however, clinical benefit of computerized physician order entry systems in pediatric or ICU settings has not yet been demonstrated. The quality of the implementation process could be a decisive factor determining overall success or failure. (PsycInfo Database Record (c) 2021 APA, all rights reserved)

Systematic review

Unclassified

Journal Implementation science : IS
Year 2009
<b>BACKGROUND: </b>Electronic guideline-based decision support systems have been suggested to successfully deliver the knowledge embedded in clinical practice guidelines. A number of studies have already shown positive findings for decision support systems such as drug-dosing systems and computer-generated reminder systems for preventive care services.<b>METHODS: </b>A systematic literature search (1990 to December 2008) of the English literature indexed in the Medline database, Embase, the Cochrane Central Register of Controlled Trials, and CRD (DARE, HTA and NHS EED databases) was conducted to identify evaluation studies of electronic multi-step guideline implementation systems in ambulatory care settings. Important inclusion criterions were the multidimensionality of the guideline (the guideline needed to consist of several aspects or steps) and real-time interaction with the system during consultation. Clinical decision support systems such as one-time reminders for preventive care for which positive findings were shown in earlier reviews were excluded. Two comparisons were considered: electronic multidimensional guidelines versus usual care (comparison one) and electronic multidimensional guidelines versus other guideline implementation methods (comparison two).<b>RESULTS: </b>Twenty-seven publications were selected for analysis in this systematic review. Most designs were cluster randomized controlled trials investigating process outcomes more than patient outcomes. With success defined as at least 50% of the outcome variables being significant, none of the studies were successful in improving patient outcomes. Only seven of seventeen studies that investigated process outcomes showed improvements in process of care variables compared with the usual care group (comparison one). No incremental effect of the electronic implementation over the distribution of paper versions of the guideline was found, neither for the patient outcomes nor for the process outcomes (comparison two).<b>CONCLUSIONS: </b>There is little evidence at the moment for the effectiveness of an increasingly used and commercialized instrument such as electronic multidimensional guidelines. After more than a decade of development of numerous electronic systems, research on the most effective implementation strategy for this kind of guideline-based decision support systems is still lacking. This conclusion implies a considerable risk towards inappropriate investments in ineffective implementation interventions and in suboptimal care.