Appl Clin Inform 2012; 03(02): 154-163
DOI: 10.4338/ACI-2012-01-RA-0001
Research Article
Schattauer GmbH

Using Computerized Provider Order Entry to Enforce Documentation of Tests with Pending Results at Hospital Discharge

J. Cadwallader
1  Indiana University School of Medicine, Indianapolis, IN
2  Regenstrief Institute Inc, Indianapolis, IN
,
C. Asirwa
1  Indiana University School of Medicine, Indianapolis, IN
2  Regenstrief Institute Inc, Indianapolis, IN
,
X. Li
2  Regenstrief Institute Inc, Indianapolis, IN
,
J. Kesterson
2  Regenstrief Institute Inc, Indianapolis, IN
,
W.M. Tierney
1  Indiana University School of Medicine, Indianapolis, IN
2  Regenstrief Institute Inc, Indianapolis, IN
,
M.C. Were
1  Indiana University School of Medicine, Indianapolis, IN
2  Regenstrief Institute Inc, Indianapolis, IN
› Author Affiliations
Further Information

Publication History

received: 24 January 2012

accepted: 21 March 2012

Publication Date:
16 December 2017 (online)

Summary

Background: Small numbers of tests with pending results are documented in hospital discharge summaries leading to breakdown in communication and medical errors due to inadequate followup.

Objective: Evaluate effect of using a computerized provider order entry (CPOE) system to enforce documentation of tests with pending results into hospital discharge summaries.

Methods: We assessed the percent of all tests with pending results and those with actionable results that were documented before (n = 182 discharges) and after (n = 203 discharges) implementing the CPOE-enforcement tool. We also surveyed providers (n = 52) about the enforcement functionality.

Results: Documentation of all tests with pending results improved from 12% (87/701 tests) before to 22% (178/812 tests) (p = 0.02) after implementation. Documentation of tests with eventual actionable results increased from 0% (0/24) to 50% (14/28)(p<0.001). Survey respondents felt the intervention improved quality of summaries, provider communication, and was not time-consuming. Conclusions: A CPOE tool enforcing documentation of tests with pending results into discharge summaries significantly increased documentation rates, especially of actionable tests. However, gaps in documentation still exist.