Int J Med Inform - What do physicians tell laboratories when requesting tests? A multi-method examination of information supplied to the microbiology laboratory before and after the introduction of electronic ordering.

Tópicos

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Resumo

CKGROUND: The provision of relevant clinical information on pathology requests is an important part of facilitating appropriate laboratory utilization and accurate results interpretation and reporting.PURPOSE: (1) To determine the quantity and importance of handwritten clinical information provided by physicians to the Microbiology Department of a hospital pathology service; and (2) to examine the impact of a Computerized Provider Order Entry (CPOE) system on the nature of clinical information communication to the laboratory.METHODS: A multi-method and multi-stage investigation which included: (a) a retrospective audit of all handwritten Microbiology requests received over a 1-month period in the Microbiology Department of a large metropolitan teaching hospital; (b) the administration of a survey to laboratory professionals to investigate the impact of different clinical information on the processing and/or interpretation of tests; (c) an expert panel consisting of medical staff and senior scientists to assess the survey findings and their impact on pathology practice and patient care; and (d) a comparison of the provision and value of clinical information before CPOE, and across 3 years after its implementation.RESULTS: The audit of handwritten requests found that 43% (n=4215) contained patient-related clinical information. The laboratory survey showed that 97% (84/86) of the different types of clinical information provided for wound specimens and 86% (43/50) for stool specimens were shown to have an effect on the processing or interpretation of the specimens by one or more laboratory professionals. The evaluation of the impact of CPOE revealed a significant improvement in the provision of useful clinical information from 2005 to 2008, rising from 90.1% (n=749) to 99.8% (n=915) (p<.0001) for wound specimens and 34% (n=129) to 86% (n=422) (p<.0001) for stool specimens.CONCLUSION: This study showed that the CPOE system provided an integrated platform to access and exchange valuable patient-related information between physicians and the laboratory. These findings have important implications for helping to inform decisions about the design and structure of CPOE screens and what data entry fields should be designated or made voluntary.

Resumo Limpo

ckground provis relev clinic inform patholog request import part facilit appropri laboratori util accur result interpret reportingpurpos determin quantiti import handwritten clinic inform provid physician microbiolog depart hospit patholog servic examin impact computer provid order entri cpoe system natur clinic inform communic laboratorymethod multimethod multistag investig includ retrospect audit handwritten microbiolog request receiv month period microbiolog depart larg metropolitan teach hospit b administr survey laboratori profession investig impact differ clinic inform process andor interpret test c expert panel consist medic staff senior scientist assess survey find impact patholog practic patient care d comparison provis valu clinic inform cpoe across year implementationresult audit handwritten request found n contain patientrel clinic inform laboratori survey show differ type clinic inform provid wound specimen stool specimen shown effect process interpret specimen one laboratori profession evalu impact cpoe reveal signific improv provis use clinic inform rise n n p wound specimen n n p stool specimensconclus studi show cpoe system provid integr platform access exchang valuabl patientrel inform physician laboratori find import implic help inform decis design structur cpoe screen data entri field design made voluntari

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