PACS, CPOE implementation provides mixed results in U.K.
The deployment of computerized physician order entry systems (CPOE) and PACS in four National Health Service (NHS) hospital trusts in England were associated with both an increase and a reduction in tests and exams, according to a retrospective analysis of the technologies’ impact.

“The rate at which information technology (IT) systems are being ordered and deployed by healthcare providers around the world has far outpaced the growth of the evidence base of clinical and operational benefits associated with such systems,” wrote the authors of the study, which was published online before print in the British Medical Journal.

The researchers examined requests per inpatient, outpatient, or day-case patient for full blood count, urine culture and urea and electrolytes tests for the CPOE and plain x ray film, CT and ultrasonography exams for the PACS as their outcomes measure.

They reviewed records for four NHS trusts from 2000 through 2005: a 954-bed facility, an 821-bed institution, a 1,110-bed hospital and a 470-bed site. The researchers noted that only the 954-bed facility had successfully implemented a CPOE, while only the 470-bed site had fully implemented PACS. The 821-bed institution and 1,110-bed hospital only had limited PACS functionality during the study period.

“We found evidence for an effect of CPOE on five out of 18 primary outcomes and on three out of seven secondary outcomes; and for PACS, on four of 17 primary outcomes and one of eight secondary outcomes,” the authors wrote. “Of the five effects on primary outcomes attributable to CPOE, four were indicative of efficiency gains; for PACS, two out of four.”

The analysis found the CPOE system enabled clinicians to access the patient’s pathology test history during an outpatient appointment, which could have reduced the number of tests ordered because of a missing previous test result.

The researchers noted that the data demonstrated that implementation of PACS was associated with fewer CT exams being requested for inpatients but more scans requested at outpatient appointments. In addition, they found that PACS deployment was also associated with an increase in CT procedures being repeated within 48 hours during inpatient stay.

On a positive note, PACS implementation corresponded to fewer x-ray exam repeats being ordered by clinicians.

“As with repeat full blood counts at consecutive outpatient appointments, attribution of this effect to implementation of PACS is plausible if PACS enables the clinician to access the patient’s radiological examination history during the outpatient appointment,” the researchers wrote. “Fewer repeats could also be related to lower rejection rates.”

Although managers and end users at the facility considered the PACS implementation to be successful, the authors noted that the trust did not explain the puzzling CT results.

The researchers said that their study benefitted from a large number of observations, but that efficiency gains from healthcare IT systems are difficult to quantify.

“Given the large overall benefit that would accrue from small efficiency gains occurring in all trusts across the NHS, further research is justified,” they wrote. “Although our underlying methods are promising, quantitative research must be closely allied with qualitative research to provide context and to explain observed changes.”

The authors noted that the CPOE and PACS implementation could provide better quantitative results when the systems were implemented at other NHS trusts, as well as with the overarching goal of a national electronic health record (EHR) system.

“CPOE and PACS, when fully integrated with the other information technology systems that comprise NPfIT (national electronic health records, patient administration systems, electronic referral), might contribute to more dramatic quantitative changes,” they wrote.