Embedded guideline information without patient specificity in a commercial emergency department computerized order-entry system.
BACKGROUND
Clinical practice guidelines and computerized provider order entry (CPOE) have potential for improving clinical care. Questions remain about feasibility and effectiveness of CPOE in the emergency department (ED). However, successful implementations in other settings typically incorporate decision support functions that are lacking in many commercially available ED information systems.


OBJECTIVE
To compare acute coronary syndrome (ACS) guideline compliance before and after implementation of a locally implemented ACS guideline, first on paper and then in a commercially available ED information system without patient-specific clinical decision support.


METHODS
Clinical data were abstracted retrospectively on patients seen before and after introduction of paper and, subsequently, CPOE versions of ACS guideline-based order-sets. Order-set use was determined. Risk category assignments were made retrospectively using guideline criteria and compliance with the guideline regarding beta-blockers, heparin, and aspirin was determined. Association between order-set use and compliance was determined.


RESULTS
The authors found increasing use of order-sets over the period of study. However, there was poor association between the order-sets used and risk stratification category. Some association between ED beta-blocker use and use of CPOE order-sets was found, but there was no improvement in overall compliance with any of the guideline recommendations.


CONCLUSIONS
Adherence to an ACS guideline did not improve with implementation of a commercial ED information system without provision for patient-specific decision support. This suggests that the lack of patient-specific decision-support functionality in most current ED information system products may hamper progress in the development of effective decision support.
Asaro
Phillip V
PV
Emergency Medicine Division, Washington University School of Medicine, St. Louis, MO 63110, USA. asarop@msnotes.wustl.edu
Sheldahl
Amy L
AL
Char
Douglas M
DM
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000789:Angina, Unstable / Q000628:therapy*; D001241:Aspirin / Q000627:therapeutic use; D000077144:Clopidogrel; D020000:Decision Support Systems, Clinical; D004636:Emergency Service, Hospital; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D019983:Guideline Adherence; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D050316:Medical Order Entry Systems; D009203:Myocardial Infarction / Q000628:therapy*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D020379:Risk Adjustment; D013988:Ticlopidine / Q000031:analogs & derivatives / Q000627:therapeutic use
D000319:Adrenergic beta-Antagonists; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D006493:Heparin; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin