Martin Were, the top winner of the AMIA 2008 Student Paper Competition, tackled the problem of improving the implementation of consultant recommendations. As an intern this topic is near and dear to me.
When a consult is called, particularly in a large academic hospital, the consultant will generally leave a note with recommendations. While consultants can input orders directly for the patient, it is considered best for the primary team to enter all orders so that they have a full understanding of what treatments the patient is getting. Exceptions are made for complex orders, such as dialysis instructions and chemotherapy dosing.
According to Dr. Were’s research, only half of all geriatric consultant recommendations are followed. Maybe the primary team doesn’t agree. Or, the team didn’t see all the recommendations. In some cases it’s not clear how to dose a recommended medication.
At the university hospital, Were extended the existing CPOE system to allow a consulting service to enter actual orders. This forced the consultants to be specific with their recommendations. The primary team was prompted to accept or reject the suggestions. The picture above is Figure 4 from his paper showing the primary team interface.
Were piloted the tool with geriatrics consultants and the hospitalist service. Intervention patients had 249 recommendations versus 192 for the controls (p<0.05). 78% of intervention recommendations were implemented versus 59% for controls. Providers indicated in a survey that the system improved quality and saved time.
I would like to see Consultant Recommended Orders (CROs) implemented in more hospitals. I'm curious to see what objections other physicians have to this idea.
Update: The full paper will appear in the next issue of JAMIA. A preprint is available at the JAMIA website for subscribers.
Were MC, Abernathy G, Hui SL, Kempf C, Weiner M. Using Computerized Provider Order Entry and Clinical Decision Support to Improve Referring Physicians’ Implementation of Consultants’ Medical Recommendations. AMIA 2008 Symposium Proceedings. 2008. p. 803. PMID 18952934. [PDF]
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