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Evidence Table 5KQ1: primary process outcomes for all technologies assisting monitoring

Article InformationHIT Studied
Integrated systems
SettingsOutcomes MeasuredResultsOutcome
Abboud (2006)1
Design: Before- after
N = 336 orders
Implementation: 04/2002
Study Start: 10/2003
Study End: 03/2004
CDSS/CDS/CCDS/reminders CPOE/POE system
Integrated CDSS/CDS/CCDS/reminders EHR/EMR system, Formulary, Hospital information system, Imaging systems, Laboratory system, Pharmacy
Pediatric stand alone hospital, 423 BedsAntibiotics courses with no lab order*There were no significant differences between the baseline and the corollary order periods on courses of antibiotics associated with no laboratory monitoring [31(19.5%) vs. 31(17.5%), p = NS].
Bertoni (2009)12
Design: RCT
N = 8,878 patients
Implementation: 00/0000
Study Start: 06/2001
Study End: 04/2006
CDSS/CDS/CCDS/reminders
Integrated Handheld
Ambulatory careadherence to guideline- screening*, adherence to guideline-appropriate lipid management*There was no difference in screening rates between the CDSS-PDA group and the control. The control group had a 10.8% drop in appropriate management from baseline, while the PDA group had a 1.1% drop, p <0.01. Stable adherence was observed in the PDA intervention group, whereas a decline in guideline adherence was observed in the control group.
Bertsche (2009)211
Design: Before- after
N = 100 patients
Implementation: 00/0000
Study Start: 00/0000
Study End: 00/0000
CDSS/CDS/CCDS/reminders
Integrated Formulary
Acute care/tertiary, 1621 Beds Academicnumber of patients with at least one deviation from international guidelines*At discharge, the number of patients with at least one deviation from international guidelines decreased by the intervention from 37 (74%) in control group to 7 (14%) in the intervention group (p <0.001).+
Chambers (2008)212
Design: Before- after
N = 87 patients
Implementation: 00/0000
Study Start: 01/2005
Study End: 06/2006
CDSS/CDS/CCDS/reminders Computer-Based Antimicrobial Monitoring System
Integrated EHR/EMR system, Laboratory system, Pharmacy
Unspecified HospitalVancomycin de- escalation rates*, Mean duration of Vancomycin therapy (days)*, Combination- Antimicrobial de- escalation rate*, Mean duration of Combination- Antimicrobial therapy (days)*Vancomycin de-escalation rates significantly improved from 33% to 68% with intervention (p = 0.001). In addition, the average duration of therapy was decreased from 10.4 ± 7.3 days to 7.7 ± 2.4 days (p = 0.014). Combination- Antimicrobial de-escalation rates were not statistically improved upon (67% vs. 63%, p = 0.763). The average duration of therapy was decreased from 12.8 ± 5.5 days to 9.5 ± 2.5 days, p = 0.335).+
Chisholm (2003)19
Design: Before- after
N = 790 children admitted to hospital with asthma exacerbations
Implementation: 10/2002
Study Start: 11/2001
Study End: 12/2003
CPOE/POE system
Integrated Billing/administration system, EHR/EMR system, Laboratory system
Pediatric stand alone hospital, 323 Bedssystemic corticosteroids use*, metered-dose inhaler use*More use was made of systemic corticosteroids (OR 5.61, 95% CI 3.46 to 9.11) and of metered-dose inhalers (OR 1.42, 95% CI 1.04 to 1.94) after implementation of standard order sets in the CPOE for asthma patients.
Cobos (2005)23
Design: RCT
N = 2,221 patients
Implementation: 04/2000
Study Start: 04/2000
Study End: 05/2002
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system
Ambulatory careproportion of patients prescribed lipid lowering drugs (secondary)The proportion of patients prescribed lipid lowering drugs was significantly lower in the CDSS guideline intervention group (59.1% vs. 40.8% RRR 31%, p <0.0001).+
Demakis (2000)213
Design: RCT
N = 12,989 patients
Implementation: 00/0000
Study Start: 01/1995
Study End: 06/1996
CDSS/CDS/CCDS/reminders
Integrated Hospital information system
Ambulatory care Academicadherence rates for 5 medication management standards of care*, monitoring warfarin treatment; treatment of atrial fibrillation with warfarin, aspirin or ticlopidine; treatment of myocardial infarction with beta-blockers or switching NSAID therapy for gastrointestinal bleeds, pneumococcal vaccinationAdherence rates for medication management standards of care were not significantly different for 4 of the 5 medication management standards of care. There was a large effect for pneumococcal vaccination (12.7% vs. 4.3%; OR 3.26; 95% CI, 2.09 to 5.09). adherence was significantly improved for 13 standards (53.5% vs. 58.8%, OR 12.4 (95% CI 1.08 to 1.42, p = 0.002).
Evans (1990)36
Design: Before- after
N = 7,656 patients
Implementation: 00/0000
Study Start: 06/1985
Study End: 09/1986
CDSS/CDS/CCDS/reminders Hospital information system
Integrated Laboratory system, Pharmacy
Unspecified Hospitalmean number of antibiotic doses per patient, proportion of patients receiving perioperative antibiotics, proportion of patients receiving antibiotics for too longSurgical patients received an average of 19 antibiotic doses before implementation of the ‘stop orders’ and 13 after (p <0.001). There were non significant changes in the proportion of patients receiving perioperative antibiotics (64% vs. 66%, NS) or those receiving antibiotics for too long (40% vs. 35%, NS).+
Evans (1999)214
Design: Before- after
N = 13,384
Patients Implementation: 01/1005
Study Start: 04/2005
Study End: 03/2006
CDSS/CDS/CCDS/reminders
Integrated Pharmacy
Critical care units (CCU, ICU, NICU) 12 beds in the shock/trauma/respiratory intensive care unit. of a 520 bed academic hospital Beds Not specified, Inpatient hospital based, AcademicThe mean number of days with excessive antibiotic dosing*The mean number of days with excessive antibiotic dosing was lower after the intervention (4.7 days vs. 2.9 days, p <0.001).+
Feldstein (2006)215
Smith (2009)216
Design: RCT
N = 961 patients
Implementation: 09/2004
Study Start: 09/2003
Study End: 01/2005
CDSS/CDS/CCDS/reminders
Integrated Billing/administration system, EHR/EMR system, Pharmacy
Ambulatory care HMO pharmacyrates of completing lab monitoring*Patients in the EMR group were 2.5 times more likely than patients in the Usual Care group to complete laboratory monitoring (p <0.001), patients in the automated telephone voice message group were 4.1 times more likely (p <0.001), and patients in the pharmacy team outreach group were 6.7 times more likely (p <0.001).+
Field (2009)40
Design: RCT
N = 833 patients (10 physicians and 213,967 patient days)
Implementation: 00/000
Study Start: 00/0000
Study End: 00/0000
CDSS/CDS/CCDS/reminders CPOE/POE system
Integrated EHR/EMR system
Long term care (nursing homes)proportion of appropriate orders*, proportion of inappropriate drugs avoidedThe proportion of appropriate antidepressant order rates for patients with renal insufficiency was higher in the CDSS group (52% vs. 63%, OR 1.2, 95% CI 1.0 to 1.4). More inappropriate drugs were avoided (15% vs. 46%, OR 2.6, 95% CI 1.4 to 5.0). Improvements were seen in frequency and missing information but not for doses in the CDSS group.+
Galanter (2004)57
Design: Before- after
N = 620 patients
Implementation: 00/0000
Study Start: 02/2001
Study End: 03/2002
CDSS/CDS/CCDS/reminders
Integrated CDSS/CDS/CCDS/reminders CPOE/POE system, Laboratory system
Acute care/tertiary, Academiccompliance with digoxin monitoring guidelines - synchronous alerts*, compliance with hypokalemia and hypomagnesemia treatment guidelines - synchronous alerts*, compliance with hypokalemia and hypomagnesemia treatment guidelines - asynchronous alerts*Postimplementation, synchronous alerts significantly increased test ordering for digoxin levels, K levels and Mg levels at 1 hr and 24 hrs (p <0.01 for all). Supplementation of Mg at 1 hour was significantly improved, but not at 24 hrs. Supplementation of K was not improved at 1 or 24 hrs. Synchronous alerts resulted in improved compliance at 1 hr and 24 hrs for bot K and Mg supplementation (p <0.01).+
Gill (2009)60
Design: RCT
N = 64,150 patients
Implementation: 00/0000
Study Start: 00/0000
Study End: 10/2006
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system
Ambulatory careUp-to-date lipid test*, Lipid medication if not at goal (high risk patients only)*Outcomes improved for most measures from before to 1 year after the intervention (univariate analysis). However, after controlling for confounding variables and for clustering in multilevel modeling, only up-to-date lipid testing for high-risk patients was statistically better in the intervention group as compared to the control group (adjusted OR 15.0, p <0.05). Intervention status was NS for any other analysis.
Gilutz (2009)61
Design: RCT
N = 7,448 patients from 56 control and 56 intervention clinics
Implementation: 00/0000
Study Start: 01/2000
Study End: 12/2003
CDSS/CDS/CCDS/reminders
Integrated Hospital information system, Laboratory system, Pharmacy
Ambulatory care Academicrate of adequate monitoring, Positive treatment trend, overall up-titration rate in patients with LDL = 110 mg/dlA higher rate of adequate monitoring was documented in the intervention arm (54.8% vs. 48.7%, p <0.001). Medication initiation or up-titration was recommended for patients with LDL levels above 110 mg/dl. The results showed that overall positive trends were minimally more prominent in the intervention arm (59.1% vs. 53.7%, p <0.003). Difference constitutes a higher rate of drug initiation (2.5%), up-titration (1.8%) and avoiding drug cessation (1.1%). Overall up-titration in patients with LDL = 110 mg/dl was poor, both in the intervention arm and in the control arm (8.6% vs. 7.4%, NS).+
Grant (2008)217
Design: RCT
N = 244 patients
Implementation: 00/2002
Study Start: 09/2005
Study End: 03/2007
PHR
Integrated Billing/administration system, EHR/EMR system, Imaging systems, Laboratory system, Patient decision support system
General Hospital, Ambulatory care HomeProportion of followup visits with DM related medication changes.For the secondary outcome, significantly more followup visits included DM related medication changes in intervention patients than the control group, 15% vs. 53%, RRR 253%, p <0.001.+
Hicks (2007)66
Design: RCT
N = 1,422 patients
Implementation: 00/0000
Study Start: 07/2003
Study End: 02/2005
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system
Other, Academicblood pressure controlled, receiving a recommended drug class medication within 1 week of the clinic visit adjusted
This study had 4 groups: usual care, CDS, NPs, and NPs+CDS.
No difference was seen across all 4 groups for blood pressure readings: Usual care vs. CDS: 45% controlled vs. 48% controlled, OR 0.96 (95% CI 0.78 to 1.19). Patients in the CDS group were more likely to have received a recommended drug class medication within 1 week of the clinic visit than patients in the usual care group: adjusted OR 1.32 (95% CI 1.09 to 1.61).+
Javitt (2005)218
Design: RCT
N = 39,462 patients
Implementation: 00/0000
Study Start: 00/0000
Study End: 00/0000
CDSS/CDS/CCDS/reminders
Integrated Insurance
Ambulatory careCompliance with recommendations to add-a-drug*Physicians complied with 24% of these “add-a-drug” recommendations in the intervention group. In the control group, physicians spontaneously instituted the treatment that would have been recommended in 17% of instances in which the recommendation was triggered but not issued. This 42% relative difference in compliance was statistically significant (p = 0.007).+
Koide (1999)84
Design: Before- after
N = 1,024 prescriptions for 111 patients and 68 physicians
Implementation: 09/1994
Study Start: 09/1994
Study End: 09/1996
CDSS/CDS/CCDS/reminders
Integrated CPOE/POE system, Hospital information system, Laboratory system
Acute care/tertiary, 1040 Beds Academicrate of appropriate prescribingOf 491 preintervention prescriptions, 127 (25.9%) were classified as appropriate because they were accompanied by a normal value of ALT or AST within 3 months. Of 533 postintervention prescriptions, 353 (66.2%) were classified as appropriate. Sudden increase occurred immediately after the start of the intervention (p <0.0001).+
Kucher (2005)89
Design: RCT
N = 2,506 patients
Implementation: 00/0000
Study Start: 09/2000
Study End: 01/2004
CDSS/CDS/CCDS/reminders
Integrated CPOE/POE system, Hospital information system
Acute care/tertiary, Academicreceived pharmacological interventionsMore patients in the CDSS group received pharmacological interventions. (13% vs. 24%, RRR 69%, p <0.001).+
Kuilboer (2006)219
Design: RCT
N = 32 primary care practices (78,926 patients of whom 9,798 had asthma or related symptoms)
Implementation: 07/1998
Study Start: 07/1998
Study End: 05/1999
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system
Ambulatory carerate of prescribing for cromoglycate-12 to 39yr, rate of prescribing for cromoglycate-40–59yrOf 20 potential changes in measurement rates, 8 were observed: The AsthmaCritic group had more contacts for the 12 to 39 year group (p = 0.03), more measurement of peak flow total for the 0 to 11 year group (p = 0.02), more FEV1 total peak flow ratio measurement in the 12–59 year groups (p = 0.04 and 0.009), and more measurement of FEV1 rates in the 3, 12 and older groups (p = 0.01, 0.01, and 0.016) Prescribing for cromoglycate was reduced in the 12 to 39 year and 40 to 59 year groups (12 to 39: 9.9/1000 patients vs. 4.1, p = 0.03) and (40 to 59: 9.0/1000 patients vs. 4.2, p = 0.05). Other prescribing (3 drugs or drug classes and 4 age groups) did not differ across groups.+
Lester (2005)94
Design: RCT
N = 235 patients and 14 clinicians
Implementation: 07/2003
Study Start: 07/2003
Study End: 07/2004
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system
Ambulatory care Academicproportion of patients receiving statins*, proportion of patients receiving statins at 1 yr*At 1 month more patients in the email group had received statins than control patients (3%, 15%, RRR 400, p <0.001). At 1 year the difference in receipt of statins had disappeared (17% vs. 25%, NS).+
Lo (2009)220
Design: RCT
N = 3,673 potential alert trigger events (prescriptions)
Implementation: 00/2000
Study Start: 07/2003
Study End: 01/2004
CDSS/CDS/CCDS/reminders
Integrated CDSS/CDS/CCDS/reminders
Imaging systems
Ambulatory care Academicproportion of events resulting in lab testing3,673 total events where baseline lab tests would have been advised: 1,988 events in the control group and 1,685 in the intervention group. In the control group, baseline labs were requested for 771 (39%) of the medications. In the intervention group, baseline labs were ordered by clinicians in 689 (41%) of the cases. Overall, no significant association existed between the intervention and the rate of ordering appropriate baseline laboratory tests (RRR 5%, p = 0.782).
Matheny (2008)221
Design: RCT
N = 2,507 outpatient visits in 1,922 geriatric patients and 303 primary care physicians
Implementation: 00/0000
Study Start: 01/2004
Study End: 06/2004
CDSS/CDS/CCDS/reminders
Integrated CDSS/CDS/CCDS/reminders
Laboratory system
Ambulatory care Academicrate of receiving appropriate laboratory testing within 14 days of the clinical encounter/10 medication-lab reminder categoriesReminders for appropriate laboratory monitoring had no impact on rates of receiving appropriate testing for creatinine, potassium, liver function, renal function, or therapeutic drug level monitoring for patients overdue for lab monitoring NSAIDs; Angiotensin Receptor Blockers; Metformin; Potassium Supplements; Potassium Sparing Diuretics, Thiazide Diuretics; ACE Inhibitors; HMG Co-A Reductase Inhibitors; Thyroxine; (or the following therapeutic drugs combined: Carbamazapine; Cyclosporine, Phenobarbital, Phenytoin, Proc-NAPA, Valproate).
McDonald (1976)222
Design: RCT
N = 601 patient visits
Implementation: 00/0000
Study Start: 00/0000
Study End: 00/0000
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system
General Hospital, Academiccompliance with drug monitoring test alerts*, compliance with recommendations to change therapeutic regimens*Alerts to patients overdue for drug monitoring tests resulted in an increased number of tests ordered (11% vs. 36%, RRR -227%, p <0.0001). Recommendations for changes to therapeutic regimens were followed in 28% of study events compared to 13% of control events (p <0.026).+
McGregor (2006)104
Design: RCT
N = 4,507 patients
Implementation: 00/000
Study Start: 05/2004
Study End: 08/2004
CDSS/CDS/CCDS/reminders
Integrated Laboratory system, Pharmacy
Acute care/tertiary, 648 Beds Inpatient hospital based, Academicmean time spent on antimicrobial managementTeam members spent 3.2 hours per day on management of antimicrobials with the decision support system compared with 4 hours per day without. No statistical testing was done.+
McMullin (1999)105
Design: Before- after
N = 265 patients
Implementation: 01/1996
Study Start: 00/0000
Study End: 00/0000
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system, Laboratory system, Pharmacy
Acute care/tertiary, Pharmacy, Inpatient hospital basedrate of concomitant orders for contraindicated medications with cisapride*The rate of ordering contraindicated drugs with cisapride was reduced with COPE (9% vs. 3.1%, RRR 65%, p <0.001).+
Montgomery (2000)107
Design: RCT
N = 552 patients
Implementation: 00/0000
Study Start: 09/1996
Study End: 09/1998
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system
Ambulatory careprobability of patients taking 2 drugs, probability of patients taking 3 drugsAdjusted data showed that compare with those in the risk chart group alone, those with computer support had a lower probability of patients taking 2 drugs (OR 0.5, 95% CI 0.2 to 0.9)< p <0.05) or 3 drugs (OR 0.3, CI 0.1 to 0.6, p <0.05).
Niiranen (2008)113
Design: Time series
N = 18,818 patient followups
Implementation: 03/2005
Study Start: 04/2005
Study End: 12/2007
CDSS/CDS/CCDS/reminders
Integrated Laboratory system
Ambulatory care Homeproportion of patient followups assigned by nurses, year 1 to 2, proportion of patient followups assigned by nurses, year 2 to 3In general, the share of patient followups assigned by nurses was similar in year 1 and 2 (56.7% vs. 55.1%, RRR 3%, NS), and increased significantly between year 2 and 3 (55.1% vs. 58.7%, RRR -7%, p <0.001).+
Okon (2009)223
Design: Before- after
N = 51,619 severe pain events
Implementation: 09/2005
Study Start: 10/2005
Study End: 06/2007
CDSS/CDS/CCDS/reminders
Integrated CPOE/POE system, nurse charting system
Acute care/tertiary, 504 Bedsrate of reassessment errors, time to resolution of pain events-minutes (4 time periods)Aggregate delayed reassessment error postintervention rate of 35.8% compared with preintervention (56.2%, p <0.0001) for relative error reduction of 36%. Observed median time to resolution of severe pain events among all hospitalized patients decreased from 195 (T0) to 117 minutes ( T1), 106 minutes (T2), and 101 minutes (T3) (all p <0.0001).+
Overhage (1997)117
Design: RCT
N = 86 physicians on 6 services (services randomized)
Implementation: 00/0000
Study Start: 10/1992
Study End: 04/1994
CDSS/CDS/CCDS/reminders
Integrated, CPOE/POE system, EHR/EMR system, Laboratory system
General Hospital, Academicimmediate compliance with corollary ordering*, 24 hour compliance*, hospital-stay compliance*Intervention physicians placed corollary orders twice as often as control physicians did when measured by immediate compliance (46.3% vs. 21.9%, RRR -111%, p <0.0001). Significant differences between study and control physicians also appear in 24 hour compliance (50.4% vs. 29.0%, RRR - 74%, p <0.0001) and hospital stay compliance (55.9% vs. 37.1%, RRR 51%, p <0.0001).+
Palen (2006)120
Design: RCT
N = 26,586 index dispensings
Implementation: 00/0000
Study Start: 11/2002
Study End: 10/2003
CDSS/CDS/CCDS/reminders
Integrated CDSS/CDS/CCDS/reminders
CPOE/POE system, EHR/EMR system, Pharmacy
Ambulatory carecompliance rateThere was no significant difference between the control and intervention group physicians in the overall rate of compliance with ordering the recommended laboratory monitoring for patients prescribed study medications. Laboratory monitoring was performed as recommended 56.6% of the time in the intervention group compared with 57.1% of the time in the control group (p = 0.31). In cases in which a statistically significant difference was demonstrated, improved compliance favored the intervention group 71.2% vs. 62.3% (p = 0.003) for gemfibrozil; 75.7% vs. 73.9% (p = 0.05) for statins, 52.8% vs. 46% for colchicine (p = 0.05); 42.9% vs. 0% for methotrexate (p = 0.03)
Patel (2009)224
Design: Before- after
N = 25,503 patients
Implementation: 00/2001
Study Start: 00/2001
Study End: 00/2007
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system, Hospital information system
Acute care/tertiary, 617 Beds Academicpercent compliance*There were no statistical differences in percent compliance for all outcomes at 2001 baseline between hospitals (p >0.05). Adherence to all outcome criteria in the 5 high-risk populations over the 6- year time frame resulted in a 119% change compared with 91% at the non- REACH® hospital (p = 0.470).+
Quinn (2008)127
Design: RCT
N = 30 patients
Implementation: 00/0000
Study Start: 00/0000
Study End: 00/0000
CDSS/CDS/CCDS/reminders
Diabetes Management Tool
Integrated Web-based data anlytics and therapy optimization tools
Ambulatory careChanges in medication (medication intensified)Patients using WellDoc System were more likely to have physicians intensify diabetes medications (84.6% vs. 23.08%, p = 0.002).+
Raebel (2005)129
Design: RCT
N = 10,169 dispensings
Implementation: 00/0000
Study Start: 09/2002
Study End: 12/2003
CDSS/CDS/CCDS/reminders
Integrated Laboratory system, Pharmacy
Ambulatory care HMO pharmacypercentage of dispensings with baseline monitoringRecommended laboratory monitoring was completed in 74.7% (n=7,598) of dispensings at initiation of therapy. Compared to the usual care group, monitoring was higher in the intervention group (70% vs. 79%, RRR -13%, p <0.001)+
Riggio (2009)133
Design: Before- after
N = 100 patients with heparin induced thrombocyte-penia
Implementation: 06/2005
Study Start: 03/2004
Study End: 09/2006
CDSS/CDS/CCDS/reminders
CPOE/POE system
Integrated Hospital information system
Acute care/tertiary, 728 Beds AcademicTime from platelet count criterion until heparin/enoxaparin stop*, Time from platelet count criterion until 1st HIT laboratory test drawn*, Time from platelet count criterion until direct thrombin inhibitor started*Counter to expectations, the time (in days) taken from alert to heparin stop order was significantly higher after implementation (1.3 vs. 2.9, p = 0.04). There were no significant differences in time (in days) from alert to lab test (2.3 vs. 3.0, NS), nor time to start of treatment with direct thrombin inhibitor (19.3 vs. 15.0, NS).
Rind (1994)225
Design: Time series
N = 562 patients
Implementation: 00/0000
Study Start: 00/0000
Study End: 00/0000
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system, Formulary, Hospital information system, Laboratory system, Pharmacy
Acute care/tertiary, 504 Beds Academicmean time interval between event and medication change*The mean interval between the occurrence of an event and discontinuation of a medication or a change in its dosage was 97.5 hours during the control period and 75.9 hours during the intervention period, a difference of 21.6 hours (p <0.0001).+
Rollman (2002)136
Design: RCT
N = 200 Patients with documented major depression
Implementation: 00/0000
Study Start: 04/1997
Study End: 12/1998
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system
Ambulatory careantidepressant prescribing rate (secondary)Prescribing of antidepressants (continuous use of change in prescriptions) did not differ across the 3 groups at 3 or 6 months.
Rood (2005)137
Design: RCT
N = 484 patients
Implementation: 04/2001
Study Start: 00/0000
Study End: 00/0000
CDSS/CDS/CCDS/reminders
Integrated Hospital information system
Critical care units (CCU, ICU, NICU) 18 Beds Academicadherence to glucose measurement timing recommendations*, adherence to insulin dose advice*Rate of compliance with glucose measurement timing recommendations control-intervention-control (29% vs. 38% vs. 41% with period 2 and 3 greater than period 1, p = 0.05). During the intervention period the rate for computerized group was higher than the control (36% vs. 40%, p = 0.05) Rate of compliance with insulin dose advice was higher in period 2 than 1, and decreased significantly in period 3 (56% vs. 70% vs. 42%, p = 0.05). During the intervention period the rate for computerized group was higher than the control (64% vs. 77%, p = 0.05).+
Roumie (2006)226
Roumie (2007)227
Design: RCT
N = 871 patients
Implementation: 00/0000
Study Start: 06/2004
Study End: 12/2004
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system
Ambulatory care Outpatient hospital basedprescribing changes*No differences were seen comparing the groups who had provider education alone vs. those who had provider education and computer alerts for prescribing of any medication, changing doses, or adding medications (all data adjusted for multiple variables).
Safran (1995)141
Safran (1993)142
Design: RCT
N = 349 patients with HIV
Implementation: 00/0000
Study Start: 05/1992
Study End: 09/1993
CDSS/CDS/CCDS/reminders
CPOE/POE system
Integrated EHR/EMR system
Ambulatory care Academicmean response time to alerts*, mean response times to reminders*Physicians who got alerts responded more quickly to them (mean 52 vs. 11 days, p <0.0001). Physicians who got reminders responded more quickly to them (mean 500 vs. 114 days, p = 0.0001).+
Schnipper (2008)143
Design: Before- after
N = 30 clinicians
Implementation: 00/0000
Study Start: 00/0000
Study End: 00/0000
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system
Ambulatory careAntiplatelet prescribed or contraindication documented*, Beta-blocker prescribed *, Change in diabetic therapy if A1c > 7.0 *Antiplatelet prescribed or contraindication documented improved from 3.2% in the preintervention to 31.0% in the postintervention period (p <0.001). Beta-blocker prescribed or contraindication documented was 4.2 % in the preintervention compared to 66.7% in the post period (p = 0.03). Change in diabetic therapy if A1c >7.0 was 10.7% in the pre-period and 16.9% in the post period, p = 0.11.+
Sequist (2005)228
Design: RCT
N = 6,243 Patients
Implementation: 07/2000
Study Start: 10/2002
Study End: 04/2003
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system, Imaging systems, Laboratory system
Acute care/tertiary, General Hospital, Ambulatory care Community (school, community centre etc) Academiccompliance rate with Diabetes reminders*, compliance rate with Coronary Artery Disease reminders*Diabetes reminders resulted in the recommended action in 19% in the intervention group vs. 14% in the control group.
After adjusting for baseline patient and physician characteristics, patients in the intervention group were more likely than control patients to receive recommended diabetes care based on the composite outcome (OR 1.30, 95% CI 1.01 to 1.67). Coronary artery disease reminders resulted in the recommended action for overdue items in 22% in the intervention group vs. 17% in the control group.
Using the composite outcome, patients in the intervention group received recommended coronary artery disease care more often than those in the control group (OR 1.25, 95% CI 1.01 to 1.55) after adjusting for baseline differences.
+
Shiffman (2000)147
Design: Before- after
N = 9 physicians
Implementation: 00/0000
Study Start: 09/1996
Study End: 10/1998
CDSS/CDS/CCDS/reminders
Integrated Handheld
Ambulatory careadherence rate with metered-dose inhaler/nebulization*, rate of systemic corticosteroid prescriptions*Adherence with metered-dose inhaler/nebulization rates did not differ between control and intervention (73% vs. 91%, NS), nor did rate of prescribing systemic corticosteroids (43% vs. 57%, NS).
Tierney (2003)166
Design: RCT
N = 706 patients, 20 pharmacists, 94 physicians and 1 nurse practitioner
Implementation: 00/0000
Study Start: 01/1994
Study End: 05/1996
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system, Pharmacy,
Ambulatory care Outpatient hospital based, Academiccompliance with cardiac care suggestions*Neither the physician nor the pharmacist intervention had any significant effect on whether patients’ cardiac care was compliant with the suggestions (p > 0.8 across the 4 intervention groups by analysis of variance, with p > 0.7 and p > 0.4 when testing the physician and pharmacist interventions separately).
Tierney (2005)167
Design: RCT
N = 706 patients
Implementation: 00/0000
Study Start: 01/1994
Study End: 05/1996
CDSS/CDS/CCDS/reminders
Integrated CPOE/POE system, EHR/EMR system, Pharmacy
Ambulatory care Pharmacy, Outpatient hospital based, Academicadherence to the care suggestions*There were no differences between the four study groups in either adherence to the care suggestions, combined or individually (32% control, 32% physician intervention, 32% pharmacist intervention, 37% both interventions, NS).
White (1984)229
Design: RCT
N = 396 patients
Implementation: 00/0000
Study Start: 00/0000
Study End: 00/0000
CDSS/CDS/CCDS/reminders
Integrated EHR/EMR system, Imaging systems, Laboratory system
Acute care/tertiary, Academicphysician actions*Physicians were 1.22 times as likely to take action in the alert group as compared to the non-alert group (p <0.003). Actions included medication and lab monitoring changes.+
Wrona (2007)177
Design: Observational study
N = 536 PCA patients
Implementation: 00/2003
Study Start: 01/2003
Study End: 03/2004
CPOE/POE system
Integrated EHR/EMR system, Imaging systems, Laboratory system
Pediatric stand alone hospitalRates of respiratory monitoring.
Rates of oxygen saturation monitoring
Compared to the control group of ‘no order set’, patients in the Acute Pain Team Service had a higher rate of respiratory monitoring (43% vs. 66.3%, RRR -54%, p <0.05) and oxygen saturation monitoring (86.1% vs. 98.6%, RRR -15%, p <0.05). Compared to the control group of ‘no order set’, patients in the prescriber initiated PCA had higher respiratory rate monitoring (43% vs. 57.8%, RRR -34%, p <0.05). No other comparisons were significant.+

The HIT system studied is in bold, followed by the systems that it was integrated with. The outcome column indicates whether at least 50% of the relevant outcomes abstracted were positively impacted by the MMIT (+) or not (−).

*

indicates outcomes noted as being the primary outcome by the paper’s authors

Abbreviations: A1c = haemoglobin A1c; ACE = Angiotensin Converting Enzyme; ALT = Alanine Aminotranceferase; AST = Aspartate Aminotransferase; CCDS = Computerized Clinical Decision Support; CCU = Critical Care Unit; CDS = Clinical/Computerized Decision Support ; CDSS = Clinical Decision Support System; CI = CI; CPOE = Computerized Provider Order Entry; DM = Diabetes Mellitus ; EHR = Electronic Health Record; EMR = Electronic Medical Records; GP = General Practitioner; HIT = Health Information Technology; HIV = Human Immunodeficiency Virus; HMO = Health Maintenance Organization; ICU = Intensive Care Unit; K = Potassium; Mg = Magnesium; N = Sample Size; NICU = Neonatal Intensive Care Unit; NPs = Nurse Practitioners; NS = Not statistically significant; NSAID = Nonsteroidal anti-inflammatory drug; OR = Odds Ratio; p = Probability; PCA = Patient-Controlled Analgesia PDA = Personal Digital Assistants ; PHR = Patient Health Record; POE = Provider Order Entry; RCT = Randomized Controlled Trial; RRR = Relative Risk Reduction; vs. = Versus; yr = Year

indicates outcomes noted as being the primary outcome by the paper’s authors

From: Appendix C, Evidence Tables

Cover of Enabling Medication Management Through Health Information Technology
Enabling Medication Management Through Health Information Technology.
Evidence Reports/Technology Assessments, No. 201.
McKibbon KA, Lokker C, Handler SM, et al.

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