The effect of incorporating guidelines into a computerized order entry system for diagnostic imaging

The objectives of this collaborative evaluation of the Manitoba Demonstration Project in Demand-Side Control for Diagnostic Imaging were to determine the impacts of both the computerized order entry and decision support components of the intervention, identify barriers to implementation, and provide insight into quantitative findings.

Mixed methodology was used. A stakeholder committee guided project implementation and evaluation and assisted in interpreting findings. Orders placed through the software (July 2006 to August 2007) were analyzed in conjunction with qualitative data from semistructured interviews, focus groups, consultations, and observational methods. Data were collected before implementation, after the introduction of the computerized ordering system, after the introduction of decision support prompts, and at project completion. Analysis was conducted simultaneously with data collection.

Although the process change of computerized provider order entry was well accepted, there was low acceptance of the practice change of decision support. Of 8,757 orders placed after guidelines were activated, 1,678 (19.2%) had relevant guidelines and 957 (10.9%) were inappropriate according to the guidelines. In only 19 (2%) of these cases did the physician follow the advice given. Contributing factors included setting, implementation of only a subsection of the Canadian Association of Radiologists guidelines, implementation issues, physician perspectives on usefulness of decision support, the timing of advice, a lack of integration with existing patient information systems, and software limitations. Setting predicted satisfaction with ordering time. The potential for computerized provider order entry to decrease useful information accompanying orders was identified.

The results of this study highlight the importance of ensuring both appropriate timing of decision support and integration with patient information systems. Implementation evaluation, as well as impact evaluation, is needed to assess new system adoption; early engagement of users can support this process. Further research is needed to determine the actual extent of inappropriate ordering.