Rural Trial of Clinic Order Entry with Decision Support

This project measured the value of a health information technology (health IT) intervention called the Computerized Clinic Order Entry (CCOE) tool. The study builded on a recently completed rural community randomized trial using handheld computers (PDAs) equipped with standalone clinical decision support systems (CDSS) to promote appropriate use of antimicrobials. To create a CDSS integrated with workflow and with much broader potential, the CCOE tool was developed and pilot tested. The CCOE has a user interface designed by clinicians for clinicians. It is tailored for use on PDAs but because it is Web-based it will be accessible via any type of computer. The core utility of the tool is electronic writing of outpatient orders, including prescriptions, immunizations, laboratory tests, X-ray studies, and work notes. Orders were stored on highly secure, redundant servers and electronically transmitted via wireless connections to pharmacies and other vendors or to local printers in the clinic offices. The system allows common access to records across providers who share patients while maintaining strict levels of confidentiality. The CCOE decision support logic encompasses drug interactions, allergy contraindications, disease management of acute respiratory infections, laboratory testing in diabetics, laboratory monitoring during medication therapy, printing of medication-specific patient education materials, and formation of disease-specific registries. The decision support logic operates in the background and becomes manifest to the user only when clinically relevant and needed. Ten rural primary care practices in Utah were randomly assigned to implementation of the tool and ten other rural primary care practices assigned to continue paper-based writing of outpatient prescriptions and orders. Both arms received patient self-care education materials. The decision support functions were rolled out in four stages during the course of the study. During the third year, the comparator arm was crossed over to use of the CCOE tool. Clinical endpoints that were assessed include appropriateness of antimicrobial therapy for acute respiratory infections, frequency of appropriate laboratory monitoring of hemoglobin A1c in diabetics, incidence of outpatient adverse drug events, and proportion of patients who meet indications for influenza vaccine who are immunized. Effects of the CCOE tool on provider productivity, office efficiency, user satisfaction, and medication practices will also be evaluated. The cost impact of the intervention was measured to allow a comprehensive assessment of the value of this health IT.