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January 20, 1993, Vol 269, No. 3 >
ARTICLE | January 20, 1993

Physician Inpatient Order Writing on Microcomputer Workstations: Title and subTitle BreakEffects on Resource Utilization FREE

William M. Tierney, MD; Michael E. Miller, PhD; J. Marc Overhage, MD, PhD; Clement J. McDonald, MD
[+] Author Affiliations

Reprint requests to Computer Science Research Section, Regenstrief Institute for Health Care, 5th Floor RHC, 1001 W Tenth St, Indianapolis, IN 46202 (Dr McDonald).


JAMA. 1993;269(3):379-383. doi:10.1001/jama.1993.03500030077036
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References

Objective.  —To assess the effects on health care resource utilization of a network of microcomputer workstations for writing all inpatient orders.

Design.  —Randomized controlled clinical trial.

Setting.  —Inpatient internal medicine service of an urban public hospital.

Subjects.  —A total of 5219 internal medicine patients and the 68 teams of house officers, medical students, and faculty internists who cared for them.

Intervention.  —Microcomputer workstations, linked to a comprehensive electronic medical record system, for writing all inpatient orders.

Main Outcome Measures.  —Total inpatient charges for each admission and charges for specific categories of orders. A time-motion study of selected interns assessed the ordering system's time consumption.

Results.  —Intervention teams generated charges that were $887 (12.7%) lower per admission than did control teams (P=.02). Significant reductions (P<.05) were demonstrated separately for bed charges, diagnostic test charges, and drug charges. Reductions of similar proportion and statistical significance were found for hospital costs. The mean length of stay was 0.89 day shorter for intervention resident teams (P=.11). Interns in the intervention group spent an average of 33 minutes longer (5.5 minutes per patient) during a 10-hour observation period writing orders than did interns in the control group (P<.0001).

Conclusions.  —A network of microcomputer workstations for writing all inpatient orders significantly lowered patient charges and hospital costs. This would amount to savings of more than $3 million in charges annually for this hospital's medicine service and potentially tens of billions of dollars nationwide. However, the system required more physician time than did the paper charts. Research at other sites and system advances to reduce time requirements are warranted.(JAMA. 1993;269:379-383)

REFERENCES

1 +
Eisenberg JM, Williams SV.  Cost-containment and changing physicians' practice behavior: can the fox learn to guard the chicken coop? JAMA . 1981;; 246:2195-2201.
2 +
Richart RH.  Evaluation of a medical data system. Comput Biomed Res . 1970;;3:415-425.
3 +
Knapp DE, Knapp DA, Speedie MK, Yaeger DM, Baker CL.  Relationship of inappropriate drug prescribing to increased length of hospital stay. Am J Hosp Pharm . 1979;;36:1334-1337.
4 +
Committee on Improving the Medical Record, Institute of Medicine. The Computer-Based Patient Record: An Essential Technology for Health Care . Washington, DC: National Academy Press; 1991;.
5 +
McDonald CJ.  Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med . 1976;;295:1351-1355.
6 +
McDonald CJ, Hui SL, Smith DM, et al.  Reminders to physicians from an introspective computer medical record: a two-year randomized trial. Ann Intern Med . 1984;;100:130-138.
7 +
McPhee SJ, Bird JA, Fordham D, Rodnick JE, Osborn EH.  Promoting cancer prevention activities by primary care physicians: results of a randomized, controlled trial. JAMA . 1991;;266:538-544.
8 +
Barnett GO, Winickoff RN, Morgan MM, Zielstorff RD.  A computer-based monitoring system for follow-up of elevated blood pressure. Med Care . 1983;;21:400-409.
9 +
Barrett JP, Barnum R, Gordon B, Pascet R. Evaluation and Implementation of a Medical Information System in a General Community Hospital: Batelle Memorial Report . Washington, DC: National Center for Health Services Research; 1975;. National Technical Information Service publication PB358340.
10 +
Tierney WM, McDonald CJ, Martin DK, Hui SL, Rogers MP.  Computerized display of past test results: effects on outpatient testing. Ann Intern Med . 1987;;107:569-574.
11 +
Tierney WM, McDonald CJ, Hui SL, Martin DK.  Computer predictions of abnormal test results: effects on outpatient testing. JAMA . 1988;;259:1194-1198.
12 +
Tierney WM, Miller ME, McDonald CJ.  The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests. N Engl J Med . 1990;;233:1499-1504.
13 +
McDonald CJ, Tierney WM, Martin DK, Overhage JM.  The Regenstrief Medical Record System: 20 years' experience in hospital outpatient clinics and neighborhood health centers. MD Comput . 1992;; 9:206-217
14 +
McDonald CJ, Tierney WM.  The Medical Gopher: a microcomputer system to help find, organize and decide about patient data. West J Med . 1986;;145:823-829.
15 +
Campbell DT, Stanley JC. Experimental and Quasi-experimental Designs for Research . Chicago, Ill: Rand McNally College Publishing Company; 1966;:22.
16 +
Overhage JM, Tierney WM, McDonald CJ, Pickett KE.  How do interns spend their days? a time-motion study of internal medicine interns. Clin Res . 1991;;39:794A. Abstract.
17 +
Overhage JM, Tierney WM, McDonald CJ, Pickett KE.  Computer-assisted order entry: impact on intern time use. Clin Res . 1991;;39:794A. Abstract.
18 +
McDonald CJ, Tierney WM, Miller ME, Fitzgerald JF, Engeler MT, Wolinsky FD.  Toward quantification of small area variations. Clin Res . 1990;; 38:914A. Abstract.
19 +
Fitzgerald JF, Tierney WM, Engeler MT, Miller ME, McDonald CJ.  Predicting inpatient charges: a model using clinical admission information. Clin Res . 1990;;38:912A. Abstract.
20 +
Schimmel VE, Alley C, Heath AM.  Measuring costs: product line accounting versus ratio of cost to charges. Top Health Care Financ . 1987;;13:76-86.
21 +
Milliken GA, Johnson DE. Analysis of Messy Data: Designed Experiments . New York, NY: Van Nostrand Reinhold Co; 1984;:250.
22 +
Weinberger M, Smith DM, Katz BP, Moore PS.  The cost-effectiveness of intensive postdischarge care: a randomized trial. Med Care . 1988;;26:1092-1102.
23 +
Avorn J, Soumerai SB.  Improving drug-therapy decisions through educational outreach: a randomized controlled trial of academically based 'detailing.' N Engl J Med . 1983;;308:1457-1463.
24 +
Fries JF.  Alternatives in medical record formats. Med Care . 1974;;12:871-881.
25 +
Whiting-O'Keefe QE, Simborg DW, Epstein WV, Warger A.  A computerized summary medical record system can provide more information than the standard medical record. JAMA . 1985;;254:1185-1192.
26 +
Wilson GA, McDonald CJ, McCabe GP.  The effect of immediate access to a computerized medical record on physician test ordering: a controlled clinical trial in the emergency room. Am J Public Health . 1982;;72:698-702.
27 +
Selker HP, Beshansky JR, Pauker SG, Kassirer JP.  The epidemiology of delays in a teaching hospital. Med Care . 1989;;27:112-129.
28 +
Classen DC, Pestotnik SL, Evans RS, Burke JP.  Computerized surveillance of adverse drug events in hospital patients. JAMA . 1991;;266:2847-2851.
29 +
Larsen RA, Evans RS, Burke JP, Pestontnik SL, Gardner RM, Classen DC.  Improved perioperative antibiotic use and reduced surgical wound infections through use of computer decision analysis. Infect Control Hosp Epidemiol . 1989;;10:316-320.
30 +
General Accounting Office. Medical ADP Systems: Automated Medical Records Hold Promise to Improve Patient Care . Washington, DC: General Accounting Office; 1991;. Publication GAO/IMTEC-91-5.

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1 +
Eisenberg JM, Williams SV.  Cost-containment and changing physicians' practice behavior: can the fox learn to guard the chicken coop? JAMA . 1981;; 246:2195-2201.
2 +
Richart RH.  Evaluation of a medical data system. Comput Biomed Res . 1970;;3:415-425.
3 +
Knapp DE, Knapp DA, Speedie MK, Yaeger DM, Baker CL.  Relationship of inappropriate drug prescribing to increased length of hospital stay. Am J Hosp Pharm . 1979;;36:1334-1337.
4 +
Committee on Improving the Medical Record, Institute of Medicine. The Computer-Based Patient Record: An Essential Technology for Health Care . Washington, DC: National Academy Press; 1991;.
5 +
McDonald CJ.  Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med . 1976;;295:1351-1355.
6 +
McDonald CJ, Hui SL, Smith DM, et al.  Reminders to physicians from an introspective computer medical record: a two-year randomized trial. Ann Intern Med . 1984;;100:130-138.
7 +
McPhee SJ, Bird JA, Fordham D, Rodnick JE, Osborn EH.  Promoting cancer prevention activities by primary care physicians: results of a randomized, controlled trial. JAMA . 1991;;266:538-544.
8 +
Barnett GO, Winickoff RN, Morgan MM, Zielstorff RD.  A computer-based monitoring system for follow-up of elevated blood pressure. Med Care . 1983;;21:400-409.
9 +
Barrett JP, Barnum R, Gordon B, Pascet R. Evaluation and Implementation of a Medical Information System in a General Community Hospital: Batelle Memorial Report . Washington, DC: National Center for Health Services Research; 1975;. National Technical Information Service publication PB358340.
10 +
Tierney WM, McDonald CJ, Martin DK, Hui SL, Rogers MP.  Computerized display of past test results: effects on outpatient testing. Ann Intern Med . 1987;;107:569-574.
11 +
Tierney WM, McDonald CJ, Hui SL, Martin DK.  Computer predictions of abnormal test results: effects on outpatient testing. JAMA . 1988;;259:1194-1198.
12 +
Tierney WM, Miller ME, McDonald CJ.  The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests. N Engl J Med . 1990;;233:1499-1504.
13 +
McDonald CJ, Tierney WM, Martin DK, Overhage JM.  The Regenstrief Medical Record System: 20 years' experience in hospital outpatient clinics and neighborhood health centers. MD Comput . 1992;; 9:206-217
14 +
McDonald CJ, Tierney WM.  The Medical Gopher: a microcomputer system to help find, organize and decide about patient data. West J Med . 1986;;145:823-829.
15 +
Campbell DT, Stanley JC. Experimental and Quasi-experimental Designs for Research . Chicago, Ill: Rand McNally College Publishing Company; 1966;:22.
16 +
Overhage JM, Tierney WM, McDonald CJ, Pickett KE.  How do interns spend their days? a time-motion study of internal medicine interns. Clin Res . 1991;;39:794A. Abstract.
17 +
Overhage JM, Tierney WM, McDonald CJ, Pickett KE.  Computer-assisted order entry: impact on intern time use. Clin Res . 1991;;39:794A. Abstract.
18 +
McDonald CJ, Tierney WM, Miller ME, Fitzgerald JF, Engeler MT, Wolinsky FD.  Toward quantification of small area variations. Clin Res . 1990;; 38:914A. Abstract.
19 +
Fitzgerald JF, Tierney WM, Engeler MT, Miller ME, McDonald CJ.  Predicting inpatient charges: a model using clinical admission information. Clin Res . 1990;;38:912A. Abstract.
20 +
Schimmel VE, Alley C, Heath AM.  Measuring costs: product line accounting versus ratio of cost to charges. Top Health Care Financ . 1987;;13:76-86.
21 +
Milliken GA, Johnson DE. Analysis of Messy Data: Designed Experiments . New York, NY: Van Nostrand Reinhold Co; 1984;:250.
22 +
Weinberger M, Smith DM, Katz BP, Moore PS.  The cost-effectiveness of intensive postdischarge care: a randomized trial. Med Care . 1988;;26:1092-1102.
23 +
Avorn J, Soumerai SB.  Improving drug-therapy decisions through educational outreach: a randomized controlled trial of academically based 'detailing.' N Engl J Med . 1983;;308:1457-1463.
24 +
Fries JF.  Alternatives in medical record formats. Med Care . 1974;;12:871-881.
25 +
Whiting-O'Keefe QE, Simborg DW, Epstein WV, Warger A.  A computerized summary medical record system can provide more information than the standard medical record. JAMA . 1985;;254:1185-1192.
26 +
Wilson GA, McDonald CJ, McCabe GP.  The effect of immediate access to a computerized medical record on physician test ordering: a controlled clinical trial in the emergency room. Am J Public Health . 1982;;72:698-702.
27 +
Selker HP, Beshansky JR, Pauker SG, Kassirer JP.  The epidemiology of delays in a teaching hospital. Med Care . 1989;;27:112-129.
28 +
Classen DC, Pestotnik SL, Evans RS, Burke JP.  Computerized surveillance of adverse drug events in hospital patients. JAMA . 1991;;266:2847-2851.
29 +
Larsen RA, Evans RS, Burke JP, Pestontnik SL, Gardner RM, Classen DC.  Improved perioperative antibiotic use and reduced surgical wound infections through use of computer decision analysis. Infect Control Hosp Epidemiol . 1989;;10:316-320.
30 +
General Accounting Office. Medical ADP Systems: Automated Medical Records Hold Promise to Improve Patient Care . Washington, DC: General Accounting Office; 1991;. Publication GAO/IMTEC-91-5.

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