Ronela Hanson MD, Presenter: Nothing to Disclose

Ivan Dale Hanson MD, Abstract Co-Author: Nothing to Disclose

Mahendra Shah MD, Abstract Co-Author: Nothing to Disclose

When orders for radiologic studies are transcribed by someone other than the ordering physician, the true reason for the study may not be adequately conveyed. Direct electronic order entry by physicians may be a promising way to rectify this problem, but has not been previously tested. We conducted a retrospective chart review analysis to assess the affect of direct physician order entry (POE) on the adequacy of the “study reason” found in requisitions for computed tomography (CT) scans at Sinai-Grace Hospital.

We identified all patients who had CT scans within a 48-hour time period both before and after implementation of POE function in the electronic medical record (EMR) system. The study reason specified in the requisition was compared to the information found in the dictated clinical note by the ordering physician on the day the scan was completed. Adequacy of the study reason relative to the information in the clinical note was quantified using a 3-point Leikert scale. Scans without a corresponding dictated note and CT-guided procedures were excluded. Relationships between study reason, POE and adequacy of study reason were assessed via student’s t-test and chi-square statistics.

There were a total of 206 cases in the study group, 105 cases prior to POE and 101 after its implementation. Both groups were evenly matched by the types of studies done each year. Although there was a trend in improvement of adequacy of study reason after implementation of POE, the difference was not statistically significant (χ2=2.947, p=0.229).

In this small retrospective analysis, direct computerized physician order entry did not significantly affect adequacy of the order reason.

The trend toward improvement in adequacy of order reason after the implementation of direct POE suggests that this feature of the EMR may improve accuracy of radiologist interpretations of CT scans.

Hanson, R, Hanson, I, Shah, M, Direct Physician Order Entry into the Electronic Medical Record: Has It Improved Quality of Requisitions?.  Radiological Society of North America 2008 Scientific Assembly and Annual Meeting, February 18 - February 20, 2008 ,Chicago IL. http://archive.rsna.org/2008/6009611.html