Computer-generated standing orders are more effective than computer-generated reminders for physicians, at least for making sure that patients receive influenza and pneumonia vaccinations as recommended by current guidelines. Thats the conclusion of a study published Tuesday in the Journal of the American Medical Association.
“Its a sure bet” that standing orders—that is, default treatment instructions for patients meeting certain criteria—increase preventive care, said Clement McDonald, the studys senior author.
McDonald, of the Regenstrief Institute in Indianapolis, said that besides vaccination, standing orders could help make sure that more patients receive cholesterol tests, mammograms and other widely recommended procedures.
But he hastened to add that any kind of computer prompt is much better than none at all in making sure that patients who enter a hospital for other reasons receive preventive treatment.
Based on a survey of a hospital that did not use computer systems to identify those eligible for the vaccine, McDonald said “only about 1 percent of patients get these vaccines. Its not in the minds of people to do these vaccines yet.”
The study published in JAMA (the Journal of the American Medical Association) used a hospitals computerized order entry system to find patients eligible for vaccinations against flu or pneumonia. Over 14 months, 3,777 patients that entered the hospital were screened for eligibility.
For about half of the eligible patients, vaccine orders were produced automatically and given to nurses when patients were discharged. For the other patients, the computer sent reminders for vaccine orders to physicians during routine order entry.
Before administering the vaccinations, nurses always asked patients if they wanted a vaccination, had already received a vaccination or had potential allergies to the vaccine.
After correcting for patients who said they had already received vaccinations, 52 percent of patients in the standing order group received influenza vaccines, compared with 36 percent in the reminder group. Results for the pneumococcal vaccine were similar.
McDonald said the work showed how improved health care often relies on the initiative of a health care organization, as opposed to that of individual physicians. “If the system thinks it should be done, the system should get it done,” he said.
He speculated that physicians sometimes did not follow through on reminders because they wanted to discharge a patient more quickly or because the patient had told them a vaccine was unwanted. But he said some reminders probably got lost amid other distractions or just because the physicians were given “an easy opportunity to say no.”
Nurses and Computers
To increase vaccinations, McDonald said, the combination of nurse and computer is much more powerful than that of physician and computer. He also said the technology involved for having nurses administer preventive care is more available in hospitals.
Physician reminders require computerized order entry, which is only in place in a few hospitals, he said. But most large health organizations have a computerized management system that the nurses use to handle orders, he said.
McDonald warned that generating standing orders automatically wouldnt work for complex decisions, such as deciding whether to recommend statins to someone with liver disease.
But he said it could be highly effective in making sure that patients receive well-understood preventive treatments and tests that they might otherwise skip.
“If youve got the data, you can make the recommendation” whenever the patient comes into a hospital or doctors office, he said.
He said some hospitals had tried to generate standing orders manually by inspecting patients files, but attempts fell short because of the time required to go through the files. But he said, an appropriately designed computer system could generate orders almost instantly.
“Anytime you have a computer that has enough information, you can get this done with less work and less burden with standing orders,” McDonald said.