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Technology Helps CA EDs Improve Timely Clot-Buster Administration

OAKLAND, CA – New technology that provided both care-decision support for emergency physicians and enabled electronic order entry substantially improved timely administration of clot-busters for acute ischemic stroke, according to a recent study.

The report, which appeared in Annals of Emergency Medicine, summarized what happened when computerized physician order entry was integrated into electronic health records across 16 Kaiser Permanente Northern California medical centers from 2007 to 2012.

Kaiser researchers noted that, after implementation, emergency department stroke guidelines were made available to physicians using order sets. Those provided standardized laboratory, radiographic and drug ordering, as well as information to help clinicians decide the best course of treatment.

"This study demonstrates that computerized physician order entry generally -- and an order set embedded with decision support specifically – can facilitate the delivery of time-sensitive interventions for stroke while minimizing errors," said lead author Dustin Ballard, MD, an emergency medicine physician at the Kaiser Permanente San Rafael Medical Center and an adjunct researcher at the Kaiser Permanente Division of Research. "In this case, the investigation showed that these tools can safely lead to more frequent administration of medication to thin blood and break up blood clots in the brain, a treatment that has been associated with better neurological recovery after stroke."

Study authors point out that improved outcomes and fewer complications usually occur with a systematic approach to the acute management of patients with ischemic stroke, including timely administration of intravenous tissue plasminogen activator (IV tPA) for eligible patients.

"While the technology is not likely to be solely responsible for the improved outcomes observed in this study, it may represent a proxy measure for optimum care for certain patients, in particular those for whom the speed of initiating therapy, the completeness of information available to the clinician, and the intensity of inpatient care make a real difference in short-term outcomes," said co-author David Vinson, MD, an emergency medicine physician at the Kaiser Permanente Roseville Medical Center.

The study team reviewed the cases of 10,081 patients, including 6,686 (66.3%) who were treated in medical centers after computerized physician order entry had been implemented. While 8.9% of those patients received IV tPA in the ED, only 3.3% of patients in EDs without the new technology were given clot-busters.

When the stroke order set was used in combination with the computerized physician order entry, according to the results, IV tPA administration further increased to 12.7%.

"Ultimately, we see the order set itself as optimizing the confluence of two separate processes – a robust computerized physician order entry that integrates care across many providers and locations while limiting errors of omission, combined with a quality initiative that has identified disease-specific best practices and guidelines," study authors write. "We believe that our findings represent a dawning era of electronic health records, one that blends decision support and best practices."