The project was undertaken across three Local Health Districts/Special Health Networks in New South Wales covering a resident population of around 1.2 million people.22 The focus was on a group of six hospitals serviced by a single fully accredited pathology laboratory service which provides comprehensive biomedical laboratory services including the following laboratory specialties: Anatomical Pathology, Blood Bank, Clinical Chemistry, Microbiology, Endocrinology, Haematology, Molecular Genetics and Immunology. The entire pathology service (of which we investigated only a component) employs over 828 staff and deals with approximately 13 million tests annually.
During the initial implementation, the electronic medical record (EMR), which allowed clinicians to create electronic orders, was based on the Cerner PowerChart system, Version 2007.16 and became available at Hospitals A, B, and C on 26 October 2009; Hospital D on 29 June 2009, Hospital E on 1 October 2008, and Hospital F on 9 March 2009. In May 2011, the EMR was upgraded to Cerner PowerChart system, Version 2010.02.16. The Laboratory Information System (LIS) in Hospitals A, B, C, and E is Integrated Software Solutions (ISS) Omnilab v9.4.2 SR10 while in Hospitals D and F the laboratory information system is ISS Omnilab v9.5.2 SR26. Table 1 shows the number of available beds, the number of pathology tests, and number of patients who had pathology tests, at each of the six study hospitals for the month of September 2011. The three large metropolitan general hospitals (A, E, and F) accounted for both the bulk of pathology tests and patients who had pathology tests. The two specialist hospitals, (B and C) and the regional hospital (D), accounted for the smallest proportion of pathology tests.
Hospital | Available Beds | Test numbers | Patients who had tests |
A | 567 | 85208 | 5387 |
B | 187 | 15316 | 2129 |
C | 159 | 23600 | 1847 |
D | 197 | 25234 | 1916 |
E | 654 | 116045 | 6362 |
F | 538 | 82942 | 5155 |
Total | 2302 | 348345 | 22796 |
Table 1. Number of pathology tests compared by numbers of patients and available beds
The number and proportion of tests that were ordered electronically (EMR) and using the paper system, for each of the six hospitals during the period August-September of 2008 to 2011, are shown in Table 2. In 2009, 41% of all orders across all sites were electronic orders, the remainder were paper orders. With the introduction of EMR at Hospitals A, B, and C, in 2010 the proportion of tests ordered with EMR increased to 64%, and to 66% in 2011. The greatest rate of electronic ordering utilisation was at Hospital D (around three-quarters of tests ordered electronically); the smallest rate of electronic ordering was at Hospital B (around one-third of tests ordered electronically).
Number of Tests (Proportion of Tests Accounted for) | ||||||||
Hospital | 2008 | 2009 | 2010 | 2011 | ||||
EMR | Paper | EMR | Paper | EMR | Paper | EMR | Paper | |
| A | - | 181256 (100%) | - | 160690 (100%) | 115825 (70%) | 50480 (30%) | 122024 (68%) | 56795 (32%) |
| B | - | 33287 (100%) | - | 31887 (100%) | 9998 (32%) | 21205 (68%) | 10124 (33%) | 21006 (67%) |
| C | - | 57216 (100%) | - | 52502 (100%) | 31544 (60%) | 20729 (40%) | 27755 (56%) | 21413 (44%) |
| D | - | 47226 (100%) | 31968 (79%) | 8395 (21%) | 33443 (79%) | 8953 (21%) | 36422 (73%) | 13193 (27%) |
| E | - | 223041 (100%) | 132601 (65%) | 72095 (35%) | 140108 (63%) | 81378 (37%) | 161935 (68%) | 76229 (32%) |
| F | - | 178432 (100%) | 100547 (62%) | 61749 (38%) | 102627 (62%) | 62445 (38%) | 112029 (66%) | 57122 (34%) |
| Overall | - | 720458 (100%) | 265116 (41%) | 387318 (59%) | 433545 (64%) | 245190 (36%) | 470289 (66%) | 245758 (34%) |
Table 2. The volume and proportion of paper- and electronically-ordered (EMR) tests at the six hospitals for August-September 2008-2011.
Any errors identified in the patient demographics or any non-compliance in laboratory requirements regarding test order forms and specimens were documented in the CSR department’s error log. Prior to 21 September 2009 this was a paper-based system using error-detail entry sheets (see Appendix I) that were manually collated into a daily log (see Appendix II). The errors were categorised as per the information on the error-detail sheets. On 21 September 2009, a computerised error log (devised in-house and using a Microsoft Access database) was implemented and was available on all CSR computers thus eliminating paper forms and making error logging accessible to staff at their workstations. Initially, the data entry fields and error categories in the computerised error log were similar (but not always identical) to the paper-based system. From 1 March 2010, a revised version of the computerised error log was introduced with the inclusion of a new error category: “EMR test order problem.” Appendix III shows a screen shot of the computerised error log screen and the available error category options (including the new “EMR test order problem” category).
Ethics approval
Ethics approval was granted by the South Eastern Sydney Local Health District Human Research Ethics Committee (HREC; Project No. 11/146), and ratified by the University of New South Wales HREC (Project No. 11380).Document download
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The impact of the implementation of electronic ordering on hospital pathology services(PDF 2082 KB)