ANDREW GEORGIOU, ISLA M. HAINS, DAVID MILLISS, LLOYD RIDLEY and JOHANNA I. WESTBROOK

Overview

This chapter presents research evidence on the effective utilization of picture archiving communication systems (PACSs) and computerized provider order entry (CPOE) systems in the intensive care unit (ICU). PACSs provide a centralized communication repository for all imaging data that replaces previous film-based systems by delivering diagnostic images electronically to clinicians. CPOE systems allow clinicians to place orders (e.g., medication, imaging, and pathology) directly into computers with the potential to link to databases containing patient-specific clinical information and decision support software.¹ Both CPOE systems and PACSs can be seen as complementary components of an integrated health information technology (IT) infrastructure. They are key building blocks for the hospital electronic medical record that help improve communication between hospital units (e.g., clinical wards, radiology, pathology, and pharmacy), and they contribute to enhanced evidence-based decision-making and quality of patient care.

In the last 30 years PACSs have evolved from in-house radiology systems to fully fledged commercial systems that can network across the hospital and beyond. Their integration with radiology information systems and CPOE and incorporation of technologies such as voice recognition and computer-aided diagnosis are part of the move toward paperless systems. The uptake of PACSs has continued to rise. In the United States, 76% of hospitals reported using PACSs in 2008,² and at the time of writing, England and Scotland are expected to complete a national rollout of a PACS by the end of 2012.³ Although CPOE has been in existence since the early 1970s, its uptake is considerably less than PACS. A 2009 report examining CPOE implementation estimated that 15% of U.S. hospitals and only a handful of sites in Australia (predominantly in Sydney) had installed CPOE systems.⁴

There have been optimistic predictions about the potential for health IT to have a positive impact on the quality and effectiveness of patient care. Systematic reviews, however, continue to highlight the complex, variable, and fragmented nature of the evidence for health IT and its effect on patient care outcomes.^5,6 A survey of users’ experience undertaken in seven trusts in the United Kingdom by Tan and Lewis⁷ found that although the majority of respondents could point to the benefits of PACSs, there were also a number of concerns related to the lack of training, system unreliability, and poor quality of images and monitors. We also note that very little research attention has been paid to the effect of PACSs on ICU clinical work processes.⁸

Impact of health information technology on work practices in the intensive care unit

A systematic review by Hains et al⁸ investigated the effect of PACSs on clinical work practices in the ICU. The review identified five key performance indicators from 11 studies conducted in either the United States (N = 9) or the United Kingdom (N = 2). The reported indicators included (1) time until an image is available, (2) time that it was accessed, (3) time that it was reviewed, (4) time that a decision is made, and (5) indicators of the frequency and types of communication that are undertaken between ICU clinicians and the medical imaging department.⁸

Studies of the availability of images generally revealed that PACSs are associated with quicker access to images.⁸ Watkins et al⁹ examined routine and nonroutine chest examinations in a before and after study and reported an improvement in examination accessibility of up to 30 minutes for routine examinations but no difference for nonroutine images. These results are mirrored in a survey of ICU staff by Cox and Dawe¹⁰ in which it was shown that 90% of users believed that images were available sooner than before the introduction of a PACS and 72% perceived that there were no longer problems related to lost images. The improved availability of images is complemented by decreases in the time taken for an ICU physician to review images. One study by Humphrey et al¹¹ showed that the mean time from image exposure to image viewing was 39 minutes in a surgical ICU with a PACS versus 78 minutes in a medical ICU without a PACS.¹¹ Changes in viewing patterns were also highlighted by De Simone et al,¹² who found that physicians incorporated the viewing of electronic images into their morning ward rounds as part of their routine. This replaced the practice before implementation of a PACS in which the majority of films were viewed as part of the daily radiologist conference in the ICU at 3:00 pm. This was associated with reduced time to reach clinical decisions.¹² These findings correspond to surveys reported in separate studies by Cox and Dawe¹⁰ and Humphrey et al¹¹ in which it was shown that the majority of clinicians perceived that PACSs led to quicker decision-making.

In contrast to the positive findings of the effect of PACSs on efficiency and timeliness, the prevailing evidence about the impact of PACSs on communication patterns within the ICU and across hospitals is variable, with studies showing no difference in the frequency of communication between ICU physicians and the radiology department¹³ or significant reductions in the input received (via telephone, direct contact, or reports) from radiologists.¹⁴

Decision support systems

One of the most important potential benefits of health IT relates to the incorporation of decision support systems (DSSs), which can provide on-screen reminders and prompts to enhance adherence to evidence-based guidelines. This can lead to a reduction in the number of low-yield requests, which constitutes an ineffective use of resources and poor risk-benefit return. A systematic review by Georgiou et al⁶ published in 2011 identified 14 studies that investigated the impact of CPOE systems on medical imaging services. The studies were either preintervention-postintervention comparisons (n