This review assessed the effects of Health Information-Technology (HIT) based interventions of selected high-risk medications in the ambulatory setting and concluded that whether or not HIT improved laboratory monitoring remained uncertain. The conclusions appear to be supported by the data presented, but limitations in the review and primary study quality made their reliability uncertain.

To assess the effects of Health Information Technology (HIT) based interventions to improve laboratory monitoring of selected high risk medications in the ambulatory setting and to describe the characteristics of interventions effective at improving laboratory monitoring.

MEDLINE was searched for studies published between 1980 and 2008. Search terms were indicated. The search was restricted to articles published in English. Additional searches included relevant journals and authors (unspecified) and references of relevant articles.

Studies were eligible if they were clinical trials, randomised controlled trials (RCTs) or comparative studies. Eligible studies had to be conducted in an ambulatory setting, have sufficient information about the HIT intervention for assessment and examine laboratory test monitoring. Laboratory testing had to be for assessment of effectiveness, toxicity or side-effects. Only studies without cointerventions were included. Studies that targeted anticoagulants were excluded.

Most of the included studies were conducted in USA; one study was in Israel. Three quarters of the studies were conducted in large integrated healthcare delivery systems. All studies included patients nested within providers.

Interventions included electronic alerts to prescribing physicians and electronic alerts to pharmacists who could then order laboratory tests and contact the patient. All studies were carried out within healthcare systems with electronic records (half used their own systems and half used modifications of proprietary systems). Most interventions were built-in systems with computerised physician order entry. These were either interruptive (required the provider to respond to the alert) or non-interruptive (no action required). Most studies targeted a broad range of medications; one study targeted a single medication.

Outcomes included completion of laboratory test monitoring (75% of studies) and evaluation of physician test ordering (25% of studies). Baseline rates of appropriate laboratory monitoring varied greatly (14% to 95%) depending on the study drug.

Each study was independently assessed by two reviewers for inclusion. Disagreements were resolved by consensus.

Validity was assessed by two independent reviewers using the Downs and Black method (maximum score 27). Disagreements were resolved by consensus.

Studies were classified by clinical setting, targeted medications, time frame, HIT intervention type and duration, randomisation, comparison group and outcomes assessed. Where necessary, authors were contacted for additional data.

The authors did not state how many reviewers performed data extraction.

The authors summarised studies using text and tables. No statistical analyses were carried out.

Eight studies were included: six RCTs and two before-and-after studies. Sample sizes were reported in various units. Studies included between 44 and 504 physicians and between 196 and 26,586 patients. Studies received quality ratings that ranged from 16 to 25 (out of 27). RCTs received scores between 22 and 25. Before-and-after studies received scores between 16 and 18. Only three studies adjusted for possible confounders.

In five of the eight studies, laboratory monitoring was significantly improved with the study intervention (improvement in appropriate tests ordered or increase in the completion rate). Improvements ranged from 3.0% to 26.1%. The two before-and-after studies and half of the RCTs reported positive results. All of the RCTs that showed improvements with HIT included pharmacist-based interventions. Studies with lower baseline rates of monitoring reported greater improvements in response to HIT interventions. There was no consistent difference between study results based on intervention components or target medications.

Whether or not HIT improved laboratory monitoring of certain high-risk medications for ambulatory patients remained uncertain. Further high-quality research was needed.

This systematic review addressed a clear research question. Inclusion criteria (especially interventions and outcomes) were a bit vague. Some measures were taken to reduce reviewer bias and error. The literature search was restricted to articles in English in one database, so relevant articles may have been missed. Supplementary searches were carried out, but were not clearly reported. Study quality was assessed and data were summarised narratively and in tables. Only a small number of quite disparate trials could be included and these had a range of quality deficits. Studies of anticoagulants had to be excluded as these included dosing recommendations that could not be separated out from the improvement of laboratory monitoring. Studies were conducted in a limited number of clinical settings and this made generalisability uncertain. Lower-quality trials and trials that addressed confounders such as clustering were less likely to report significant improvements in laboratory monitoring. Results were dependent on baseline rates of monitoring: some studies already had high baseline rates of monitoring and reported little change and studies with low rates tended to show the largest improvements.

The conclusions appear to be supported by the data presented, but limitations in both the review and primary study quality made their reliability uncertain.

The authors made no specific recommendations for practice.

Research: The authors stated that future studies of laboratory monitoring should include a better assessment of patient and provider characteristics and should account for fixed physician or clinical site effects by multilevel analysis. Studies should have a clearer reporting of outcomes and should include settings outside the large integrated healthcare delivery systems.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.