Computerized physician order entry systems and medication errors.
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Healthcare is evolving from a task-based industry to a knowledge-based one. To gain and retain value as intellectual capital, nursing likewise must evolve from a vocation of task performers to a profession of knowledge-workers. Information technology can transform nursing tasks into nursing knowledge.
The world of applied medical informatics is changing rapidly. This is the first of a three-part series of articles on applied medical informatics that will bring the practicing chest physician up to date on the structure, function, benefits, and drawbacks of the electronic medical record and all of its components, including the virtual ICU and the daily practice of medicine.
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Computerized provider order entry (CPOE) is a promising conduit for medical knowledge in support of guideline-consistent decision-making at the point of care. While there are many published examples of successful implementations of CPOE with decision support, there remain questions about the effectiveness of commercially available information system products, particularly in the emergency department (ED). We describe an attempt at using the available CPOE functionality in a commercial ED information system to deliver guideline knowledge and report the results of physician surveys regarding paper-based guideline/order-sets and the corresponding CPOE order-sets that replaced them. Physicians reported that they liked the CPOE order-sets better than the paper version and did use the order-sets, but guide-line compliance did not improve. Cultural and organizational issues as well as limitations in the functionality of the commercial system appear to have limited the effectiveness of this implementation.
Computerized Physician Order Entry (CPOE) addresses critical functions in healthcare systems. As the name clearly indicates, these systems focus on order entry. With regard to medication orders, such systems generally force physicians to enter exhaustively documented orders. But a cognitive analysis of the physician's medication ordering task shows that order entry is the last (and least) important step of the entire cognitive therapeutic decision making task. We performed a comparative analysis of these complex cognitive tasks in two working environments, computer-based and paper-based. The results showed that information gathering, selection and interpretation are critical cognitive functions to support the therapeutic decision making. Thus the most important requirement from the physician's perspective would be an efficient display of relevant information provided first in the form of a summarized view of the patient's current treatment, followed by in a more detailed focused display of those items pertinent to the current situation. The CPOE system examined obviously failed to provide the physicians this critical summarized view. Following these results, consistent with users' complaints, the Company decided to engage in a significant re-engineering process of their application.
In the current paper, we describe the challenges in measuring return on investment (ROI) and review published ROI studies on health IT. In addition, given the absence of a robust ROI literature base, we review the general benefits and potential costs of various health IT applications including electronic health records (EHRs), computerized physicians order entry (CPOE) systems, and clinical decision support systems (CDSS). We conclude that articles examining these benefits are much more common than studies examining ROI itself. This trend suggests the early stage of this knowledge base. Additional research utilizing broader perspectives and multidisciplinary techniques will be needed before a better understanding of ROI from health IT is achieved.
While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs. To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand what classes of CDS their CPOE systems can support, assure that clinical knowledge underlying their CDS systems is reasonable, and appropriately represent electronic patient data. These issues often influence to what extent an institution will succeed with its CPOE implementation and achieve its desired goals. Medication-related decision support is probably best introduced into healthcare organizations in two stages, basic and advanced. Basic decision support includes drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug-drug interaction checking. Advanced decision support includes dosing support for renal insufficiency and geriatric patients, guidance for medication-related laboratory testing, drug-pregnancy checking, and drug-disease contraindication checking. In this paper, the authors outline some of the challenges associated with both basic and advanced decision support and discuss how those challenges might be addressed. The authors conclude with summary recommendations for delivering effective medication-related clinical decision support addressed to healthcare organizations, application and knowledge base vendors, policy makers, and researchers.
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The 1999 Institute of Medicine report raised public awareness of the frequency and cost of adverse drug events in medicine. In response, in November 2000 a coalition of healthcare purchasers announced the formation of the Leapfrog Group, an organization dedicated to making "great leaps forward" in the safety and quality of health care in America. Their first target-computerized physician order entry (CPOE)-was selected specifically for its potential to reduce harm to patients from medications. The Leapfrog inpatient CPOE standard included a requirement that the organization operating CPOE should demonstrate via a test that their inpatient CPOE system can alert physicians to at least 50% of common serious prescribing errors. This paper outlines the development of this test which evaluates the ability of implemented CPOE systems to prevent the occurrence of medication errors that have a high likelihood of leading to adverse drug events. A framework was developed to include 12 different categories of CPOE based decision support that could prevent prescribing errors leading to adverse drug events. A scoring system was developed based on the known frequency and severity of adverse drug events. Simulated test patients and accompanying simulated test medication orders were developed to evaluate the ability of a CPOE system to intercept prescribing errors in all 12 decision support categories. The test was validated at a number of inpatient sites using both commercially available and custom developed CPOE systems. A web based application was developed to allow hospitals to self-administer the evaluation.
Despite media attention on converting the nation's paper-based medical record systems to electronic systems, few hospitals, and even fewer community hospitals, have done so. University of Pittsburgh Medical Center St. Margaret has converted to a comprehensive electronic health record system, known as eRecord, in a short time. The authors describe key factors that were critical to the success of the conversion, along with positive results on quality of care.
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