Yet Another "Anecdote" - Inpatient Results of Electronic Prescribing "Disappointing"

Many of those in the Medical Informatics community, especially the academics in the upper echelons of the American Medical Informatics Association, are not of a risk recognition / risk management mindset.  Typical of academics, they are often also hostile towards dissent from the party line, as you can read about at my post "<b>The Dangers of Critical Thinking in A Politicized, Irrational Culture</b>" at <a href="http://hcrenewal.blogspot.com/2010/09/dangers-of-critical-thinking-in.html">http://hcrenewal.blogspot.com/2010/09/dangers-of-critical-thinking-in.html</a>.<br /><br />The academics, with a few exceptions, have repeatedly conflated <i>scientific anecdote</i>s<i> of supposed positive results</i> from health IT with <i>risk management-relevant incident reports</i> <i>of bad outcomes and 'near misses'</i>, as an Australian colleague wrote about, via me, on August 17, 2011 at "<b>Anecdotes and Medicine, We are Actually Talking About Two Different Things</b>" at <a href="http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html">http://hcrenewal.blogspot.com/2011/08/from-senior-clinician-down-under.html</a>).<br /><br />They dismiss the latter incident reports, even when from well-qualified observers, while giving great attention and credence to the former <span style="color: red;"><i><b>[a few years as a safety manager in a large urban transit authority disabused me of that type of behavior - ed.]</b></i></span>, when the former conveniently fit their most cherished beliefs about the beneficence and efficacy of today's health IT.  Further, quality or lack thereof of the former type of evidence is often not considered.  See for instance my post of March 9, 2011 "<b>ONC: The Benefits Of Health Information Technology: A Review Of The Recent Literature Shows Predominantly Positive Results</b>" at <a href="http://hcrenewal.blogspot.com/2011/03/benefits-of-health-information.html">http://hcrenewal.blogspot.com/2011/03/benefits-of-health-information.html</a> for a stunning example of this phenomenon directly from the national leadership of health IT.<br /><br />In my view, this phenomenon has led to a substantial loss of focus on health IT realities needed in order to remediate the industry and realize the true benefits of which the technology is capable.<br /><br />Now there's yet another "anecdote" at <b>Med Page Today.com </b>for the experts to chomp on:<br /><br /><blockquote class="tr_bq"><a href="http://www.medpagetoday.com/MeetingCoverage/ASHP/43400?utm_source=cardio-meetings&utm_medium=email&utm_content=mpt&utm_campaign=DCH">http://www.medpagetoday.com/MeetingCoverage/ASHP/43400?utm_source=cardio-meetings&utm_medium=email&utm_content=mpt&utm_campaign=DCH</a><br /><br /><b>E-Prescribing: Inpatient Results Disappointing</b><br />Published: Dec 12, 2013<br />By Sarah Wickline , Contributing Writer, MedPage Today<br /><br />ORLANDO -- Electronic prescription order entry and medication reconciliation reduced some errors in hospital settings but increased others, and did not meet overall expectations, researchers reported here.<br /><br />After implementation of a computerized prescriber order entry (CPOE) system, one hospital experienced a 29.2% increase in medication dispensation errors (P less than 0.05), Ramadas Balasubramanian, PharmD, PhD, of the Carolinas Medical Center-Pineville in Charlotte, N.C., and colleagues reported at the midyear meeting of the American Society of Health-System Pharmacists.</blockquote><br />It is likely these are qualified observers who in fact might be expected to be biased towards showing good results of this technology.<br /><br /><blockquote class="tr_bq">In a second study, another hospital experienced a 12% improvement in accuracy (P less than 0.001) after implementation of electronic medication reconciliation charts, according to Jill Covyeou, PharmD, of Ferris State University in Big Rapids, Mich., and colleagues.</blockquote><br />For the tens of millions of dollars likely spent to achieve a mere 12% improvement, one wonders if a far less expensive investment in experienced human resources might not have accomplished the same results or even far better.<br /><br /><blockquote class="tr_bq">For their study, Balasubramanian and colleagues looked at the impact of CPOE on medication errors in a community hospital setting.<br /><br />At the end of 2011, when the Carolinas Medical Center-Pineville hospital had only 119 beds, officials there implemented the CPOE-CANOPY system. In early 2012, the hospital nearly doubled in capacity to 210 beds and opened the pharmacy to 24-hour operation. The researchers looked at medical errors from October 2008 through October 2012.<br /><br />The categories of medication errors included: <b>drug omission, administration at the wrong time, unauthorized drug, wrong dose, and wrong form of dose. </b></blockquote><br />Any of which, of course, can harm or kill, I note.<br /><br /><blockquote class="tr_bq">There was a 57% increase in medication doses from prior to the CPOE system to after implementation, but even after volume adjustments, <b>the number of errors per 1,000 dispensed medications still increased by 29.2%</b> (P less than 0.05).</blockquote><br />Bad health IT such as CPOE systems designed for (per Joan Ash) "calm and solitary office environments" would be expected to perform more poorly as caseloads increase and clinicians have less time for computer fritter.<br /><blockquote class="tr_bq"><br />Unauthorized drug dispensation and improper dose of medication decreased post-CPOE, but <b>drug omission and administration at the wrong time were responsible for the increase.</b></blockquote><br />Those seem to match the expressed concerns of another large group of "anecdote-profferers", e.g., the nurses at my Nov. 17, 2013 post <b>"Another 'Survey' on EHRs - Affinity Medical Center (Ohio) Nurses Warn That Serious Patient Complications 'Only a Matter of Time' in Open Letter"</b> at <a href="http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html">http://hcrenewal.blogspot.com/2013/11/another-survey-on-ehrs-affinity-medical.html</a>:<br /><br />From those nurses' Open Letter to management on health IT risks:<br /><br /><blockquote class="tr_bq">... Some of the concerns that nurses have brought to the attention of management include:<br /><ul><i></i><li><i><b>Medication errors/scanning issues - perhaps the biggest concern of all RNs</b></i></li><li>RNs unable to access patient records for hours at  a time</li><li>Incorrect descriptors and inaccurate drop-down menus</li><li>Incorrect calculations in the I&O<span style="color: red;"> </span>and MAP<span style="color: red;"><i><b> [mean arterial pressure - ed.]</b></i></span> portions of the chart </li><li><i><b>Inaccurate medication times and the inability of RNs to ensure medications are scheduled correctly</b></i></li><li>Endless loops of computer prompts that are unable to be dismissed by RNs in an emergency</li></ul></blockquote><br />Back to the current Med Page Today.com article:<br /><br /><blockquote class="tr_bq">The use of CPOE software created a<b> time cut-off issue that explained the wrong time of administration increase</b>, the study authors told MedPage Today. If drugs were ordered 5 minutes after the cut-off for the morning medication administration, they <b>would not make it to the patient until the evening rounds unless a special alert was sent to the nurse staff.</b></blockquote><br />That is, a time-eating and fragile (and thus potentially dangerous} workaround.  I note that one does not have to work around something that is not standing in their way.<br /><br /><blockquote class="tr_bq">Balasubramanian and colleagues suggested that the<b> lack of flexibility in the CPOE software </b>was responsible for the drastic increase in medication errors, despite the fact that they thought it would improve error rates across the board.</blockquote><br />In other words, the software is not truly fit for purpose.  See definition of "bad health IT" below.<br /><br /><blockquote class="tr_bq">... The authors suggested that electronic prescribing would be better with electronic medical records. "[E]lectronic prescribing alone<b> may </b>fail to increase medication list accuracy to the extent we would like," Covyeou wrote.</blockquote><br />Replace <b>"may </b>fail<b>"</b> with "in our case,<b> did</b> fail."<br /><br />The point about adding an EHR is certainly in the category of "wishful thinking." <br /><br />If the EHRs are bad health IT, I opine the situation would likely get even worse (<i>cf. </i>Affinity Health, above).<br /><br />From my site at <a href="http://cci.drexel.edu/faculty/ssilverstein/cases">http://cci.drexel.edu/faculty/ssilverstein/cases</a>/:<span style="font-family: inherit;"><span style="color: black;"><b> </b></span></span><br /><br /><blockquote class="tr_bq"><span style="font-family: inherit;"><span style="color: black;"><b>Bad Health IT</b> ("BHIT") is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for <span class="SpellE">hypervigilance</span> (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.</span></span></blockquote><br /><span style="font-family: inherit;"><span style="color: black;">In summary, the technology is not a panacea, and can in fact be worse than paper.  Those who blindly ignore that reality and push for mass rollout of this still-experimental technology "no matter what" do not share, in my opinion, the ethics I was taught in Medical School.</span></span><br /><br /><span style="font-family: inherit;"><span style="color: black;">-- SS </span></span>

Yet Another "Anecdote" - Inpatient Results of Electronic Prescribing "Disappointing"

Many of those in the Medical Informatics community, especially the academics in the upper echelons of the American Medical Informatics Association, are not of a risk recognition / risk management mi…

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Can Digital Disappearing Ink (An EHR "Glitch") Kill Patients? Part 2

At "<a href="http://hcrenewal.blogspot.com/2013/08/another-health-it-glitch-can.html">Another Health IT "Glitch" - Can Digital Disappearing Ink Kill Patients?</a>" just yesterday, on August 5, 2013, I wrote about a Siemens EHR "glitch" worse than any paper records system problem.  Typed order changes in the medication reconciliation process on patient discharge are disappearing into thin air, unknown to the clinicians typing the orders.  This is likely due to an issue such as some programmer forgetting to put in a statement to write the text to disk, complicated by software testing problems that missed the defect.<br /><br />I noted:<br /><blockquote class="tr_bq">... "<a href="http://hcrenewal.blogspot.com/search/label/glitch">Glitch</a>" is a banal term used by health IT extremists (those who have abandoned a rigorous scientific approach to these medical devices as well as basic patient protections, in favor of unwarranted and inappropriate overconfidence and hyper-enthusiasm).  The term is used to represent potentially injurious and lethal problems with health IT, usually related to inadequate software vetting and perhaps even "sweatshop floor in foreign country directly to production for U.S. hospital floors" development processes (this industry is entirely unregulated).</blockquote>  <br />Paper records may have illegible writing that would generally cause the reader to make a phone call or otherwise contact the writer, but those events are one-offs.  EHR defects potentially affect hundreds of installations and thousands of patients, en masse.  (If patients are not dying en masse from such errors, then the whole argument against paper and for IT on the issue of vastly improved safety goes out the windows, but that's an argument for another time.)<br /><br /><b>Siemens has just released another "glitch" announcement,</b> this time with CPOE (computerized order entry):<br /><br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlf06mny1stnwAAlLHkyNdwsIaVZoVr4Ftj3MJ0gFspDqC1S8mEHtybkYsgnOntpI-v6uI4j8BUP-XAo0YeldipSlCT8MguHKKiDepn-YABtnVzVy9PpNTY5a43jQDrNAqV54fZYw9CAz1/s1600/Siemens_CPOE.bmp" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlf06mny1stnwAAlLHkyNdwsIaVZoVr4Ftj3MJ0gFspDqC1S8mEHtybkYsgnOntpI-v6uI4j8BUP-XAo0YeldipSlCT8MguHKKiDepn-YABtnVzVy9PpNTY5a43jQDrNAqV54fZYw9CAz1/s400/Siemens_CPOE.bmp" width="307" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">(Medication orders "glictch" safety complaint.  Click to enlarge, text below)</td></tr></tbody></table><br />Text is as follows: <br /><br /><blockquote class="tr_bq">August 2, 2013<br /><br />Safety Advisory Notification<br /><br />Soarian® Clinicals Medication Orders, Safety Complaint ID# EV06643783<br /><br />Dear Customer:<br /><br />This notification is to inform you that the Soarian Clinicals Medication Orders may not be operating properly in some cases <b>in Soarian Clinicals 3.3 Service Pack 6 and above</b>.</blockquote><br />I note that "glitches" are not uncommon after software patches and upgrades.  See examples at the query link <a href="http://hcrenewal.blogspot.com/search/label/glitch">http://hcrenewal.blogspot.com/search/label/glitch</a>.   This reflects inadequate vetting of the patches.<br /><br />I also note that "medication orders not operating properly" is a very, very serious matter.<br /><br /><blockquote class="tr_bq">Although this may affect only some customers, we are taking a conservative approach and are alerting you to this potential problem. As such, please forward this notification to appropriate personnel as soon as possible.</blockquote><br />"<b>May only</b> affect <b>some</b> customers?" (I suspect from this double-indefinite that who is affected is not rigorously known).  "Taking a conservative approach?"  I ask:  <i>what would a non-conservative approach entail?</i><br /><br /><blockquote class="tr_bq">This letter is being sent as a precautionary measure as there have been no adverse events reported from customers.</blockquote><br />Again, they mean "yet."<br /><br />When does this issue occur and what are the potential risks?<br /><br /><blockquote class="tr_bq">The issue occurs while placing medication orders. In certain cases, when users select orders from predefines or personal favorites <b>and make changes on the order detail forms, the changes are correctly saved and displayed on the forms but the Order As Written (OAW) is not refreshed to reflect the changes.</b> The incorrect OAW is displayed in Siemens Pharmacy in the Order As Written window but the discrete order details are correct. As a result dispensing or administering relying solely on the OAW prior to pharmacy validation may result in error.  <span style="color: red;"><i><b>[Putting patients directly in harm's way, patients who never consented to the use of these experimental and unvetted medical devices - ed.]  </b></i></span>Once the order is validated the OAW in Soarian is updated correctly.</blockquote><br />This problem - manually changed data apparently not written to disk - seems similar to the "digital disappearing ink" med reconciliation bug in the aforementioned Aug. 5, 2013 post.<br /><br />Immediate steps you should take to avoid the potential risk of this issue:<br /><br /><blockquote class="tr_bq">To prevent this issue from occurring at your facility, dispensing or administering of unvalidated order should rely on the order details displayed. <b>Secondly, any deviations from the predefined or personal favorites should be phoned in to pharmacy as a verbal order. </b>During validation, <b>if the pharmacist sees a discrepancy between the order detail and the OAW, verbal follow up with the ordering physician is required.</b></blockquote><br />Again, a workaround.  How many times will this workaround be forgotten, compared to issues of illegibility in a paper record resulting in a phone call to the writer?<br /><br /><blockquote class="tr_bq">Steps that Siemens is taking to correct this complaint:<br /><br />We are diligently working to develop a correction and will test and deliver it as soon as possible.</blockquote><br />Perhaps they should have been working more diligently to detect the "glitch" before it went live.<br /><br />Also, perhaps the touted power of EHRs to reduce medical errors needs to be re-examined.  Considering bugs like these - creating <i>en-masse</i> problems far worse than possible with paper (another en-masse example at <a href="http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html">http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html</a>) - then, if the EHRs are so essential to safety, one would expect significant morbidity and mortality from these defects.<br /><br />If one is to believe patients are <b>not</b> being injured by "glitches", then the expenditure of hundreds of billions of dollars for these systems on the basis of "error reduction" compared to paper is likely a waste of money and resources. <br /><br />--  SS<br /><br /><br />

Can Digital Disappearing Ink (An EHR "Glitch") Kill Patients? Part 2

At "Another Health IT "Glitch" - Can Digital Disappearing Ink Kill Patients?" just yesterday, on August 5, 2013, I wrote about a Siemens EHR "glitch" worse than any paper records system problem.  Type…

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JAMIA: Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems

A new article appeared online 20 February 2013 in the Journal of the American Medical Informatics Association entitled "<b>Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems</b>" (<a href="http://jamia.bmj.com/content/early/2013/01/27/amiajnl-2012-001241.full" target="_blank">link to fulltext</a>) by David C Radley, Melanie R Wasserman, Lauren EW Olsho, Sarah J Shoemaker, Mark D Spranca and Bethany Bradshaw.<br /><br />The authors performed a meta-analysis of the literature on Computerized Practitioner Order Entry (CPOE) systems in inpatient settings and concluded:<br /><br /><blockquote class="tr_bq">"Processing a prescription drug order through a CPOE system decreases the likelihood of error on that order by 48% (or in<!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-US</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> <w:SplitPgBreakAndParaMark/> <w:DontVertAlignCellWithSp/> <w:DontBreakConstrainedForcedTables/> <w:DontVertAlignInTxbx/> <w:Word11KerningPairs/> <w:CachedColBalance/> </w:Compatibility> <w:BrowserLevel>MicrosoftInternetExplorer4</w:BrowserLevel> <m:mathPr> <m:mathFont m:val="Cambria Math"/> <m:brkBin m:val="before"/> <m:brkBinSub m:val="--"/> <m:smallFrac m:val="off"/> <m:dispDef/> <m:lMargin m:val="0"/> <m:rMargin m:val="0"/> <m:defJc m:val="centerGroup"/> <m:wrapIndent m:val="1440"/> <m:intLim m:val="subSup"/> <m:naryLim m:val="undOvr"/> </m:mathPr></w:WordDocument></xml><![endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"> </span> a range of 41% to 55% with ninety five percent confidence).  Given this effect size, and the degree of CPOE adoption and use in hospitals in 2008, we estimate a 12.5% reduction in medication errors, <b>or ∼17.4 million medication errors averted in the USA in one year.</b>" </blockquote><br />It is important to know the potential benefits of CPOE, as the government has been pushing this technology since the foundation of the <a href="http://www.healthit.gov/newsroom/about-onc" target="_blank">Office of the National Coordinator</a> (for health IT) within HHS since 2004.  Indeed, reimbursement penalties on Medicare will start in 2015 for non-adopters of government <a href="http://hcrenewal.blogspot.com/2010/03/on-oncs-proposed-establishment-of.html" target="_blank">certified</a> health IT.<br /><br />It is especially important to get to the truth about CPOE specifically, and health IT in general, in terms of risks, benefits, return on investment, improvements, and alternatives.<br /><br />Not long before this new JAMIA article appeared, an active study of EHR problems with voluntary reporting <span style="font-size: small;"><span style="font-family: inherit;">by<span style="font-size: small;"> </span></span></span>members of the <a href="https://www.ecri.org/Pages/default.aspx" target="_blank">ECRI Institute's</a> Patient Safety Organization (PSO) <a href="http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html" target="_blank">produced some concerning data</a>.  Namely, that over a 9-week period starting April 16, 2012, and ending June 19, 2012, 171 health information technology-related problems were reported from just 36 healthcare facilities, primarily hospitals. <b>Eight of the incidents reported involved patient harm, and three may have contributed to patient deaths.</b><br /><br />Obviously, extrapolating those number to:  1)  a much higher number of hospitals, of which the U.S. alone has <a href="http://www.aha.org/research/rc/stat-studies/fast-facts.shtml" target="_blank">approximately 5,700</a> plus other facilities such as long-term care, and private physician offices; 2)  over a full year, not just 9 weeks;  3) accounting for the perhaps 5% voluntary reporting level (per Koppel) of issues such as medication errors; 4) plus accounting for (per FDA) the issue of lack of recognition of IT as contributing to medical incidents (this list is not all-inclusive) - the results are of concern.<br /><br />Thus, work such as in this new JAMIA article on CPOE is important.  The article can be downloaded in its entirety as of this writing from the link above.  The article describes a methodology that is quite complex, and obviously a great deal of time and effort was put into it.  It appears to be a valiant effort to get us one step closer to the truth.  This should be applauded.<br /><br />I was impressed on first reading of this literature meta-analysis and its statistical calculations. (Actually I needed to read it several times to fully grasp the methodologies involved.)<br /><br />The question arose in my mind, however: can this article's conclusions be true, and the ECRI PSO Deep Dive study be true, at the same time?<br /><br />Prior to going into an analysis and perhaps detailed critique of the methodology, and knowing the difficulties and contradictions the literature on this topic presents, I decided first to look at the source articles selected from the literature for inclusion in the JAMIA meta-analysis.<br /><br />In doing so, issues became apparent that shed light on the difficulties of meta-analyses on topics such as this.<br /><br />The only methodological issue I will mention at this time is that the study used a <a href="http://hcrenewal.blogspot.com/2008/06/criticism-of-surrogate-endpoints-in.html" target="_blank">surrogate endpoint</a> - medication "error" rates before, and after, implementation of CPOE, rather than patient outcomes.  (The reason I put "error" in quotes is that, as the authors describe regarding study limitations, the exact definition varies from site to site and study to study.  They also acknowledge the limitations of using such an endpoint.)  Surrogate endpoints, however, may or may not reflect the actual information being sought regarding outcomes.<br /><br />As Roy Poses noted in a June 2008 post "<a href="http://hcrenewal.blogspot.com/2008/06/criticism-of-surrogate-endpoints-in.html" target="_blank">Criticism of Surrogate Endpoints in Whose Interests?</a>":<br /><br /><blockquote class="tr_bq">... The problem with surrogate endpoints is that they are surrogates for the real thing. In many cases, a treatment may appear beneficial when measured by its affect on such endpoints, but not turn out to be beneficial when measured by its affect on real clinical outcomes, e.g., alleviation of symptoms, improvement of function, and prolongation of survival. There are many reasons why this may be the case. <br /><br /></blockquote>This weakens the present study as a basis for social re-engineering.  The authors responsibly acknowledge that via the statement in the conclusion that:<br /><br /><blockquote class="tr_bq">Future research in this area will be critically important to inform policy and funding decisions regarding the development and implementation of CPOE in care delivery. </blockquote><br />When I reviewed the studies that were used for the meta-analysis, however, my enthusiasm for the results was diminished.<br /><br />The authors write:<br /><br /><blockquote class="tr_bq">Using the search terms of Ammenwerth et al, we updated the search using PubMed in February 2009, identifying 390 studies. Each was reviewed by two study authors (MRW and DCR). After applying the a priori inclusion/exclusion criteria, 10 studies were retained. <span style="color: red;"><i><b>[Listed in footnotes 10–19 - ed.]</b></i></span></blockquote><div id=":1cb"><br />Here are the 10 studies retained, as per footnotes #10 - 19.  Short excerpts (I am trying to keep this post relatively short) and my very brief comments about each of them are as follows.  Hyperlinks to the summaries and in some cases to fulltext are present in the online study itself at the full text link at top of this post<b>.</b><br /><br />First, I note no <i>randomized, controlled clinical trials</i>, the gold standard of medical research.  That lack is not the fault of the authors; it is a general feature in the domain of healthcare information technology.<br /><br />That said:<b> </b><br /><br /><u><b>Included study #1 </b><b>(footnote 10)</b></u><b>:</b><u><b> </b></u><br /><b><br /></b></div><div id=":1cb">Bates DW, Teich JM, et al, The impact of computerized physician order entry on medication error prevention. Brigham and Women's Hospital, J Am Med Inform Assoc 1999;6:313–21.</div><div id=":1cb"><br /><blockquote class="tr_bq">... During the study, the non-missed-dose medication error rate fell 81 percent, from 142 per 1,000 patient-days in the baseline period to 26.6 per 1,000 patient-days in the final period (P < 0.0001). Non-intercepted serious medication errors (those with the potential to cause injury) fell 86 percent from baseline to period 3, the final period (P = 0.0003). Large differences were seen for all main types of medication errors: dose errors, frequency errors, route errors, substitution errors, and allergies. For example, in the baseline period there were ten allergy errors, but only two in the following three periods combined (P < 0.0001).  <b>The study periods were as follows: baseline, 51 days, Oct-Nov 1992; period 1, 68 days, Oct-Dec 1993; period 2, 49 days, Nov-Dec 1995; and period 3, 52 days, Mar-Apr 1997. </b></blockquote><b><br /></b>I note that this was a highly advanced setting with long-standing Medical Informatics expertise, performed by Medical Informatics experts of the highest caliber.  This was an ideal environment for the implementation of good health IT.  The results may thus not be generalizable to facilities without that level of experience.  </div><div id=":1cb"></div><div id=":1cb">Also, the study was a considerable number of years ago, some of it two decades ago.  While one might assume the technology has improved, the increased commercial sector involvement since the 1990's, and especially after the HITECH incentives of 2009, may be creating an increased occurrence of bad health IT, and/or implementation in facilities with far less (if any) informatics expertise.<br /><br />Thus, in my view the study's applicability to current times and to all medical organizations is not extremely strong.<b> </b><br /><br /><u><b>Included study #2 </b></u><b><u>(footnote 11)</u>:</b><br /><br />Medication Administration Variances Before and After Implementation of Computerized Physician Order Entry in a Neonatal Intensive Care Unit, Pediatrics 2008;121:123–8 <br /><br /><blockquote class="tr_bq">... Data on 526 medication administrations, including 254 during the pre-computerized physician order entry period and 272 after implementation of computerized physician order entry, were collected. Medication variances were detected for 19.8% of administrations during the pre-computerized physician order entry period, compared with 11.6% with computerized physician order entry (rate ratio: 0.53). Overall, administration mistakes, prescribing problems, and pharmacy problems accounted for 74% of medication variances; <b>there were no statistically significant differences in rates for any of these specific reasons before versus after introduction of computerized physician order entry.</b></blockquote><br />Here, 'n' is very small, and there is a finding that the CPOE had no effect on administration mistakes, prescribing problems, and pharmacy problems.  Thus, a ringing endorsement for national CPOE implementation this study is (unfortunately) not.<b> </b><br /><br /><u><b>Included study #3 </b></u><b><u>(footnote 12)</u>:</b><br /><br />The effect of computer-assisted prescription writing on emergency department prescription errors, Acad Emerg Med 2002;9:1168–75.<cite></cite><br /><br />Without even a summary, my concern here is that ePrescribing and CPOE are different entities.   Inclusion of ePrescibing in a study of CPOE is not entirely without some risk of conflation of results of one with the other.<b> </b><br /><br /><u><b>Included study #4 </b></u><b><u>(footnote 13)</u>:</b><br /><br />Impact of computerized physician order entry on clinical practice in a newborn intensive care unit, J Perinatol. 2004 Feb;24(2):88-93.<br /><br />This article studies gentamicin dosing and turn around times and found that:<br /><br /><blockquote class="tr_bq">"...the accuracy of gentamicin dose at the time of admission for 105 (pre-CPOE) and 92 (post-CPOE) VLBW infants was determined. In the pre-CPOE period, 5% overdosages, 8% underdosages, and 87% correct dosages were identified. In the post-CPOE, no medication errors occurred. Accuracy of gentamicin dosages during hospitalization at the time of suspected late-onset sepsis for 31 pre- and 28 post-CPOE VLBW infants was studied. Gentamicin dose was calculated incorrectly in two of 31 (6%) pre-CPOE infants. No such errors were noted in the post-CPOE period. </blockquote><br />My comments are that a NICU is a specialized environment with a high ratio of clinicians/staff to patients.  Findings in such an environment again may not be generalizable.  Also, one should ask if complex CPOE systems are really needed for dosing calculations and turn around time improvements.  Simpler and cheaper human/technological solutions might have achieved similar or better results.  Thus, again, while not demeaning the results achieved by this study's interventions in 2004, I have my concerns that this study is not strong evidence of generalizability of even the CPOE surrogate measurement, namely decrease of med "errors."<b> </b><br /><br /><u><b>Included study #5 </b></u><b><u>(footnote 14)</u>:</b><br /><br />A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med 1998;338:232–8.<br /><br /><blockquote class="tr_bq">We have developed a computerized decision-support program linked to computer-based patient records that can assist physicians in the use of antiinfective agents and improve the quality of care. This program presents epidemiologic information, along with detailed recommendations and warnings. The program recommends antiinfective regimens and courses of therapy for particular patients and provides immediate feedback. We prospectively studied the use of the computerized antiinfectives-management program for one year in a 12-bed intensive care unit. RESULTS: During the intervention period, all 545 patients admitted were cared for with the aid of the antiinfectives-management program. Measures of processes and outcomes were compared with those for the 1136 patients admitted to the same unit during the two years before the intervention period. The use of the program led to significant reductions in orders for drugs to which the patients had reported allergies (35, vs. 146 during the preintervention period; P less than 0.01), excess drug dosages (87 vs. 405, P less than 0.01), and antibiotic-susceptibility mismatches (12 vs. 206, P less than 0.01). There were also marked reductions in the mean number of days of excessive drug dosage (2.7 vs. 5.9, P less than 0.002) and in adverse events caused by antiinfective agents (4 vs. 28, P <span style="color: red;"><span style="color: black;">less than 0.02).</span> <b> </b></span><b><i><span style="color: red;">[Several other benefits omitted for brevity - they can be seen at the JAMIA footnote hyperlink -  ed.]</span></i></b><!--0--></blockquote></div><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><!--0--><br />My thoughts here are that, while the results were commendable, once again this study took place 15 years ago, and was in a high-staff-to-patient specialized ICU environment.  I also wonder if complex, expensive CPOE is needed to accomplish these tasks as opposed to, say, an online DSS and appropriate workflows and process.<b> </b><br /><br /><u><b>Included study #6 </b></u><b><u>(footnote 15)</u>:</b><br /><br />Impact of computerized prescriber order entry on medication errors at an acute tertiary care hospital. Hosp Pharm 2003;38:227–31.<br /><br /><blockquote class="tr_bq">The authors analyzed medication errors documented in a hospital's database of clinical interventions as a continuous quality improvement activity. They compared the number of errors reported prior to and after computerized prescriber order entry (CPOE) was implemented in the hospital. Results indicated that in the first 12 months of CPOE, overall medication errors were reduced by more than 40%, incomplete orders declined by more than 70%, and incorrect orders decreased by at least 45%. Illegible orders were virtually eliminated but the level of medication errors categorized by drug therapy problems remained significantly unchanged. The study underscores the positive impact of CPOE on medication safety and reemphasizes the need for proactive clinical interventions by pharmacists.</blockquote><br />This study appears reasonable for inclusion in a meta-analysis, although ideally there might have been accounting for possible influence of non-intervention (computer)-related pre-post interval changes.  The transition to CPOE, training, increased awareness, etc. can influence results, especially short term.<b> </b><br /><br /><u><b>Included study #7 </b></u><b><u>(footnote 16)</u>:</b><br /><br />Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. Arch Pediatr Adolesc Med 2006;160:495–8.<br /><br /><blockquote class="tr_bq">Before-and-after study from 2001 to 2004. After CPOE deployment, daily chemotherapy orders were less likely to have improper dosing (relative risk [RR], 0.26; 95% confidence interval [CI], 0.11-0.61), incorrect dosing calculations (RR, 0.09; 95% CI, 0.03-0.34), missing cumulative dose calculations (RR, 0.32; 95% CI, 0.14-0.77), and incomplete nursing checklists (RR, 0.51; 95% CI, 0.33-0.80). There was no difference in the likelihood of improper dosing on treatment plans and a higher likelihood of not matching medication orders to treatment plans (RR, 5.4; 95% CI, 3.1-9.5).</blockquote><br />Again, the results appear commendable.  However:  there was no difference in the likelihood of improper dosing on treatment plans, and worse, there was found <i><b>a higher likelihood of not matching medication orders to treatment plans.</b></i><br /><br />In fact, this article was accompanied by a letter in response entitled "Primum non nocere", David Dickens, MD; Dianne Sinsabaugh, RPh; Brenda Winger, PharmD, Arch Pediatr Adolesc Med. 2006;160(11):1185-1186 (after some digging, text found at <a href="http://archpedi.jamanetwork.com/article.aspx?articleid=486317" target="_blank">http://archpedi.jamanetwork.<wbr></wbr>com/article.aspx?articleid=<wbr></wbr>486317</a>):<br /><br /><blockquote class="tr_bq">Kim et al. demonstrated that in the practice of pediatric oncology, computerized physician order entry (CPOE) reduced improper dosing, missing cumulative doses, and incomplete nursing checklists.  In contrast to these benefits, however, CPOE also resulted in a 5-fold increase in “not matching medication orders to treatment plans.” Although little detail was provided on the nature of these medication order/treatment plan “mismatches,” it implies that chemotherapy ordered through CPOE deviated more often from intended protocol therapy as compared with paper-ordered chemotherapy. While CPOE ostensibly led to more precise chemotherapy dosing, <i><b>it increased the risk of that chemotherapy being the wrong chemotherapy.</b></i></blockquote><br />The author did respond: "Mismatches between treatment plan and orders at point of therapy increased, but were intercepted and clarified at POC. <b><span style="color: red;"><i>[By people - ed.]</i></span>.  </b>No incorrect meds were given.<br /><br />On its face, this is not an entirely dispositive proof of CPOE beneficence and raises significant concern that, sooner or later, a person might miss the discrepanc(ies) resulting in unintended adverse consequences.<b> </b><br /><br /><u><b>Included study #8 </b></u><b><u>(footnote 17)</u>:</b><br /><br />Effects of an integrated clinical information system on medication safety in a multi-hospital setting. Am J Health Syst Pharm 2007;64:1969–77.<br /><br /><blockquote class="tr_bq">This study took place at Lifespan health care system that includes Rhode Island Hospital (RIH), a private, 719-bed, not-for-profit, acute care hospital and academic medical center that has a pediatric division, the Hasbro Children’s Hospital; and The Miriam Hospital (TMH), a 247-bed, not-for-profit, acute care general hospital.<br /><br />Methods. <b>The integrated systems selected for implementation included computerized physician order entry, pharmacy and laboratory information systems, clinical decision-support systems (CDSSs), electronic drug dispensing systems (EDDSs), and a bar-code point-of-care medication administration system.</b> The indicators for CPOE with inherent CDSSs demonstrated a significant effect of this functionality on reducing prescribing error rates for three of the four indicators measured: drug allergy detection, excessive dose, and incomplete or unclear order. <b>The fourth indicator measured, therapeutic duplication, did not show a significant effect on prescribing error rates.</b> For the rules engine software CDSS, the <b>colchicine indicator did not show a statistically significant effect on prescribing error rate</b>, but a significant decrease in prescribing errors related to metformin use in renal insufficiency was observed after implementation of the rules engine software and integration with CPOE. </blockquote><br />Again, these are commendable results, but on its face the technologies involved went far beyond just CPOE, and the results were not uniform.  The actual reduction figures for seven categories were mostly in 50% range, one at 86% (allergy), but the duplicates issue at 8%, not felt statistically significant.<br /><br />Of more concern, there was this in the news in 2011.  A software bug at this organization <b>led to thousands and perhaps tens of thousands of prescription errors</b> that could have (and without definite proof, despite organization denials I would be concerned did) led to injury and death.  I wrote about the malfunction at <a href="http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html">http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html</a>.  The bug was not discovered for about a year.<br /><br />Other organizations, especially those new to CPOE and/or health IT, face similar risks.<br /><br />Again, this is not a caveat-free endorsement of national CPOE rollout in 2013.<br /><br /><u><b>Included study #9 </b></u><b><u>(footnote 18)</u>:</b><br /><br />Effect of computer order entry on prevention of serious medication errors in hospitalized children. Pediatrics 2008;121:e421–7.<br /><br />627 pediatric admissions, with 12 672 medication orders written over 3234 patient-days.  <b>T</b>he rate of non-intercepted serious medication errors in this pediatric population was reduced by 7% after the introduction of a commercial computerized physician order entry system,<b> <u>much less than previously reported for adults, and there was no change in the rate of injuries as a result of error.</u></b> Several human-machine interface problems, particularly surrounding selection and dosing of pediatric medications, were identified.<br /><br />The issues of concern here are bolded and underlined above and need not be restated.<br /><br />Lastly:<br /><br /><u><b>Included study #10 </b></u><b><u>(footnote 19)</u>:</b><br /><br />Evaluation of reported medication errors before and after implementation of computerized practitioner order entry. J Health Inf Manag 2006;20:46–53.<br /><br /><blockquote class="tr_bq">While a major objective of CPOE is to reduce medication errors,<b> its introduction is a major system change that may result in unintended outcomes.</b> Monitoring voluntarily-reported medication errors in a university setting was used to identify the impact of initial CPOE implementation on medical-surgical and intensive care units. A retrospective trend analysis was used to <b>compare errors one year before and six months after </b>implementation. <b>Total error reports increased post-CPOE but the level of patient harm related to those errors decreased. </b>Numerous modifications were made to the system and the implementation process. The study supports the notion that CPOE configuration and implementation influences the risk of medication errors. Implementation teams should incorporate monitoring medication errors into project plans and expect to make ongoing changes to continually support the design of a safer care delivery environment.</blockquote><br />This study appeared more a study reporting unintended outcomes than benefits. The total medication error reports increased post-CPOE but the level of patient harm related to those errors decreased.   (That decrease might have been due to human factors, or to serendipity, both of which cannot be expected to protect forever.)<br /><br /><b>The reasons for the changes were described this way:</b><br /><b></b><br /><blockquote class="tr_bq">... Contributing causes. To assist in the development of safety interventions, contributing causes were identified for reported errors. The most common contributing cause was <b>noncompliance to policy and procedure, identified in 40 percent of errors</b>. For example, a previous order may not have been discontinued when a new dose change was entered, resulting in two active orders for the same medication with different dosages<br /><br /> The next most common contributing cause was <b>computer entry errors</b>, seen in 25 percent of mistakes. One example was if a <b>medication order was placed on the wrong patient.</b>  <span style="color: red;"><i><b>["Use error" due to confusing user interfaces as recently defined by NIST - as opposed to "user error" - was likely to have contributed to at least some of these errors - ed.] </b></i></span> The next most common error was initial load errors (19 percent). During entry of all current medications on the day of activation, multiple category B errors were made. An example was a written order for sliding scale calcium gluconate “PRN,” which was entered into the CPOE system as “scheduled.”<br /><br /><b>There were also computer design issues that contributed to 10 percent of errors.</b> An example was when the pharmacist received two printouts for methylprednisolone 500 mg IV. He assumed it was a duplicate order, but when he reviewed the CPOE system, he saw that one order was for today and the other was for tomorrow. <b>The dates for these orders were not visible on the order printout from the CPOE system. [<span style="color: red;"><i>This again seems to be 'use error' - ed.]</i></span></b></blockquote><div><div><span style="font-family: Arial;"></span><br /><div><div><br /><span style="font-family: inherit;"><span style="font-size: small;">These issues can and will occur any<span style="font-size: small;">where.  </span>Once again, <span style="font-size: small;">this is </span>not entirely an article, either by itself or in a meta-analysis<span style="font-size: small;">, that <span style="font-size: small;">I find ideal</span> in attempte<span style="font-size: small;">d pr<span style="font-size: small;">oof of CPOE effectiven<span style="font-size: small;">ess and beneficence.</span></span></span></span></span></span><br /><br /><span style="font-family: inherit;"><span style="font-size: small;">In fact, after I reviewed this source, I noted that this study was eliminated from the inclusion set:</span></span><br /><br /><blockquote class="tr_bq"><span style="font-family: inherit;"><span style="font-size: small;">... Based on later expert reviewer feedback, we eliminated one additional study that <b>solely used a voluntary reporting method for error detection</b>,<span style="font-size: small;"> </span>leaving nine studies for our final pooled analysis. </span></span></blockquote></div></div><div><div><span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;">It would probably not be hard to convince critic<span style="font-size: small;">al thinkers of the possibility this</span></span> study was removed for reasons other than stated.</span></span><br /><br /><span style="font-size: small;"><span style="font-family: inherit;">In summary, while one should not and cannot expect perfection in the studies available in a meta-analysis, due to the difficulties in this domain the literature resources utilized were not ideal, and the surrogate endpoint also raises concern.  (I have not reviewed the entire corpus of potential literature myself.)  The authors conducted a difficult and rigorous study, but one cannot turn data "lead" (as in Pb) to gold (as in Au), no matter how hard <span style="font-size: small;">one works</span> or however good one<span style="font-size: small;">'s</span> intentions are.</span></span><br /><br /><span style="font-size: small;"><span style="font-family: inherit;">The authors did note the limitations of the study<span style="font-size: small;">, although their conc<span style="font-size: small;">l<span style="font-size: small;">usion will likely be taken by the industry as a "full steam ahead" signal.   <span style="font-size: small;">(</span>I do note with some irony the proximity of this article's re<span style="font-size: small;">lea<span style="font-size: small;">se to t<span style="font-size: small;">he soon-to-start ma<span style="font-size: small;">ss<span style="font-size: small;">ive <a href="http://www.himssconference.org/" target="_blank">HIMSS <span style="font-size: small;">2</span>013 Annual Confe<span style="font-size: small;">rence & <span style="font-size: small;">Exhibition</span> </span>trade show</a><span style="font-size: small;">, March 3-7<span style="font-size: small;">, 2013 in New Orleans<span style="font-size: small;">, LA.<span style="font-size: small;">)</span>  <span style="font-size: small;">While </span>likely<span style="font-size: small;"> a coincidence, <span style="font-size: small;">my concern is that CPOE vendors will be talking nonstop ab<span style="font-size: small;">out these res<span style="font-size: small;">ult<span style="font-size: small;">s.</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span> <br /><br /><span style="font-size: small;"><span style="font-family: inherit;">Thus, I agree with the<span style="font-size: small;"> author's</span> conclusion (especially in view of the recent <span style="font-size: small;">voluntary<span style="font-size: small;"><span style="font-size: small;"> </span>reporting<span style="font-size: small;">-ba<span style="font-size: small;">sed </span></span></span></span></span></span>ECRI PSO study) that <i>"</i><b><i>future research in this area will be critically important to inform policy and funding decisions regarding the development and implementation of CPOE in care delivery."</i></b><br /><br /><span style="font-size: small;"><span style="font-family: inherit;">From a clinical <span style="font-size: small;">perspective, </span>"<span style="font-size: small;">p</span>rimum non nocer<span style="font-size: small;">e" and <span style="font-size: small;"><span style="font-size: small;">the </span>avoidance of gambling billions<span style="font-size: small;"> of <span style="font-size: small;">dollars</span></span> </span>applies<span style="font-size: small;">, at least u<span style="font-size: small;">ntil a better understanding of the technology's risk/benef<span style="font-size: small;">it <span style="font-size: small;">ratio</span></span> and <span style="font-size: small;">how to improve it occ<span style="font-size: small;">urs.</span></span></span></span></span></span></span><br /><br /><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">A fraction of those billions would pay for more robust<span style="font-size: small;">, <span style="font-size: small;">current</span> </span>studies on<span style="font-size: small;"> the s<span style="font-size: small;">cale needed to <span style="font-size: small;">get closer to the truth<span style="font-size: small;">, such as formal post-market<span style="font-size: small;">, <b><span style="font-size: small;">m</span>andatory</b> </span>sur<span style="font-size: small;">veillance<span style="font-size: small;"> that me<span style="font-size: small;">asures not surrogate <span style="font-size: small;">but</span> <i><b>primary</b></i> var<span style="font-size: small;">iables - s<span style="font-size: small;">uch as outcomes <span style="font-size: small;">both positive and <span style="font-size: small;">negative<span style="font-size: small;">.  A</span>s noted by the authors, voluntary reporting has the least sensitivity towards uncove<span style="font-size: small;">ring</span> error<span style="font-size: small;">:</span> </span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><br /><br /><blockquote class="tr_bq"><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">... Reviewed studies used various medication error detection methods. Research suggests that the highest error rates are found through direct observation, followed by chart review, then automated surveillance, and <i><b>voluntary reporting</b>.</i>  <span style="color: red;"><i><b>[Citations were made to papers by Flynn and Jha regarding these points - ed.] </b></i></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></blockquote><br /><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">F<span style="font-size: small;">ormal studies are essential f<span style="font-size: small;">rom</span> the basis of medical (<span style="font-size: small;">e.g.</span>, s<span style="font-size: small;">afety and <span style="font-size: small;">p</span>ublic health</span></span>), business (e.g., ROI and liability), and social policy </span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">perspectives </span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span>(<span style="font-size: small;">e.g., are we spending the bill<span style="font-size: small;">ions of dollars this technology costs </span>wi<span style="font-size: small;">sely).</span></span><b><i> </i></b><br /><span style="font-size: small;"><span style="font-family: inherit;"><b><i><br /></i></b></span></span><span style="font-size: small;"><span style="font-family: inherit;">-- S<span style="font-size: small;">S</span></span></span><br /><br /><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><b>Addendum</b><span style="font-size: small;"><b>:  </b> </span></span></span></span><br /><br /><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;">I have <span style="font-size: small;"><span style="font-size: small;">often</span> been</span> the <a href="http://hcrenewal.blogspot.com/2013/02/modern-healthcare-health-it-iconoclasts.html" target="_blank">fire-breathing and </a></span></span></span></span><span style="font-size: small;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="font-size: small;"><a href="http://hcrenewal.blogspot.com/2013/02/modern-healthcare-health-it-iconoclasts.html" target="_blank">über-skeptic iconoclast</a> on matters such as this.  Ho<span style="font-size: small;">wever, I will allow a true international expert to take on that role this time, Dr. Richard C<span style="font-size: small;">o<span style="font-size: small;">ok, who had a guest post <span style="font-size: small;">here<span style="font-size: small;"> yester<span style="font-size: small;">day (<a href="http://hcrenewal.blogspot.com/2013/03/dr-richard-cook-on-health-it-sectors.html" target="_blank">link</a>)</span></span></span>.  D<span style="font-size: small;">r<span style="font-size: small;">. Coo<span style="font-size: small;">k<span style="font-size: small;">'s opinion on this JAMIA study (again, reproduced<span style="font-size: small;"> here with permission) was this:</span></span></span></span></span></span></span></span></span></span></span></span><br /><br /><blockquote class="tr_bq"><div><span style="font-family: inherit;"><span style="font-size: small;">A meta-analysis of the literature on the nature of the universe in the mid 1500's would have concluded that the sun revolves around the earth. The data isn't fake, just worthless.  </span></span></div></blockquote><br />-- SS<i><b> </b></i></div></div><span style="font-family: Arial;"></span></div></div>

JAMIA: Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems

A new article appeared online 20 February 2013 in the Journal of the American Medical Informatics Association entitled "Reduction in medication errors in hospitals due…

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Why non-medical amateurs need to be kept away from authority roles in health IT ... lest their ignorance kill people

This example of a disaster waiting to happen, in the form of an error-promoting CPOE, is a poster example of why the net of litigation needs to be cast far wider than just clinicians when EHR-related errors result in injury or death:<br /><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhErcAOGFgPHwF2RhkSw7AgRGtg9SRiSYR38-RwttcRs36NMMjonVFNJRoXgN887gCIJmThItvDT3Z3yBkir_ApP62Hq71gnlmW9Eqsbqsh3Vp85q-CpGPL31o4FIWtisxSAlYfzCeOVn9j/s1600/warfarin.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="216" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhErcAOGFgPHwF2RhkSw7AgRGtg9SRiSYR38-RwttcRs36NMMjonVFNJRoXgN887gCIJmThItvDT3Z3yBkir_ApP62Hq71gnlmW9Eqsbqsh3Vp85q-CpGPL31o4FIWtisxSAlYfzCeOVn9j/s400/warfarin.jpg" width="400" /></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-size: x-small;">CPOE selection screen for crucial blood thinner, coumadin (Warfarin).  Click to enlarge</span>.</div><br /><br />This order entry screen, from a production system (of a vendor whose stock price has recently <a href="http://hcrenewal.blogspot.com/2012/04/allscripts-shares-plunge-on-weak.html" target="_blank">taken a dive</a>) shows the following.  In all fairness, I do note it's unclear if the vendor or the customer's configuration "experts" were responsible for this:<br /><br /><div style="text-align: center;"><b>COUMADIN (warfarin) tablet 2 mg Oral daily once</b>.<br />CAUTION: Potential look-Alike or Sound-Alike medication - this product is COUMADIN</div><div style="text-align: center;"><br /></div><div style="text-align: left;">with similar entries for other doses.<br /><br />Below and not indented as is the selection, where the clinician is liable not to look very carefully, is the helpful interpretation:  "warfarin (COUMADIN) Tablet 2 milligram <b>Oral daily for 1 Times</b>."<br /><br />"Oral daily for 1 Times?"</div><div style="text-align: left;"><br /></div><div style="text-align: left;">This drug needs to be given daily, generally for a very long term.  Its effect on blood clotting varies for numerous reasons in an individual over time, and needs to be checked frequently via a blood test (International Normalized Ratio or INR) to ensure the level of effect is neither too little (which could result in clots) or too much (which could result in serious or fatal bleeding).</div><div style="text-align: left;"><br /></div><div style="text-align: left;">In this case, the clinician <b>wanted Coumadin to be administered "daily", as in "each and every day"</b>, but this was the default - daily, but only once.  "Oral daily for 1 Times."<b> </b><br /><br /><b>Brilliant!  </b></div><div style="text-align: left;"><br /></div><div style="text-align: left;">Daily Coumadin (i.e., daily EVERY DAY), the clinician related, could be ordered only with <b>"painstaking difficulty."</b></div><div style="text-align: left;"><br /></div><div style="text-align: left;"><b>"X mg Oral <i>daily once</i>"</b> is an unimaginably absurd and bizarre dosing selection to have on a CPOE system for such a critical drug - or any drug.  <b>"Daily - once?"</b>  </div><div style="text-align: left;"><br /></div><div style="color: red; text-align: left;"><b>It should not, and does not, take a rocket scientist to realize this selection could quite easily lull the busy clinician into believing they have selected a dose to be continued every day - i.e., "once daily" - as per the standard usage of this drug.</b></div><div style="text-align: left;"><br />To order this drug for (true) daily administration, <b>a user must find a "repeat" icon and click the number of days the drug is to be administered</b>.  The "repeat" icon is not readily apparent amidst screen clutter.<br /><br />For other drugs, the order choices are "<b>## mg oral daily</b>" or similar. <br /><br />This semantic and human-computer interaction ineptitude is truly a disaster waiting to happen, especially with the medical/nursing/trainee staff turnaround that goes on in hospitals, and with the reality that clinicians are working at various hospitals with different CPOE/EHR systems.<br /><br />Is this some sort scheme to prevent endless-administration Coumadin errors when the drug is actually deliberately discontinued, I ask?  If so, it's ill-conceived and dangerous at best.<br /><br />By way of further information, this drug is a common anticoagulant whose use is often protective of injurious or fatal blood clots that can cause strokes or death in people with common conditions such as atrial fibrillation or prosthetic heart valves:</div><blockquote class="tr_bq"><div style="text-align: left;"><br /></div><div style="text-align: left;"><a href="http://en.wikipedia.org/wiki/Warfarin" target="_blank">Warfarin</a> is used to decrease the tendency for thrombosis or as secondary prophylaxis (prevention of further episodes) in those individuals that have already formed a blood clot (thrombus). Warfarin treatment can help prevent formation of future blood clots and help reduce the risk of embolism (migration of a thrombus to a spot where it blocks blood supply to a vital organ).<br /><br />The type of anticoagulation (clot formation inhibition) for which warfarin is best suited, is that in areas of slowly-running blood, such as in veins and the pooled blood behind artificial and natural valves, and pooled in dysfunctional cardiac atria. Thus, common clinical indications for warfarin use are atrial fibrillation, the presence of artificial heart valves, deep venous thrombosis, and pulmonary embolism (where the embolized clots first form in veins).</div></blockquote><br />This is an example of the kinds of mission hostility (other equally bizarre examples presented <a href="http://www.tinyurl.com/hostileuserexper" target="_blank">here</a>) that results when amateurs attempt to play doctor.<br /><br />I add that this type of "errorgenicity" is inexcusable.  If patients suffer harm from this type of "feature", the net of liability needs to go further than just the clinician who was caught in a web of cybernetic clinical toxicity. <br /><br />-- SS<br /><br /><b>5/1/2012 Addendum:</b><br /><br />More EHR madness and another physician, a cardiologist and electrophysiologist, who also believes these should be considered medical devices.<br /><br />From DrWes blog (excerpts, and emphases mine; see entire post at link below):<br /><br /><blockquote class="tr_bq"><b><a href="http://drwes.blogspot.com/2012/04/why-electronic-medical-record-needs-to.html" target="_blank">The Electronic Medical Record Should be Viewed as a Medical Device</a>  </b><br />Apr. 30, 2012 </blockquote><blockquote class="tr_bq"><br />This week I received a medical record from a large academic medical center somewhere in the United States (the details were are unimportant) that has one of these new pioneering EMR systems manufactured by $13 billion-dollar company, <a href="http://www.cerner.com/" target="_blank"><span style="color: #cc6611;">Cerner Corporation</span></a> ... what I saw was one of the better examples of how EMRs are contributing to misinformation and confusion when health care is delivered. <br /><br />I received a copy of an internal medicine consult that was performed on a patient at this outside hospital. I have extracted the "medications" portion of the internist's note exactly as it was displayed in the note below ... Needless to say, I was terrified at what the system had listed as the patient's medications:<br /><br />In this example, we see multitudes of medications listed more than once. We see drugs of similar classes (antihistamines, beta blockers) on the same list. We see warfarin, one of our most dangerous drugs dispensed, without a dose included. We see what seems to be outpatient meds listed with inpatient meds, I'm not sure. <b>Honestly, we really have no idea what medications are actually being taken from this list. And yet this list of medications is listed by the EMR as the patient's "Active Medications."</b><br /><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLVg_K31W2k2woo4cxzkEWNEyihdGXVwcOQYD7QWdf9oACrepD14SekHK0sTSlMhvk2GPWFcPERiVcHdpflBjtzZtbQHJFDPdOw_wB9_TLUmhMP69VNLQg8tQKL_Bdc9nZXs_dkD_4e5ss/s1600/Medlist1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLVg_K31W2k2woo4cxzkEWNEyihdGXVwcOQYD7QWdf9oACrepD14SekHK0sTSlMhvk2GPWFcPERiVcHdpflBjtzZtbQHJFDPdOw_wB9_TLUmhMP69VNLQg8tQKL_Bdc9nZXs_dkD_4e5ss/s320/Medlist1.jpg" width="176" /></a></div><span style="font-size: x-small;">Med list (page 1).  Click to enlarge; see original post for part 2.</span><br /><br /><br />...<b> What the heck have we created?</b>  </blockquote><blockquote class="tr_bq">Certainly, any capable physician who cares for patients <b>would describe this medication list as worthless. </b></blockquote><br />This "med list" is similar to the list I showed at <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_26.html" target="_blank">part 4 of my multi-part series on the mission hostile user experience</a> of most commercial EHR's, from yet another system, redrawn by me in redacting the vendor ID.  These lists reflect a mercantile computing person's view of a med list as an inventory of pills:<br /><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgfk6_NvuGu6WBIr_QdltCZ-jdeiAxOhYdSGxhovKJWdBkByUuK3QQLblfOgxBLUhHyXiXALUrdOO_L3Mpmo0MVK0uVv9ogJKnjRU5xWhvQJV125qgLBvIipD6pBDOZJ49s3EPjoCe_AL3-/s1600/meds.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="188" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgfk6_NvuGu6WBIr_QdltCZ-jdeiAxOhYdSGxhovKJWdBkByUuK3QQLblfOgxBLUhHyXiXALUrdOO_L3Mpmo0MVK0uVv9ogJKnjRU5xWhvQJV125qgLBvIipD6pBDOZJ49s3EPjoCe_AL3-/s320/meds.jpg" width="320" /></a></div><div style="text-align: center;"> <span style="font-size: x-small;">Another "what the heck have we created?" EHR med list, on screen. Click to enlarge.</span></div><div style="text-align: center;"><br /></div><div style="text-align: left;"><span style="font-size: x-small;"> </span>Dr. Wes also asks:</div><div style="text-align: left;"><br /></div><blockquote class="tr_bq">... So how will we measure problems with EMRs? It seems industry representatives would rather not address these concerns. We should ask ourselves, is <i>anyone</i> thinking about this?</blockquote><div style="text-align: left;"><br /></div>Yes, they are.  And we are spreading our thinking to one place where action might actually occur sooner rather than later:  to the Plaintiff's Bar.<br /><br />-- SS<br /><br />

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Why non-medical amateurs need to be kept away from authority roles in health IT ... lest their ignorance kill people

This example of a disaster waiting to happen, in the form of an error-promoting CPOE, is a poster example of why the net of litigation needs to be cast far wider than just clinicians when EHR-related …

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A "safe" technology? Factors contributing to an increase in duplicate medication order errors after CPOE implementation

An article "<a href="http://jamia.bmj.com/content/early/2011/07/28/amiajnl-2011-000255">Factors contributing to an increase in duplicate medication order errors after CPOE implementation</a>" by Wetterneck et al. appeared recently in JAMIA (<cite><span id="article-slug-jnl-abbr"><abbr class="slug-jnl-abbrev" title="Journal of the American Medical Informatics Association">JAMIA</abbr> </span><span class="slug-doi" title="10.1136/amiajnl-2011-000255">doi:10.1136/amiajnl-2011-000255).</span></cite><br /><br /><br /><br />It is not available free, but the questions I want to raise are valid just from the abstract available free at the above link:<br /><br /><blockquote><div id="abstract-1" class="section abstract"> <h2 style="font-weight: bold;"><span style="font-size:100%;">Abstract</span></h2> <div id="sec-1" class="subsection"> <p id="p-2"><strong>Objective</strong> To evaluate the incidence of duplicate medication orders before and after <span style="font-weight: bold;">computerized provider order entry</span> (CPOE) with <span style="font-weight: bold;">clinical decision support</span> (CDS) implementation and identify contributing factors. </p></div> <div id="sec-2" class="subsection"> <p id="p-3"><strong>Design</strong> CPOE with duplicate medication order alerts was implemented in a 400-bed Northeastern US community tertiary care teaching hospital. In a pre-implementation post-implementation design, trained nurses used chart review, computer-generated reports of medication orders, provider alerts, and staff reports to identify medication errors in two intensive care units (ICUs). </p></div> <div id="sec-3" class="subsection"> <p id="p-4"><strong>Measurement</strong> Medication error data were adjudicated by a physician and a human factors engineer for error stage and type. A qualitative analysis of duplicate medication ordering errors was performed to identify contributing factors. </p></div> <div id="sec-4" class="subsection"> <p id="p-5"><strong>Results</strong> Data were collected for 4147 patient-days pre-implementation and 4013 patient-days post-implementation. Duplicate medication ordering errors increased after CPOE implementation (pre: 48 errors, 2.6% total; post: 167 errors, 8.1% total; p<0.0001). Most post-implementation duplicate orders were either for the identical order or the same medication. Contributing factors included: (1) provider ordering practices and computer availability, for example, two orders placed within minutes by different providers on rounds; (2) communication and hand-offs, for example, duplicate orders around shift change; (3) CDS and medication database design, for example confusing alert content, high false-positive alert rate, and CDS algorithms missing true duplicates; (4) CPOE data display, for example, difficulty reviewing existing orders; and (5) local CDS design, for example, medications in order sets defaulted as ordered. </p></div> <div id="sec-5" class="subsection"> <p id="p-6"><strong>Conclusions</strong> <span style="font-weight: bold;"><span style="font-style: italic; color: rgb(255, 0, 0);">Duplicate medication order errors increased with CPOE and CDS implementatio</span>n</span>. Many work system factors, including the CPOE, CDS, and medication database design, contributed to their occurrence. </p></div></div></blockquote><br /><br />Duplicate orders can result in over-medication, failure to discontinue, or other medication errors if not caught. They by definition <span style="font-style: italic;">increase risk.</span><br /><br /><br /><br />The questions are simple:<br /><br /><br /><br />Considering that this was a "Northeastern US community tertiary care teaching hospital", not a small hospital in a remote town somewhere lacking in HIT experience, and that <span style="font-weight: bold;">"duplicate medication order errors increased with CPOE and CDS implementation"</span>, is CPOE:<br /><br /><br /><br /><ul><li>A safe technology, in a practical sense in the complex clinical setting (with complexities that are '<a href="http://www.ctlab.org/documents/Hiding%20in%20plain%20sight.pdf">Hiding in Plain Sight</a>'), in 2011?</li><li>A technology ready for sanction-enforced national rollout?</li></ul><br /><br />I leave it to the reader to decide.<br /><br /><br /><br />-- SS<cite><span class="slug-doi" title="10.1136/amiajnl-2011-000255"><br /><br /></span></cite>

A "safe" technology? Factors contributing to an increase in duplicate medication order errors after CPOE implementation

An article "Factors contributing to an increase in duplicate medication order errors after CPOE implementation" by Wetterneck et al. appeared recently in JAMIA (JAMIA doi:10.1136/amiajnl-2011-000255…

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CPOE Cesspool

<span>An accomplished physician who <a href="http://hcrenewal.blogspot.com/2011/04/when-will-first-class-action-lawsuit-on.html">read my post on CPOE</a> at Memorial Sloan Kettering causing medical errors and near misses, and lack of FD&C Act regulation of health IT medical devices, relates the following:<br /><br /><blockquote>So I want to stop medications on a patient. The device only allows me to stop one at a time, and for each one, it requires me to type in a reason.<br /><br />Then, I get another pop up screen to enter my password.<br /><br /><span style="font-weight: bold;">Six clicks and two manual entries to stop an aspirin</span>, not counting the click to get to the med list. <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);"> [What a valuable use of physician time! - ed.]</span><br /><br />Also, I have found that when I want an order for something that is labor intensive to enter, and I ask house staff <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[trainees - ed.]</span> to do it, I get balking as to why I want that treatment or infusion.<br /><br />The arguments, I have found, are not really about the treatment. They are about their avoiding the pain in the ass of having to deal with the user unfriendly screens for that order.<br /><br />The doctors all put up with this.</blockquote><br />Yet for some reason this waste of valuable clinician time due </span>to antediluvian<span> HIT design, and even wild goose chases for critical medications such as in my Apr. 5, 2011 post "</span><a href="http://hcrenewal.blogspot.com/2011/04/special-k-red-berries-mission-hostile.html">Mission Hostile Health IT Obstructs Physicians From Ordering Life Saving Drugs In Critical Emergency</a>"<span>, are considered "progress" in medicine.<br /><br />World class medical centers such as Sloan Kettering consider CPOE a "<a href="http://hcrenewal.blogspot.com/2011/04/when-will-first-class-action-lawsuit-on.html">critical vulnerability</a>" towards near misses and outright medical errors.<br /><br />Still, this IT toxicity is considered "progress" right up to our Department of HHS and POTUS.<br /><br />Why?<br /><br />-- SS<br /></span>

CPOE Cesspool

An accomplished physician who read my post on CPOE at Memorial Sloan Kettering causing medical errors and near misses, and lack of FD&C Act regulation of health IT medical devices, relates the followi…

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Toward Meaningful Usability: Five Keys to Creating Physician- Centric CPOE (Wait - The Terms "Safety", "Risk" and "Error" Are Missing)

<span style="font-size:100%;"><span style="font-family:arial;">In a 2011 "White Paper" from a company </span><a style="font-family: arial;" href="http://www.patientkeeper.com/"><span style="font-style: italic;">PatientKeeper</span></a><span style="font-family:arial;"> entitled "</span><a style="font-family: arial;" href="http://info.patientkeeper.com/rs/patientkeeper/images/WhitePaper_CPOE_2011.pdf">Toward Meaningful Usability: Five Keys to Creating Physician-Centric CPOE</a><span style="font-family:arial;">" (PDF), an organization whose motto is "</span></span><span style="font-style: italic;font-family:arial;font-size:100%;" >Enabling Physicians to Focus on Patients ... Not Technology</span><span style="font-size:100%;"><span style="font-family:arial;">", I again note a common phenomenon.</span><br /><br /><span style="font-family:arial;">Certain verboten terms are absent.</span><br /><br /></span><span style="font-weight: bold;font-family:arial;font-size:100%;" >What might those terms be? </span><span style="font-size:100%;"><span style="font-family:arial;"> More on that in a moment...</span><br /><br /><span style="font-family:arial;">They speak of "the failure of CPOE":</span><br /><br /></span><blockquote style="font-family:arial;"><span style="font-size:100%;">The failure of CPOE to date can be attributed to many factors that ultimately lead to a lack of physician adoption. CPOE systems have historically been designed to support the workflow of the departments responsible for fulfilling the orders rather than the physician workflow around entering orders. As a result, entering orders electronically can take<span style="font-weight: bold;"> significantly longer</span> than written or verbal orders and <span style="font-weight: bold;">often requires the physician to change the way they currently practice medicine.</span></span></blockquote><span style="font-size:100%;"><br /><span style="font-family:arial;">That's a problem, considering the following observation (paraphrased from a "why-pharma-fails" post </span><a style="font-family: arial;" href="http://www.eyesopen.com/en/blog/what-is-really-killing-pharma">at this link</a><span style="font-family:arial;">):<br /><br /></span></span><p style="text-align: left;font-family:arial;"><span style="font-size:100%;"><strong><blockquote>"The machine was made for Clinicians, not Clinicians for the Machine."</blockquote></strong><br /></span></p><p style="text-align: left;font-family:arial;"><span style="font-size:100%;">But still, words are missing from the White Paper. Again, more on that in a moment.</span></p><blockquote style="font-family:arial;"><span style="font-size:100%;">... Hospitals often purchase CPOE on the premise that standardization of care through evidence-based order sets is the optimal way to improve patient care delivery and reduce healthcare costs. <span style="font-weight: bold;">In fact, most standardized care is not</span><br /><span style="font-weight: bold;">supported by evidence</span> so spending months or even years to achieve order set consensus only serves to delay implementation and use while increasing the overall cost of the order entry system.</span></blockquote><p style="text-align: left;font-family:arial;"><span style="font-size:100%;">Well, yes, but where are those missing words?</span></p><blockquote style="font-family:arial;"><span style="font-size:100%;">Most CPOE systems expose physicians to all clinical alerts regardless of severity.<br />The preponderance of these alerts disrupts the ordering process, leads to alert fatigue, and results in </span><span style="font-weight: bold;font-size:100%;" >frustration</span><span style="font-size:100%;"> on the part of the physician. Finally, the number of available workstations, including those on the hospital floors and in patient rooms, is limited, and physicians may have to wait in queue to enter their orders. This may lead to an increase in verbal orders from the physician to the nurse, pharmacist, etc. as well as </span><span style="font-weight: bold;font-size:100%;" >frustration</span> with a process that requires more physician time<span style="font-size:100%;"> than simple pen and paper.</span></blockquote><p style="text-align: left;font-family:arial;"><span style="font-size:100%;"><br /></span></p><p style="text-align: left;font-family:arial;"><span style="font-size:100%;">There must be a lot of frustrated doctors out there. Still, the shibboleth terms are missing.</span></p><p style="text-align: left;font-family:arial;"><span style="font-size:100%;">Cited are the usual KOL's:</span></p><blockquote style="font-family:arial;"><span style="font-size:100%;">1 D. W. Bates, J. M. Teich, J. Lee et al., “The Impact of Computerized Physician Order Entry on Medication Error Prevention,” Journal of the American Medical Informatics Association 6 (July/August 1999): 13–21.<br />2 D. W. Bates and A. A. Gawande, “Improving Safety with Information Technology,” New England Journal of Medicine 348 (June 19, 2003): 2526–34.<br />3 Jason Hess, KLAS Enterprises (Orem, Utah), “Are We There Yet? Getting to Meaningful CPOE Use”, July 13, 2010</span></blockquote><span style="font-size:100%;"><span style="font-family:arial;"><br />Still no mention of the missing critical terms.<br /><br /><blockquote>The next generation of CPOE solutions must ultimately save physicians time, rather than simply being time-neutral. Otherwise, they will suffer the fate of most previous attempts to implement this required functionality – at the cost of improved patient care, better outcomes, and lost ARRA stimulus dollars.</blockquote><br />In other words, the worst-case scenario is wasted promotional dollars and maintenance of the clinical status quo.<br /><br />Still, key terms are missing.<br /></span></span><p style="text-align: left;font-family:arial;"><span style="font-size:100%;">What are those terms?<br /></span></p><p style="text-align: left;font-family:arial;"><span style="font-size:100%;">Here they are, the unaccounted-for outcomes of CPOE and its toxicity in its present form:</span></p><p style="text-align: left;font-family:arial;"><span style="font-size:100%;"><br /></span></p><ul style="font-weight: bold;font-family:arial;"><li><span style="font-size:130%;">Safety (as in, "reduction of")<br /></span></li><li><span style="font-size:130%;">Risk (as in, "of injury, increased")<br /></span></li><li><span style="font-size:130%;">Danger (as of, "putting patients in")<br /></span></li><li><span style="font-size:130%;">Error (as in, "the outcome of toxic HIT")<br /></span></li><li><span style="font-size:130%;">Harm (as in, "injury and death")<br /></span></li></ul><span style="font-size:100%;"><br /></span><span style="font-size:100%;"><span style="font-family:arial;">This was no mere White Paper. A more appropriate term might be a <span style="font-weight: bold;">"Snow White"</span> paper:</span></span><span style="font-size:100%;"><span style="font-family:arial;"><br /><br /></span></span><div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjiSevn6pb57z1SXyyfyWyiPFVqqkuawTWoi-ugZxPvDk5d_oJIBowDTY3Jw3m6Cn2wJVZ7fxTrwsFsw6mhYMk0rzJetVeM1uk98EFS1ULf2XjY1214rp3Jk-CmpQS0O5TVKsrbTWuyavl5/s1600/snowwhite.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5595065095026637714" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjiSevn6pb57z1SXyyfyWyiPFVqqkuawTWoi-ugZxPvDk5d_oJIBowDTY3Jw3m6Cn2wJVZ7fxTrwsFsw6mhYMk0rzJetVeM1uk98EFS1ULf2XjY1214rp3Jk-CmpQS0O5TVKsrbTWuyavl5/s320/snowwhite.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 110px; height: 153px;" /></a><span style="font-size:85%;">CPOE, An Enchanted Technology. Find the Prince!</span><br /><br /></div><span style="font-size:100%;"><span style="font-family:arial;">Health IT, including dysfunctional and toxic CPOE, causes frustration among doctors. CPOE failure is merely "physician nonacceptance."<br /></span><br /><span style="font-family:arial;">But the </span></span><span style="font-weight: bold;font-family:arial;font-size:100%;" >frustration among injured or dead patients and their families</span><span style="font-size:100%;"><span style="font-family:arial;"> seems never to be mentioned or considered in this industry.<br /></span></span><span style="font-size:100%;"><span style="font-family:arial;"><br />I pointed out that similar terms were missing from the PCAST (President’s Council of Advisors on Science and Technology</span></span><span style="font-size:100%;"><span style="font-family:arial;">) report on health IT at my Feb. 2011 post "<a href="http://hcrenewal.blogspot.com/2011/02/presidents-council-of-advisors-on.html">Brief Comments on the PCAST Report on Health IT</a>."</span></span><br /><span style="font-size:100%;"><br /><span style="font-family:arial;">Shhhh!</span><br /><br /><span style="font-family:arial;">-- SS</span></span>

Toward Meaningful Usability: Five Keys to Creating Physician- Centric CPOE (Wait - The Terms "Safety", "Risk" and "Error" Are Missing)

In a 2011 "White Paper" from a company PatientKeeper entitled "Toward Meaningful Usability: Five Keys to Creating Physician-Centric CPOE" (PDF), an organization whose motto is "Enabling Physicians to …

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Medical center has more than 6000 "issues" with Cerner CPOE system in four months - has patient harm resulted?

<div style="text-align: left;">As I have written at Healthcare Renewal before, computerized physician order entry systems (CPOE's) are known to present risks to patients through induction of medical errors.<br /></div><br />This technology is held out to be ready for national diffusion, right up to the POTUS. Per ONC director Blumenthal in the July 13, 2010 <a href="http://hcrenewal.blogspot.com/2010/07/new-england-journal-on-meaningful-use.html">NEJM</a>:<br /><blockquote><br /><span style="font-size:100%;">The widespread use of electronic health records (EHRs) in the United States <span style="font-weight: bold;">is inevitable</span>. EHRs <strong>will</strong> improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they <strong>will demand</strong> nothing less from their providers. Hundreds of thousands of physicians have <strong>already seen these benefits</strong> in their clinical practice.</span></blockquote><br />Vendors deny major problems with their CPOE and other health IT products.<br /><br /><span style="font-style: italic;">The true story is a bit more complex.</span><br /><br />Fortunately, there are some medical centers who are <span style="font-weight: bold;">open and honest about HIT problems</span>. These medical centers seem a rarity. However, those that do share are actually conducting themselves in an honorable and mission-true manner, per <a href="http://hcrenewal.blogspot.com/2009/03/health-it-hold-harmless-and-defects-gag.html">Joint Commission Safety Standards</a>, the ethics of the medical profession, and the expectations of the public. They should be commended.<br /><br />One such example is <a style="font-weight: bold;" href="http://www.munsonhealthcare.org/locations/mmc/mmc.php">Munson Medical Center</a> in Michigan.<br /><br />From the October 2010 "<span style="font-weight: bold;">News for Physicians affiliated with Munson Medical Center</span>" newsletter, a large medical center in Northern Michigan, about <span style="font-weight: bold;">more than six thousand</span> <span style="font-weight: bold;">"issues"</span> with their Cerner CPOE:<br /><br /><blockquote><span style="font-weight: bold;">POE Program Continues to be Improved, Enhanced</span><br /><br />The Provider Order Entry (POE) program continues to be improved. Since implementation in June <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[four months ago - ed.]</span>, <span style="font-weight: bold;">more than 6,000 issues</span> have been reported. Issues are defined as an <span style="font-weight: bold;">aspect of the program not working as intended</span> <span style="font-weight: bold; font-style: italic; color: rgb(255, 0, 0);">[does that include medication and treatment errors and 'near-misses'? - ed.]</span>, process issues <span style="font-weight: bold; font-style: italic; color: rgb(204, 0, 0);">[can these 'issues' kill? - ed.]</span>, education needs, or <a href="http://www.google.com/search?client=firefox-a&rls=org.mozilla%3Aen-US%3Aofficial&channel=s&hl=en&source=hp&q=cerner+powerplan">PowerPlan</a> <span style="font-weight: bold; font-style: italic;"><span style="color: rgb(255, 0, 0);">[Cerner - ed.]</span> </span>change requests.<br /><br /><span style="font-weight: bold;">About 600 of these remain open</span>. Issues are prioritized by the POE Team and addressed according to existing standards.</blockquote><br />One wonders how many of those 6,000, and how many of the 600 remaining "issues" <a href="http://hcrenewal.blogspot.com/2009/03/draft-patient-rights-statement-and.html">fall into categories of</a> "likely to cause patient harm in short term if uncorrected" or "may cause in patient harm in medium or long term."<br /><br />I note that Cerner CPOE is not a new product, nor are similar products from other vendors also afflicted with long lists of "issues." That there could be more than 6,000 "issues" at a new site suggests deep rooted, severe problems with CPOE specifically and health IT design and implementation processes in general.<br /><br />Did patient harm result here or at other CPOE sites (using products of any vendor, not just this one) that had hundreds or thousands of "issues"? We may never know.<br /><br />That national rollout is mandated as if this technology were proven, safe, and plug and play is a scandal of <a href="http://hcrenewal.blogspot.com/2010/09/national-programme-for-health-it-fails.html">UK NPfIT-like</a> proportions.<br /><br />-- SS

Medical center has more than 6000 "issues" with Cerner CPOE system in four months - has patient harm resulted?

As I have written at Healthcare Renewal before, computerized physician order entry systems (CPOE's) are known to present risks to patients through induction of medical errors.This technology is held o…

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