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3/9/2005
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Computerized Systems Can Cause New Medical Mistakes, Study Says

Computerized physician order-entry systems should reduce medical errors, but they may introduce new ones.

Computerized physician order-entry--or CPOE--systems are touted for their ability to reduce medication errors by eliminating illegible handwriting and red-flagging potential drug allergies and dangerous interactions. But they're also capable in many ways of introducing other errors, says a new study published in Wednesday's Journal Of The American Medical Association.

And one of the biggest risks comes from asking doctors and nurses to change how they work to fit a computerized system, particularly with older software. Hospital IT staffs often will need to significantly customize off-the-shelf software, the report's author concludes. "Don't put too much faith in the technology," says Ross Koppel of the Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania School of Medicine. "It's only as good as the willingness to refine it."

The study of one hospital by researchers at the University of Pennsylvania identified 22 "discrete ways" in which medication errors were facilitated by a CPOE system that had been deployed at an unidentified hospital in 1997.

The study showed that while illegible handwriting is resolved satisfactorily by CPOE systems, other risks of medical errors are accentuated. The medication errors identified fell into two main categories: information errors and flaws in the interaction of people and machines.

Information errors resulted from "fragmentation" of data and information, which can occur when a hospital fails to integrate information from its multiple systems with the CPOE, the study said. This could result in a doctor ordering a wrong dose of a medication for a patient because the doctor confused the computer's display listing a pharmacy's entire inventory of a drug with information about correct recommended dosing for that patient.

Failures in human-machine interface occur when a computerized process' workflow doesn't correspond to how medical staff works. For instance, an ordering system that requires a doctor to study many screens of drug information about one patient's medication history increased the risk of the physician selecting a wrong drug.

The report's author says that in general, the problem with CPOE is that oftentimes, the system too drastically tries to change the way hospital staff work, rather than adapt to their needs. "The largest problem is that the system asks house staff to twist the software like a pretzel rather than the software corresponding to the way the work is done," Koppel says. In some cases, "the house [hospital] staff had to come up with bizarre workarounds" to use the system, he says.

Since the study was completed in January 2004, that hospital has replaced the old CPOE system with a new one from the same vendor, Koppel says. The new system has helped solve some of the problems caused by the old system; however, even the new system "has oodles and oodles of problems," he says. "These systems need to evolve with the hospital, they need to be integrated and monitored constantly" for the changing needs of staff.

Over the last year or so, the federal government, including President Bush, has stepped up efforts aimed at encouraging more U.S. hospitals and health-care providers to embrace technologies such as electronic medical records and computerized drug-ordering systems. Government researchers estimate that such IT systems could bring billions of dollars in annual health-care cost savings related to medical mistakes, paperwork, test redundancies, and process inefficiencies. The Institute of Medicine, in an often-quoted report published in the late 1990s, estimated that up to 98,000 American patients die each year because of medical mistakes, many of which can be eliminated through technology.

Koppel says that despite the study's findings, he believes CPOE deployments can offer "extraordinary advantages" in reducing many mistakes, but hospitals that deploy those systems "need vigilance and self-examination, otherwise it will come back and bite," he says.

Health-care industry organizations estimate that fewer than 10% of American hospitals have installed computerized drug-ordering systems.

Among hospitals that have had disappointing deployments of CPOE was an installation at Cedar Sinai Medical Center in Los Angeles, which discontinued use of its system two years ago after doctors complained it was unreliable and slowed down their work processes.

Other CIOs, however, have deployed CPOE at their hospitals and say the newer and better-designed systems can eliminate the types of errors identified by the University of Pennsylvania study as well as avoid the sort of complaints that doctors at Cedar Sinai had.

At CareGroup Health System, which operates several Boston-area hospitals, an in-house developed, Web-based CPOE system deployed in its Beth Israel Deaconess Medical Center in 2001 has reduced drug errors by more than 50%, CIO John Halamka says in an E-mail interview. At Beth Israel, 100% of drug orders by doctors are done electronically.

"We go from the doctor's brain to the patient's vein without any handoffs or transcription of orders," Halamka says. Beth Israel clinicians enter orders via a "user friendly" Web-based system to select "the right patient, right medication, and right dose," he says.

"Decision support provides drug/drug interaction checks, drug/allergy checks, and even dose adjustment based on patient kidney function. No manual system could provide all of this error checking," Halamka says.

"The lesson learned from Penn and Cedars Sinai is that CPOE is process, not a product," Halamka says. "Working with doctors, nurses, and pharmacists, IT continuously enhances the system to support best practices, new medications, and new knowledge in an easy-to-use application."

Says Halamka, "An implementation which integrates the workflow of the hospital into the technology platform reduces errors, not increases them."

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