Medication Systems Need Treatment

New technology has long been a hard sell for health-care CIOs working to convince doctors to give up their prescription pads. Now, they are facing an added challenge after a recent study found computers can increase the risk of dangerous medication errors.

Only about 10 percent of U.S. hospitals have installed systems to automate drug ordering. But more are considering the investment because, up until now, studies have shown that computerized physician order entry (CPOE) can dramatically reduce the frequency of medication errors. In a recent study, however, researchers at the University of Pennsylvania medical school found—after observing doctors and nurses using a CPOE system at one hospital—that the software was poorly designed and often ignored how the health-care professionals work in a hospital setting.

“This study will certainly make us more vigilant,” says John Glaser, CIO of Partners HealthCare System in Boston. “If doctors are making mistakes, there are consequences to real people. We need to pay attention to the design of these systems and monitor use.”

The CPOE study, conducted from 2002 to early 2004 at the Hospital of the University of Pennsylvania, found 22 ways that the hospital’s drug ordering system could increase the risk of medical errors. One reason errors are introduced, the study said, is because a doctor might have to scroll through 20 screens to find a single patient’s information. Computer crashes and confusing displays of patients’ medications also led to errors.

“It’s critical that the software not require physicians to twist themselves around like pretzels to fit the code,” says Ross Koppel, the principal author of an article about the study that was published in March in the Journal of the American Medical Association. Koppel, a sociologist and researcher at the Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania School of Medicine, acknowledges that CPOE is still better than paper. Still, he urges hospitals to examine their technology and plan for continuous revision and improvements.

The Institute of Medicine, a nonprofit health-care policy organization, estimates that errors of all kinds kill 44,000 to 98,000 patients a year, and studies have shown that roughly 770,000 medication mistakes occur in U.S. hospitals annually. Hospitals are under growing pressure to replace paper-based ordering systems with computers to eliminate errors due to sloppy handwriting and to improve their ability to track patients’ medication histories. Studies by David Bates, a physician at Brigham and Women’s Hospital, a member of Partners HealthCare System, have shown that CPOE can reduce medication error rates by 83 percent and cut serious medication errors by 55 percent.

Although CPOE experts say that Koppel raises important warnings, he has been criticized for studying a system that was developed in the late 1960s and early 1970s. That system, TDS 7000, made by Eclipsys, was replaced in January 2004 by the Sunrise Clinical Manager solution, also from Eclipsys.

“The conclusion that using an archaic system can lead to problems is not startling,” says John D. Halamka, CIO of CareGroup and Harvard Medical School. Though he says the study is flawed, Halamka has responded by spending extra time educating users that CPOE, if implemented correctly, can reduce errors and improve clinician workflow.

Koppel counters that his recommendations focus on better integration between software and workflow, a need he believes newer CPOE systems have as well.

Bates, chief of general medicine at Brigham and Women’s and a leading proponent of computerized drug-ordering, agrees that health-care organizations need to follow up and update technologies after they have been introduced. Bates says one of the biggest mistakes made at Brigham and Women’s after the hospital implemented its homegrown CPOE system in 1993 was “not recognizing how frequently we would need to update it.”

Bates says he hopes the recent study won’t slow down CPOE adoption.

“This study provided a needed reality test for us,” Bates says. “CPOE is an important tool, and clearly one that needs constant attention.”