Transcript Computerised Physician Order Entry

Computerized Physician Order
Entry: a focus on medication
prescription
Nicolette de Keizer & Saeid Eslami
Dept Medical Informatics
University of Amsterdam
Outline
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Definition and context
Advantages of CPOE
Disadvantages of CPOE
Outcome measures and examples
Same system other outcome
What is Computerized Physician Order Entry
(CPOE)?
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Ordering of tests, medications, and
treatments for patient care using
computers
Involves electronic communication of
the orders
Often use rules-based methods for
checking appropriateness of care
CPOE, EHR and DSS
Documentation
Medication
EHR
Test reports
(EKG, PFT)
Radiology, lab
results
CPOE
D
S
S
CPOE
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Has a positive influence on patients’
outcome
Has a negative influence on
patients’ outcome
CPOE Advantages
 Automate
ordering process
 Reduces Order Errors
Standardized, legible complete
orders
 DSS/Alerts
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 Data
collected on variances in
practice
Case Example
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Metformin is prescribed to a patient
with an elevated creatinine level.
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A drug-lab interaction alert warns that
use of this medication could result in
an increased risk of fatal lactic acidosis.
Case Example
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A physician prescribes warfarin for a
patient with chronic atrial fibrillation.
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System:
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vitamin K rich food likely to interfere
with the efficacy of the drug.
Specific patient information
Example DSS in CPOE – medication
prescription
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Allergy
Age (check drug name and dose)
Duplicate drugs on active orders,
not one-time
Severe drug interactions
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Drug-drug, drug-food
Dose maximum
Drugs with opposite actions
CPOE Disadvantages
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Errors still possible
Alerts
Multiple steps
Access
PubMed indexed papers on CPOE
160
140
120
100
80
60
40
20
0
<2000
2000
2001
2002
2003
no. of papers
2004
2005
2006
CPOE
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Has a positive influence on patients’
outcome
Has a negative influence on
patients’ outcome
On which outcome measure?
Outcome measures
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Adherence to guideline
Alerts - user response
Time
Safety
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Cost and Efficiency
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Medication errors
ADEs (mortality)
Medication costs
Pharmacists interventions
Satisfaction, usage and usability
Example CPOE improves adherence to
guideline
Teich JM et al. Arch Intern Med. 2000 Oct 9;160(18):2713-4.
Example CPOE reduce errors
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Potts studied ADE rates in 13,828 medication orders
before/after CPOE implementation at Vanderbilt
Children’s PICU:
Potts AL, Barr FE, et al. Pediatrics. 2004 Jan;113(1 Pt 1):59-63.
Example CPOE introduces errors
•
Brigham and Womens' Hospital, Boston introduced a
CPOE
Potential
ADEs/1000
pt-days
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•
•
pre
period1
period2
period3
15.8
31.3
59.4
0.5
After implementation, the rate of intercepted Adverse
Drug Events (ADE) doubled!
Reason: The system allowed to easily order much too
large dosages of potassium chloride without clear
indicating that it be given in divided doses.
Bates et al The impact of computerized physician order entry on medication error
prevention. JAMIA 1999, 6(4), 313-21.
Example CPOE introduces errors
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Association with increased PICU mortality:
 2.8% 14 months before CPOE
 6.4% 5 months after CPOE
Han YY, Carcillo JA, et al. Pediatrics. 2005 Dec;116(6):1506-12.
Example CPOE reduce costs
Brigham and Women’s Experience: Cost-Effective
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Cost:
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$3.7 million
implementation
$ 600,000 to $1.1
million operational costs
Results:
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Decreased drug costs
ADE cost is
approximately $4,700
Kausal R et al. J Am Med Inform Assoc. 2006; 13(3): 365-7
CPOE and cost
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Huge variation in actual costs based
on hospital size and complexity of
system
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Hardware and Software: $1-$5 million
Staff training
Ongoing maintenance
Total costs for large, fully integrated
systems could be up to $60 million
Costs will decrease when DSS is
geared to cost reduction
Usability Problems
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Potential selection errors
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Similar medication names
Similar patient names
Overly trust default values
Influence workflow and communication
Physician resistance
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Frequent data entry required
Must not require additional time
Most decision-support steps must be turned off
to encourage use
“Not-invented-here” syndrome
CPOE as a Sociotechnical intervention
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Health information systems has to deal with the actors,
the artefacts, and their interaction.
CPOE =
socio-technical systems
Same system other outcome
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Upperman vs. Han
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same hospital: Pittsburgh Childrens
Hospital
other outcome measure: ADE vs
mortality
Han vs. Del Beccaro
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Same CPOE
Different hospitals
Same outcome measure (mortality)
Upperman et al. J Pediar Surg. 2005;40:57–59; Han et al. Pediatrics. 2005
Dec;116(6):1506-12; Del Beccaro. Pediatrics 2006;118;290-295.
Upperman et al
Pre-CPOE
Post-CPOE
Verbal order
regulatory
compliance
All ADEs
80%
95%*
0.3
0.37
Harmfull ADEs
0.05
0.03*
* p<0.05
Han et al
Mortality
* p<0.05
Pre-CPOE
Post-CPOE
2.80%
6.57%*
Del Becarro et al
Mortality
Pre-CPOE
Post-CPOE
4.22%
3.46%
Same results for:
• transported patients
• congenital cardiovascular disease patients
Upperman vs Han
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Surrogate outcome measures such
as medication errors and ADEs are
not sufficient
More studies on mortality are
necessary
Han vs. Del Beccaro
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Methodological differences:
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Han used unbalanced before after
periods
Del Beccaro did not correct for case
mix differences in before vs after
period
Populations Han vs. Del Beccaro were
not comparable
Han vs. Del Beccaro
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Pittsburgh implemented too fast
without pilot and usability testing:
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Order entry only allowed when patient
physically entered hospital
All medication in central pharmacy
Pharmacy processed order only after
complete activation by nurse
Go live without necessary order sets
Han vs. Del Beccaro
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Seattle hospital learned from Pittsburgh
Factors influencing successful
implementation:
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response time and user time
meeting information needs (e.g.using order
sets)
multidimensional integration with workflow
Involvement leaders, support staff, clinicians
training
improvement through evaluation and learning
Will a CPOE improve quality of
care?
Yes if you implement it the right
way!!
Successful CPOE implementation
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Technical Infrastructure:
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Sociotechnical implementation strategy
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EHR
Drug information database
DSS
Usability pilots
Teams of informaticians, physicians, nurses, clerks,
therapists
Strong leader and good project management
Training and support
R. Gardner: “implementation is 90%
organizational and political and 10% technical”