health information technology (IT) stimulusprovisions of the American Recovery and Rein- vestment Act (ARRA) of 2009.Computerized physician order entry interactswith other applications in the suite of digitaltools that constitute the inpatient electronichealth record (for example, to obtain infor-mation on allergies and patients
weight) andis typically one of the later modules to be imple-mented. Hospitals
adoption of the compu-terized physician order entry module is in-creasing, but slowly.
Several reports havesuggested that the successful application of decision support achieved among pioneeringorganizations is not being replicated and thatimplementation can create new problems.
Thisreportsummarizesresultsforsixty-twohos-pitals across the United States that used a new simulationtooltoassesstheiruseofmedicationsafety decision support in electronic healthrecords with computerized physician order entry.
Study Data And Methods
History Of The Assessment Tool
Theimpetusfor developing the assessment tool was initially the standard developed by the Leapfrog Group.This is an employer group that seeks to accom-plish breakthroughs, or
in hospitalpatient safety through a combination of publicawarenessandrewardstohigher-qualityprovid-ers. The group selected computerized physicianorderentryasoneofthefirstthreeleapsin2001.There was accumulating evidence concerningthe frequency, tragic consequences, and finan-cial costs of adverse drug events in hospitalizedpatients
andcomputerizedphysicianorderen-try and decision support had demonstrated theability to help avert many of them.
The Leapfrog standard includes two elementsof meaningful use to ensure that computerizedphysician order entry has been implemented insuch as way as to improve medication safety. Accordingtothestandards,physiciansandother licensedprovidersmustenteratleast75percentof medication orders using computerized entry.Clinical decision support must also be able toavert at least 50 percent of
common, seriousprescribing errors.
Clinical decision support in this setting is thelogicbuiltintothecomputerizedphysicianorder entry system that, for example, checks to see if ampicillin has been ordered for a patient who isknown to be allergic to penicillin. This tool wasdeveloped to specifically measure the ability of implemented electronic health record systemswith computerized physician order entry to de-tect and avert these common yet serious pre-scribing errors in
hospital settings.The tool was intentionally designed to giveindividual hospitals detailed and specific feed-back on their performance and to give purchas-ers, through Leapfrog, an overall score for thehospital that can be used for benchmarkingpurposes.
This assessment complements efforts by theCertification Commission for Health Informa-tion Technology (CCHIT) to evaluate the capa-bilities available in vendors
electronic medicalrecord products
on the shelf.
It evaluates how products were implemented and are actually being used in hospitals.The development of the tool was initially funded by the Robert Wood Johnson Foun-dation, the California HealthCare Founda-tion, and the Agency for Healthcare Researchand Quality, and was completed in 2006. In April2008theassessmentwasincorporatedintotheLeapfrogAnnualSafePracticesSurveyforthefirst time, and hospitals completing the assess-ment received a feedback report. Beginning in2009,assessmentresultswerealsofactoredintodetermining the extent to which the computer-ized physician order entry implementation metthe Leapfrog standard.
Design Of The Assessment Tool
The assess-mentmethodologyismodeledaftertoolsthatarecommonly used in other industries. It mimicswhat happens when a physician writes an order for an actual patient in the implemented elec-tronic health record with computerized physi-cian order entry. But it uses test patients
ineffect, fictitious patients created for purposesof the assessment
and test orders. A group of experts on adverse drug events, aswell as the use of decision support in computer-ized physician order entry to decrease adversedrug events, developed test orders that are judged likely to cause serious harm (rather thanthose with low potential for harm). The testorders belong to the categories of adversedrug events (such as drug-to-allergy or drug-to-diagnosis contraindication) that prior re-search shows cause the most harm to patients.In most cases, they are actual orders that havecaused adverse drug events, taken from primary adverse drug event data collection studies. Theassessment offers a one-time, cross-sectionallookatwhetherdecisionsupportprovidesadviceto a physician writing such an order.
Decision support for this purpose is a set of tools or logic that can be integrated into thecomputerized physician order entry system tosuggest appropriate orders (such as a dose cal-culatororaremindertoconsiderrenalfunction)ortocritiquethemoncetheyhavebeenentered,asthroughamessageoranalert.Theassessment
Focus On Quality
HEALTH AFFAIRSAPRIL 2010 29:4