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Study on the Failure of Computerized Technology to Perform from Health Affairs

Study on the Failure of Computerized Technology to Perform from Health Affairs

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Health Affairs article shows that tests of medication ordered through CPOE at 62 hospitals only worked 53% of the time.
Health Affairs article shows that tests of medication ordered through CPOE at 62 hospitals only worked 53% of the time.

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Published by: huffpostfund on Jun 30, 2010
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By Jane Metzger, Emily Welebob, David W. Bates, Stuart Lipsitz, and David C. Classen
Mixed Results In The Safety Performance Of ComputerizedPhysician Order Entry 
Computerized physician order entry is a required feature for hospitals seeking to demonstrate meaningful use of electronic medicalrecord systems and qualify for federal financial incentives. A nationalsample of sixty-two hospitals voluntarily used a simulation tool designedto assess how well safety decision support worked when applied tomedication orders in computerized order entry. The simulation detectedonly 53 percent of the medication orders that would have resulted infatalities and 10
82 percent of the test orders that would have causedserious adverse drug events. It is important to ascertain whether actualimplementations of computerized physician order entry are achievinggoals such as improved patient safety.
any people have suggestedthat electronic health rec-ordsrepresentessentialinfra-structure for the provision of safe health care in the UnitedStates. For several years, the Institute of Medi-cine, the Leapfrog Group, the National Quality Forum, and other national groups concernedabout patient safety have recommended, in par-ticular,widespreadadoptionofelectronichealthrecords with computerized physician order entry.
Background On Decision-SupportTools
 With computerized physician order entry, phy-sicians and other licensed clinicians write their orders for hospitalized patients electronically.This recommendation is based in large part ondemonstrations by pioneering organizations.The organizations have shown that importantimprovements in safety can be achieved whenrules-based decision support aids in avertingmedication errors and adverse events by provid-ing advice and warnings as physicians write or-ders using a specially programmed computer.
Inthisapplicationofclinicaldecisionsupport,physicians are made aware of potential safety issues that can result
for example, when ampi-cillinisgiventoapatientwithaknownallergytopenicillin, or the dose being ordered for a pedi-atricpatientismuchhigherthanthetherapeuticrangeforachildofthisageandweight.Prescrib-ing errors such as these can lead to anaphylaxisor seizures, which are known as adverse drugevents, if the medications are actually adminis-tered. The goal of medication safety decisionsupport in computerized physician order entry is to prevent these types of serious errors as theorders are being written. A study demonstrated that one in ten patientshospitalized in Massachusetts suffered an ad- verse drug event that could be prevented by decision-support tools in computerized physi-cian orderentry.
Thestudy spurredthe passageof legislation requiring Massachusetts hospitalsto implement computerized physician ordeentry by 2012 as a condition of licensure.
ofcomputer-ized physician order entry and clinical decisionsupport has been singled out as a requirementfor hospitals to qualify for new financial incen-tives. These incentives will be offered under the
10.1377/hlthaff.2010.0160HEALTH AFFAIRS 29,NO. 4 (2010): 655
©2010 Project HOPE
The People-to-People HealthFoundation, Inc.
Jane Metzger
(jmetzger2@csc.com) is a principalresearcher at CSC Healthcarein Waltham, Massachusetts.
Emily Welebob
is anindependent consultant inIndianapolis, Indiana.
David W. Bates
is divisionchief for general internalmedicine at Brigham andWomen
s Hospital in Boston,Massachusetts.
Stuart Lipsitz
is a researcherat Brigham and Women
David C. Classen
is anassociate professor ofmedicine at the University ofUtah in Salt Lake City, and isalso with CSC Healthcare.APRIL 2010 29:4HEALTH AFFAIRS
Focus On Quality
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 
big leaps,
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
gives credit for all of these forms of decisionsupport as relevant advice or information.Because of differences in the epidemiology of preventable adverse drug events, different ver-sions of the assessment were designed for adultand pediatric inpatient settings.
Use Of The Assessment Tool
A designatedteam in the hospital performs a self-assessmentin the following fashion. First, the team down-loads instructions and information profiles for ten to twelve test patients. Then the team down-loads around fifty test orders, instructions, andobservationsheetstobeusedintheassessment. Aparticipatingphysicianenterstestordersfor the test patients into the local electronic healthrecordandobservesandnotesanyguidancepro- videdbydecisionsupport,suchasthecalculateddose,amessageoralertdisplayed,andsoon.Theteam enters the results obtained for each testorder (decision support received or not).
Theassessment tool instantly computes an overallscore (percentage of test orders identified), aswell as the score for the orders in each adversedrug event category. It then displays results tothe testing team. The entire process takes nomore than six hours, and many hospitals com-plete it more quickly.During the development period (2002
6),multiple testing was performed at more thantwenty-five different hospitals. The testing re-flectingalloftheleadingelectronichealthrecordand computerized physician order entry ven-dors
products and ensured that the test couldeffectively evaluate each product. Details of thereliability and validity of the assessment meth-odology are available in the Online Appendix.
BetweenAprilandAugust2008,eighty-oneU.S.hospitals completed the version of the assess-ment for adult patients. Test orders and postedresults were reviewed, and information poten-tially identifying patients was removed. Ninehospitals were eliminated because registrationinformation indicated that computerized physi-cianorderentrywasbeingusedonlyintheemer-gency department rather than more broadly inthe hospital.In addition, ten hospitals were excluded be-causetheyexceededadeception-analysisthresh-old based on standard gaming detection stra-tegies (testing irregularities such as exceedingtime limits or multiple false positive results). A review of excluded hospitals did not revealresults that would have skewed the findings inthisstudy.Theresultingsamplecontainedsixty-two hospitals.The categories of adverse drug events ad-dressedbythetestordersincludeonesforwhichdecision-supporttoolsarefairlystraightforwardto implement (drug-to-drug or drug-to-allergy interactions, therapeutic duplication, inappro-priate single dose, and inappropriate route of administration). The assessment also includedtest orders that require more effort to configureor customize
for example, use of an inappro-priate daily dose or weight-based dose, drug-to-age or drug-to-diagnosis contraindication, con-traindications based on renal status or other metabolic abnormalities indicatedby laboratory tests, or lack of monitoring.The framework for basic and advanced deci-sionsupportwasbasedonpriorworkonclinicaldecision support in computerized physician or-der entry,
and the categories are consistentwith recent research on preventable adversedrug events.
Statistical Analysis
The basic unit for the analyses was the hospital.Overall scores for test orders and the scores for orders assigned to the
group were bothfoundtobeapproximatelynormallydistributed.However,scoresfortestordersinthe
group were slightly right-skewed. Thus, we pre-sentadditionalstatisticstoaidininterpretation. Afullerdescriptionofouranalysisisavailableinthe Online Appendix.
Tests based on standard assumptions aboutthe population, such as through parametrictests, gave results almost identical to those of tests that made no such assumptions (nonpara-metric tests). Thus, for simplicity, parametrictests are displayed (see the Online Appendix for details).
The total hospital scores were found to be ap-proximately normally distributed, as is typically the case with normal outcomes. Thus, we as-sumedalinearregressionmodelwiththeoverallscore as the dependent variable (estimating therelationships between the outcome and covari-ates using ordinary least squares regression).Covariatesthatweidentifiedashavingapossibleinfluence on total hospital score were vendor (there were nine), teaching status, hospital sizegroupings(numberofbeds),andwhetherornotthe hospital was part of a health system. We tested for appropriateness of our linear regression model using techniques that are de-scribed in the Online Appendix.
 We also usedstandard statistical techniques to determine thepercentage of the overall variation explained by each factor.
 Wetestedourmodelforappropriatenessusingtechniques that are described in the Online Ap-pendix.
For dichotomous outcome variables,

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