November 2006 | Back to Table of Contents

Quality Rounds

To Err is . . . Still Possible

Are computerized physician order-entry systems creating a new set of problems?

By Scott D. Smith

For the last few years, physicians, hospitals, and clinics in Minnesota have been ditching paper charts and prescription pads for computer screens and keyboards in an attempt to avert some of the drug prescribing and other errors that are estimated to injure or kill more than 770,000 people in U.S. hospitals annually.

So far, most of the research on the effects of going electronic suggests that it is improving the quality of care and reducing errors. University of California Los Angeles researchers found that health information technology can improve compliance with treatment guidelines, reduce errors, and decrease unnecessary care. Their review of 257 published studies about the effects of health information technology was published in the May 2006 issue of the Annals of Internal Medicine.

But during the past couple of years, a handful of other researchers have contended that computers may actually introduce errors into hospitals and clinics. “What we are seeing right now [in health care] is the unintended consequences becoming visible,” says Curt Boehm, M.D., medical director of inpatient informatics at Park Nicollet Health Services. Park Nicollet’s Methodist Hospital in St. Louis Park has had its health information technology system in place since 2004.

Physicians say the potential troublemaker in health information technology is not the electronic medical record piece but, rather, computerized physician order-entry (CPOE). CPOE encompasses all of the orders a physician previously would have written on paper including prescriptions and directives for lab work, imaging tests, and care instructions such as the need for a patient to fast before an appointment.

The CPOE Challenge

For many doctors, switching to an EMR is relatively easy, says William Davis, M.D., a family physician and chief medical information director of WinonaHealth, a nonprofit health care system in Winona, which has a communitywide EMR system but has yet to implement CPOE. With both paper charts and EMRs, doctors typically dictate their notes; those notes are then added to the patient’s chart by a transcriptionist. “But now you say to a doctor, ‘You can’t write your orders, you have to put them into a computer.’ That’s a much bigger deal,” Davis says.

About 25 percent of hospitals across the nation now have some form of EMR, whereas only about 5 percent have systems for CPOE. Those adoption rates may reflect the fact that CPOE is more difficult to successfully implement. Research has shown that if CPOE is poorly designed or implemented incorrectly, it can result in unintended medication errors, dropped orders, slower treatment times, and even higher mortality rates.

Children’s Hospital in Pittsburgh, which instituted a CPOE system in October of 2002, actually saw the mortality rate in its ICU jump from 3.86 percent to 6.57 percent following implementation. In an article about the unexpected increase published in the December 2005 issue of Pediatrics, researchers speculated that it was because the new system slowed response times and drew staff away from the bedsides of critically ill children—two factors that influence outcomes in pediatric ICUs.

The study’s authors noted that before CPOE implementation, physicians and nurses initially “converged” at the patient’s bedside to stabilize the patient. After CPOE implementation, one or more staff members spent that initial time in front of the computer registering the patient and ordering medications and tests—functions that staff previously took care of before the patient arrived in the ICU.

Although the Pittsburgh Children’s Hospital study is the only one to correlate a CPOE system with mortality rates, others have described problems with CPOE.

For example, Ross Koppel, Ph.D., a medical sociologist at the University of Pennsylvania, identified 22 persistent types of errors associated with a CPOE system that was used between 1997 and 2004 at the university’s hospital in Philadelphia. Koppel said in a March 22, 2005, Washington Post article that the errors uncovered by interviewing and shadowing 261 doctors were “stunningly frequent.”

Koppel’s study on the problems associated with the CPOE system used at the Hospital of the University of Pennsylvania found that 27 percent of doctors reported that antibiotics were delayed because of the system’s need for reapprovals and that 54 percent of physicians reported difficulty knowing which patients they were ordering for because the computer display used a small font and failed to include the patient’s name on every screen. The study was published in the March 9, 2005, issue of the Journal of the American Medical Association.

In another study, researchers interviewed physicians at various institutions in the Netherlands, Australia, and the United States and found that most CPOE-related problems fell into two categories: those related to data entry and retrieval and those relating to communication and coordination among the health care team.

A common problem is juxtaposition errors, which occur when one clicks the wrong line or box on a computer screen. For example, one unnamed U.S. physician quoted in the article, which was published in the November 21, 2003, Journal of the American Medical Informatics Association, said, “I was ordering Cortisporin, and Cortisporin solution and suspension comes up. The patient was talking to me. I accidentally put down solution, and realized that’s not what I wanted.”

Providers also forget to enter relevant information such as patients’ drug allergies; are bombarded with too much information from the system, making it hard to separate the relevant from the unnecessary; and must contend with information that’s displayed awkwardly and, thus, difficult to read. Barry Bershow, M.D., quality and informatics director for Fairview Health Services’ clinics, which have an EMR with a CPOE system, says it’s not surprising that as systems get implemented defects are discovered and corrected. “We occasionally see physicians making one-up and one-down errors with orders and medications,” Bershow says.

Fairview has adapted its system to reduce the possibility of those errors. For example, instead of giving physicians long lists of drugs from which to choose, Fairview now breaks the drugs into smaller groups based on specialty or drug category.

Fairview also changed its system to deal with another CPOE flaw—too many alerts. This can lead to “alert fatigue,” where physicians start to habitually ignore alerts for allergies or drug interactions because they doubt their relevance. “Fairview’s system came with close to 3 million drug interactions, most of which weren’t that important. Now we’ve reduced that to a list of about 400 pertinent interactions,” Bershow says.

Some Minnesota hospitals and clinics are also implementing what’s called “tall-man lettering,” where the key letters that differentiate similar-sounding drugs are capitalized to create a visual cue for physicians.

Still Need to Talk

Another potential downside of CPOE is that it can undermine communication among physicians, nurses, and pharmacists. “One of the dangers in all of this is that you begin to replace real communication with electronic communication,” Davis says.

The CPOE system can foster an over-reliance on the system based on the view that the computerized system eliminates the need for direct communication. For orders that must be done immediately, physicians need to enter the order into the system and tell the nurse directly, as busy nurses only sporadically look at the computer. And without a phone call from the lab to let them know, physicians may be unaware that important lab results are available.

In addition, it may not be possible to convey messages using the systems’ standardized order forms. For example, when ordering an IV for a patient, the physician might need to tell the nurse that the patient doesn’t like needles and ask the nurse to assign an experienced staff member to care for that patient. Such a message is easy to deliver in person but can’t always be conveyed in a written record.

Communication is an issue that large providers such as Fairview, Park Nicollet, and Allina that have CPOE systems continue to struggle with. “Despite our best efforts, physicians can still think that when they order something, some kind of alert goes off in the nurse’s brain or something. We have to remind our nurses and providers to talk to each other. It’s still not magic,” says Andrew Mellin, M.D., an internist and the medical director for Excellian, Allina’s electronic medical record system.

One way Mercy and Unity hospitals in Fridley and Coon Rapids have dealt with this problem is by creating cards that physicians can hand to nurses as reminders to check the computer for an order.

Work-Flow Woes

Another problem with CPOE systems is that they can be rigid, prompting staff to create work-arounds and after-the-fact entries that can lead to unintended consequences, such as important pieces of information not getting entered into a patient’s chart.

Transitioning patients between units in the hospital is one example of a situation in which problems arise. When a patient is transferred from the operating room to the hospital floor, the surgeon’s and anesthesiologist’s orders need to taper off, and the attending physician’s previously suspended orders need to resume. Mellin says that in the paper world, staff intuitively knew this and made it happen because of long-standing working relationships and processes. But CPOE systems require physicians to specifically designate the timing of orders when they enter them. If the order is written incorrectly, it can cause problems. For example, an order that is written at 12:01 a.m. with instructions for “tomorrow morning” would be carried out a full day later.

Physicians may balk, too, when the system tries to lock them into following protocols they disagree with or when there is no definitive evidence supporting the benefits of one approach over another. Allina recently encountered this regarding guidelines on when to remove bandages after certain surgeries. The hospital system configured its system so that physicians would be within the guidelines regardless of whether bandages are removed a few hours after surgery or after the patient goes home.

CPOE systems also can require too much information. Allina originally had too many “stop signs” that required physicians to include additional information before sending off an order, Mellin says. For example, when a physician orders a piece of equipment, the system might ask him to specify tubing size, a detail that the nurses would figure out at the patient’s bedside.

Still Worth It

Despite the problems CPOE creates, most physicians say the positives greatly outweigh the negatives. Physicians from Fairview, Park Nicollet, and Allina also say that they were unaware of any CPOE problems resulting in significant harm to patients.

“I think it’s about 90 percent/10 percent, with about nine benefits for every one drawback,” Bershow says. Yet even these physicians say implementing CPOE represents a dramatic change in the way they practice. “It is not something to be taken lightly,” Mellin says. “But if you talk to the bulk of doctors, they wouldn’t go back.” MM

Scott Smith is a staff writer for Minnesota Medicine.