Computerized Physician Order Entry System Research Articles

Drug waste minimisation and cost-containment in Medical Oncology: Two-year results of a feasibility study

BackgroundCost-containment strategies are required to face the challenge of rising drug expenditures in Oncology. Drug wastage leads to economic loss, but little is known about the size of the problem in this field.MethodsStarting January 2005 we introduced a day-to-day monitoring of drug wastage and an accurate assessment of its costs. An internal protocol for waste minimisation was developed, consisting of four corrective measures: 1. A rational, per pathology distribution of chemotherapy sessions over the week. 2. The use of multi-dose vials. 3. A reasonable rounding of drug dosages. 4. The selection of the most convenient vial size, depending on drug unit pricing.ResultsBaseline analysis focused on 29 drugs over one year. Considering their unit price and waste amount, a major impact on expense was found to be attributable to six drugs: cetuximab, docetaxel, gemcitabine, oxaliplatin, pemetrexed and trastuzumab. The economic loss due to their waste equaled 4.8% of the annual drug expenditure. After the study protocol was started, the expense due to unused drugs showed a meaningful 45% reduction throughout 2006.ConclusionOur experience confirms the economic relevance of waste minimisation and may represent a feasible model in addressing this issue.A centralised unit of drug processing, the availability of a computerised physician order entry system and an active involvement of the staff play a key role in allowing waste reduction and a consequent, substantial cost-saving.

S1059 Intravenous PPI Ordering Pattern in a Computerized Physician Order Entry System: Factors Affecting Inappropriate Usage

S1059 Intravenous PPI Ordering Pattern in a Computerized Physician Order Entry System: Factors Affecting Inappropriate Usage

Moving Health Information Technology Forward

Moving Health Information Technology Forward

Effect of Computer Order Entry on Prevention of Serious Medication Errors in Hospitalized Children

Although initial research suggests that computerized physician order entry reduces pediatric medication errors, no comprehensive error surveillance studies have evaluated the effect of computerized physician order entry on children. Our objective was to evaluate comprehensively the effect of computerized physician order entry on the rate of inpatient pediatric medication errors. Using interrupted time-series regression analysis, we reviewed all charts, orders, and incident reports for 40 admissions per month to the NICU, PICU, and inpatient pediatric wards for 7 months before and 9 months after implementation of commercial computerized physician order entry in a general hospital. Nurse data extractors, who were unaware of study objectives, used an established error surveillance method to detect possible errors. Two physicians who were unaware of when the possible error occurred rated each possible error. In 627 pediatric admissions, with 12,672 medication orders written over 3234 patient-days, 156 medication errors were detected, including 70 nonintercepted serious medication errors (22/1000 patient-days). Twenty-three errors resulted in patient injury (7/1000 patient-days). In time-series analysis, there was a 7% decrease in level of the rates of nonintercepted serious medication errors. There was no change in the rate of injuries as a result of error after computerized physician order entry implementation. The rate of nonintercepted serious medication errors in this pediatric population was reduced by 7% after the introduction of a commercial computerized physician order entry system, much less than previously reported for adults, and there was no change in the rate of injuries as a result of error. Several human-machine interface problems, particularly surrounding selection and dosing of pediatric medications, were identified. Additional refinements could lead to greater effects on error rates.

Implementation of a computerised physician order entry system significantly decreased the rate of medication administration variances in a NICU,

Implementation of a computerised physician order entry system significantly decreased the rate of medication administration variances in a NICU,

Fluconazole prophylaxis for prevention of invasive fungal infections in targeted highest risk preterm infants limits drug exposure

Previous reports suggest a benefit of fluconazole prophylaxis in extremely low birth weight (ELBW) infants <1000 g. Our aim was to evaluate if limiting fluconazole prophylaxis to targeted highest risk infants effectively prevents invasive fungal infections, has no undesired side effects and limits unnecessary drug exposure. This nonrandomized retrospective pre-post intervention study compared two groups of infants: (1) Infants <26 weeks gestation and/or <750 g birth weight, requiring central vascular access and admitted to the Monroe Carell Jr Children's Hospital at Vanderbilt neonatal intensive care unit (NICU) prior to 5 days of age, who received fluconazole prophylaxis and (2) a matched control group from the year prior to prophylaxis. This target population was selected for fluconazole prophylaxis based on prior infection control data from our institution and a number needed to treat of <15 to prevent one episode of fungemia. Following implementation and integration through the institution's computerized physician order entry (CPOE) system, provider adherence to the protocol was assessed during the prophylaxis period. A total of 86 patients were included in the study, 44 in the no-prophylaxis group and 42 in the prophylaxis group. In the targeted prophylaxis group, no invasive fungal infections were observed as compared to nine infants with invasive infections in the no-prophylaxis group (P=0.004). No significant adverse effects were recorded. Targeting the highest risk infants reduced the number of infants <1000 g requiring prophylaxis from 80 to 42 (48% reduction) with no preventable infection missed. Provider compliance was 91% following implementation of this protocol through the CPOE system using a standardized order set. Targeting the highest risk infants for fluconazole prophylaxis through CPOE can effectively prevent invasive fungal infections and limit drug exposure with no unwanted side effects.

Medication Administration Variances Before and After Implementation of Computerized Physician Order Entry in a Neonatal Intensive Care Unit

The goal was to determine whether implementation of a computerized physician order entry system was associated with a decrease in medication administration variances in a NICU. A prospective observational study was conducted. Research nurses recorded details of medication administrations for patients in a NICU during standardized observation periods. Details of each administration were compared with the medication order; a variance was defined as a discrepancy between the order and the medication administration. Rates of variances before and after implementation of computerized physician order entry in the NICU were compared. Specific types of and reasons for variances were also compared. Data on 526 medication administrations, including 254 during the pre-computerized physician order entry period and 272 after implementation of computerized physician order entry, were collected. Medication variances were detected for 19.8% of administrations during the pre-computerized physician order entry period, compared with 11.6% with computerized physician order entry (rate ratio: 0.53). Overall, administration mistakes, prescribing problems, and pharmacy problems accounted for 74% of medication variances; there were no statistically significant differences in rates for any of these specific reasons before versus after introduction of computerized physician order entry. Administration of a medication at the wrong time accounted for 53.1% of all variances. Variance rates related to giving a drug at the wrong time were significantly lower in the computerized physician order entry period than in the pre-computerized physician order entry period (rates: 6.7% and 9.9%, respectively; rate ratio: 0.53). Implementation of computerized physician order entry in a NICU was associated with a significant decrease in the rate of medication administration variances. However, even with the use of computerized physician order entry, variances were noted for >11% of all medication administrations, which suggests that additional methods may be needed to improve neonatal patient safety.

Physicians' resistance toward healthcare information technology: a theoretical model and empirical test

This paper presents a theoretical model of physician resistance of healthcare information technology (HIT) usage by integrating the technology acceptance and resistance to change literatures, using a dual-factor model of technology usage. This model elaborates the interdependent and asymmetric effects of inhibiting usage perceptions, such as resistance, on HIT usage intentions relative to enabling perceptions, such as perceived usefulness and perceived ease of use. It also proposes perceived threat as a predictor of resistance, perceived compatibility as predicting perceived usefulness, and related knowledge as predicting perceived ease of use. The resulting model is empirically supported using a field survey of a computerized physician order entry system among 129 practicing physicians at a large acute-care hospital. Our study illustrates the importance of incorporating user resistance in technology usage studies in general and HIT usage studies in particular, grounds resistance research within extant theories of technology usage, and provides a preliminary model of resistance that can serve as the starting point for future research in this relatively unexplored yet potentially fertile area of research.

Predicting computerized physician order entry system adoption in US hospitals: Can the federal mandate be met?

Objectives The purpose of this study is four-fold. First, the hospitals’ current level of computerized physician order entry (CPOE) adoption is reported; second, internal and external influence factors’ roles in determining CPOE adoption rates are described; third, the future diffusion rate of CPOE systems in US hospitals is empirically predicted; finally, the current technology's state-of-the-art is assessed. Data source Secondary data from 3 years of the Leapfrog Group's annual survey (2002–2004) of US tertiary-care hospitals. Study design This study estimates CPOE market penetration rates applying technology diffusion theory and Bass modeling techniques for three future CPOE adoption scenarios—‘Optimistic,’ ‘Best estimate’, and ‘Conservative’ are empirically derived. Principal findings Two of the CPOE adoption scenarios have diffusion S-curve that indicates a technology will achieve significant market penetration. Under current conditions, CPOE adoption in urban hospitals will not reach 80% penetration until 2029. Conclusions The promise of improved quality of care through medication error reductions and significant cost controls prompted the Institute of Medicine to call for universal CPOE adoption by 1999. However, the CPOE products available as of 2006 represent only a ‘second generation technology’, characterized by many limitations. Without increased external and internal pressures, such CPOE systems are unlikely to achieve full diffusion in US hospitals in a timely manner. Alternatively, developing a new generation of CPOE technology that is more ‘user-friendly’ and easily integrated into hospitals’ legacy systems may be a more expedient approach to achieving widespread adoption.

Impact of Computerized Prescriber Order Entry on the Incidence of Adverse Drug Events in Pediatric Inpatients

This study was conducted to determine the impact of a computerized physician order entry system with substantial decision support on the incidence and types of adverse drug events in hospitalized children. A prospective methodology was used for the collection of adverse drug events and potential adverse drug events from all patients admitted to the pediatric intensive care and general pediatric units over a 6-month period. Data from a previous adverse drug event study of the same patient care units before computerized physician order entry implementation were used for comparison purposes. Data for 1197 admissions before the introduction of computerized physician order entry were compared with 1210 admissions collected after computerized physician order entry implementation. After computerized physician order entry implementation, it was observed that the number of preventable adverse drug events (46 vs 26) and potential adverse drug events (94 vs 35) was reduced. Reductions in overall errors, dispensing errors, and drug-choice errors were associated with computerized physician order entry. There were reductions in significant events, as well as those events rated as serious or life threatening, after the implementation of computerized physician order entry. Some types of adverse drug events continued to persist, specifically underdosing of analgesics. There were no differences in length of stay or patient disposition between preventable adverse drug events and potential adverse drug events in either study period. This study demonstrated that a computerized physician order entry system with substantive decision support was associated with a reduction in both adverse drug events and potential adverse drug events in the inpatient pediatric population. Additional system refinements will be necessary to affect remaining adverse drug events. Preventable events did not predict excess length of stay and instead may represent a sign, rather than a cause, of more complicated illness.

Unintended transformations of clinical relations with a computerized physician order entry system

A socio-technical approach was used to study the qualitative effects of deploying a medication computerized physician order entry system (CPOE with no decision support) at two internal medical wards in a hospital in Denmark. Our results show spatial and temporal transformations of core acts and relations in medication work, i.e. of the intended use of the system inscribed in hardware and software, in the relations of care between doctors and patients, of collaboration between doctors and nurses, and prospectively of the patients’ trajectories when readmitted to hospital or another health care institution, reusing data from the system. This study throws light on problems of continuity of patient care paths, patient-related and IT-system-related error handling and time spent on core activities—when ubiquitous IT is used locally in a real physical setting with specific traditions of performing or ‘doing medication’. The paper argues for the project organization to support the local collaboration and renegotiation of time and place of enacting medication with CPOE, as well as set up feedback for maturation of the software for future clinical use.

Impact of pharmacy validation in a computerized physician order entry context

Computerised physician order entry offers a potential means of reducing prescribing errors, and can also increase the feasibility of pharmacy validation as a secondary filter for eliminating errors. The impacts of these two benefits have never been evaluated in combination. To describe (i) the pharmacists' interventions during validation of drug prescriptions on a computerized physician order entry system, (ii) the impact of these interventions on the prescribing process and (iii) the extent to which computerized physician order entry was responsible for the identified errors. Prospective collection of all medication order lines during five days in a tertiary care university hospital using computerized physician order entry for drug prescription. All orders were reviewed by a pharmacist. We described the frequency of pharmacy alerts and their short-term impact on the correction of potential prescribing errors (modification of the prescription). An independent committee reviewed their type and link with the computerized physician order entry system. About 399 (11%) prescription order lines, corresponding to 222 (52%) patients, required a pharmacy alert during the study period. Among the 81 pharmacy alerts targeted to the prescriber, 21 [26% (IC95% = 17-37%)] resulted in a modification of the prescription. Among the 95 potential prescribing error, the independent review committee judged 16 (17%) as potentially life-threatening and attributed 47 (49%) to the use of computerized physician order entry system (unit error, no use of typical order prespecified, prescription inconsistency or other). Pharmacy validation produced only a moderate short-term impact on the reduction of potential prescribing errors. However, pharmacy validation may also provide ongoing benefits by identifying necessary improvements in the computerized physician order entry system. Those improvements would allow pharmacists to concentrate on the most relevant interventions.

Just What the Doctor Ordered. Review of the Evidence of the Impact of Computerized Physician Order Entry System on Medication Errors

To examine the association between computerization of physician orders and prescribing medication errors. Data Sources. Studies published in English language were identified through MEDLINE (1990 through December 2005), Cochrane Central Register of Controlled Trials, and bibliographies of retrieved articles. Of 252 identified in the search, 12 (4.8 percent) original investigations that compared rates of prescribing medication errors with handwritten and computerized physician orders were included. Information on study design, participant characteristics, clinical settings, and outcomes rates were abstracted independently by two investigators using a standardized protocol. Compared with handwritten orders, 80 percent of studies (8/10 studies) reported a significant reduction in total prescribing errors, 43 percent in dosing errors (3/7 studies), and 37.5 percent in adverse drug events (3/8 studies). The use of computerized orders was associated with a 66 percent reduction in total prescribing errors in adults (odds ratio [OR]=0.34; 95 percent confidence interval [CI] 0.22-0.52) and a positive tendency in children (p for interaction=.028). The benefit of computerized orders was larger when the rate of errors was more than 12 percent with handwritten orders (p for interaction=.022). Significant heterogeneity in the results compromised pooled relative risks. One randomized controlled intervention demonstrated the greatest benefits of computerized orders on total prescribing errors (OR=0.02, 95 percent CI 0.01-0.02) and dosing errors (OR=0.28; 95 percent CI 0.15-0.52) with 775 avoided prescribing errors (95 percent CI 752-811) per 1,000 orders in a pediatric hospital. Computerization of physicians' orders shows great promise. It will be more effective when linked to other computerized systems to detect and prevent prescribing errors.

Mortality before and after initiation of a computerized physician order entry system in a critically ill pediatric population*

A worrisome increase in mortality has been reported recently following the initiation of a computerized physician order entry (CPOE) system in a critically ill pediatric transport population. We tested the hypothesis that such a mortality increase did not occur after the initiation of CPOE in a pediatric population that was directly admitted to the neonatal and pediatric intensive care units at Montefiore Medical Center during two 6-month periods before CPOE and one 6-month period immediately after CPOE was initiated. Mortality in the pre- and post-CPOE time periods was compared, and adjustment for potentially confounding covariates was performed. The pediatric and neonatal intensive care units at Montefiore Medical Center. All patients admitted from the emergency room or operating room or as transfers from other institutions directly to the pediatric and neonatal intensive care units at Montefiore Medical Center. None. Overall, 29 (3.16%) of the 917 patients in the pre-CPOE period and nine (2.41%) of the 374 patients in the post-CPOE period died during their hospital stay (p = .466). The power to detect the hypothesized mortality increase was 81.7%. The variables that remained significant risk factors for mortality after adjustment were shock (odds ratio, 9.41; 95% confidence interval, 2.90-30.49), prematurity (odds ratio, 3.57; 95% confidence interval, 1.74-7.30), male gender (odds ratio, 3.31; 95% confidence interval, 1.47-7.69), or a hematologic/oncologic diagnosis (odds ratio, 3.14; 95% confidence interval, 1.44-6.86). Post-CPOE initiation status remained unassociated with mortality after adjusting for all covariates (odds ratio, 0.71; 95% confidence interval, 0.32-1.57). Mortality did not increase during CPOE initiation.

Interventions pharmaceutiques avant et après informatisation de la prescription dans un service de médecine interne

To compare and analyze the number and types of pharmacist interventions when prescriptions were handwritten (period 1) or entered on 2 different computerized physician order entry systems (CPOE): Phedra (period 2) and Actipidos (period 3). This study took place over 54 weeks (18 weeks for each period) in a 46-bed internal medicine department. Pharmacist interventions were categorized as either simple substitution to an available drug or "complex" interventions such as changing dosage (D), changing drug (M), stopping or substituting in cases of contraindication or overdosing (CO), new medication (N) and identifying errors due to CPOE (C). The study analyzed 12420 prescriptions that led to 1420 interventions. There were 720 substitutions and 98 interventions in period 1, 40 and 238 in period 2, and 97 and 227 in period 3. The percentage of interventions by types for each of the three periods, respectively were D: 52, 37 and 34%; M: 21, 22 and 35%; CO: 16, 12 and 16%; N: 11, 5 and 2%; and C: 0, 24 and 13%. The errors due to CPOE were mainly wrong dosage units and duplicate orders. Introduction of CPOE drastically reduced the number of simple substitutions and significantly increased the complex interventions. CPOE introduced new risks of serious errors. In our study, CPOE did not prevent medication errors and led to new types of errors. The presence and intervention of clinical pharmacists remained necessary.

Implementation and Evaluation of the Computerized Physician Order Entry Systems using Knowledge base

Implementation and Evaluation of the Computerized Physician Order Entry Systems using Knowledge base

LTC Research Key to Medication Management

LTC Research Key to Medication Management

Effect of point of care information on inpatient management of bronchiolitis

BackgroundWe studied the effects of access to point-of-care medical evidence in a computerised physician order entry system (CPOE) on management and clinical outcome of children with bronchiolitis.MethodsThis was a before-after study that took place in a Canadian tertiary care paediatric teaching hospital. The intervention was a clinical evidence module (CEM) for bronchiolitis management, adapted from Clinical Evidence (BMJ Publishing Group) and integrated into the hospital CPOE. CPOE users were medical trainees under the supervision of staff physicians working in the infant ward. Use of antibiotics, bronchodilators and corticosteroids; disease severity; length of hospital admission; and trainee use and perception of the CEM were measured before and after CEM introduction.Results334 paediatric inpatients age 2 weeks to 2 years, with a clinical diagnosis of bronchiolitis; 147 children the year preceding and 187 children the year following introduction of a Clinical Evidence Module (CEM). The percentage of patients receiving antibiotics fell from 35% to 22% (relative decrease 37%) following the introduction of the CEM (p = 0.016). Bronchodilator use was high but following the CEM patients no longer received more than one variety. Steroid usage and length of hospitalisation were low and unaffected. Trainees found the CEM to be educational.ConclusionReadily accessible clinical evidence at the point of care was associated with a significant decrease in antibiotic use and an end to multiple bronchodilator use. The majority of physician trainees found the CEM to be a useful educational tool.

Prevention of Pediatric Medication Errors by Hospital Pharmacists and the Potential Benefit of Computerized Physician Order Entry

The purpose of this work was to characterize medication errors and adverse drug events intercepted by a system of pediatric clinical pharmacists and to determine whether the addition of a computerized physician order entry system would improve medication safety. The study included 16,938 medication orders for 678 admissions to the pediatric units of a large academic community hospital. Pediatric clinical pharmacists reviewed medication orders and monitored subsequent medication use. Medication errors and adverse drug events were identified by daily review of documentation, voluntary reporting, and solicitation. Each potentially harmful medication error was judged whether or not it was intercepted and, if not, whether it would have been captured by a computerized physician order entry system. Overall, 865 medication errors occurred, corresponding with a rate of 5.2 per 100 medication orders. A near-miss rate of 0.96% and a preventable adverse drug event rate of 0.09% were observed. Overall, 78% of potentially harmful prescribing errors were intercepted; however, none of the potentially harmful errors occurring at administration was intercepted and accounted for 50% of preventable adverse drug events. A computerized physician order entry system could capture additional potentially harmful prescribing and transcription errors (54%-73%) but not administration errors (0% vs 6%). A system of pediatric clinical pharmacists effectively intercepted inpatient prescribing errors but did not capture potentially harmful medication administration errors. The addition of a computerized physician order entry system to pharmacists is unlikely to prevent administration errors, which pose the highest risk of patient injury.

To What Extent Do Pediatricians Accept Computer-Based Dosing Suggestions?

Pediatric medication errors occur frequently among hospitalized patients and are often related to dosing. Computerized physician order entry systems with decision support can decrease dosing errors, as well as other types of errors; however, their use in pediatrics has not been extensively studied. Our objective was to determine physician acceptance of dosing and frequency decision support elements in an inpatient pediatric computerized physician order entry system at 1 academic medical center. We performed a retrospective analysis of all electronic medication orders entered for pediatric inpatients at a large, urban teaching hospital between April 15, 2004, and December 31, 2004. Rates of physician acceptance of computerized physician order entry system-generated dosing and frequency suggestions were determined. We analyzed 54,413 orders in the computerized physician order entry system, of which 27,313 orders had dosing or frequency decision support. Of the orders with decision support, approximately one third (8822) were accepted exactly by prescribers. Of the 18,491 remaining orders, 8708 were changed for dose, 2466 for frequency, and 7317 for both. Among the 18,491 orders that were changed, the majority 11,322 deviated by a substantial amount (>50%) from the total daily dose initially suggested by the decision support feature. Overall, patient weight was missing 31.3% of the time, although patient age alone sometimes was sufficient for the computer to make a dosing suggestion. Although dosing-decision support systems have the potential to improve care, more work needs to be done to determine and optimize their effectiveness. Commercial vendors of dosing knowledge bases need to deliver effective products, because most health care organizations will not have the resources to customize decision support rules.