Study: Implementation of CPOE can raise mortality
Study: Implementation of CPOE can raise mortality
Problems arise because of delays in treatment
Like many health care institutions across the country, Children’s Hospital Pittsburgh responded to the 1999 IOM report and recommendations by organizations such as the Leapfrog Group with the purchase of a computerized physician order entry (CPOE) system, anticipating that it would improve patient safety and outcomes. In a study recently published in the journal Pediatrics, however, the results of the new system were not at all what they had expected.
The researchers from the department of critical care medicine at the University of Pittsburgh School of Medicine discovered increased mortality rates after implementation. Investigators retrospectively analyzed several variables in the 13 months before and five months following implementation. Even after adjustment for mortality variables, CPOE was independently associated with a greater chance for mortality1. "This should serve as a cautionary tale," warns Joseph A. Carcillo, MD, associate professor of critical medicine in pediatrics at the University of Pittsburgh School of Medicine and one of the paper’s main authors.
Among 1,942 children who were referred and admitted for specialized care during the study period, 75 died, accounting for an overall mortality rate of 3.86%. The mortality rate increased from 2.80% (39 of 1,394) before CPOE implementation to 6.57% (36 of 548) after CPOE implementation.1
"We had the hypothesis that it was going to improve [mortality rates]," notes Carcillo, "But we proved the null hypothesis."
Time is a key element
The CPOE system was implemented hospital-wide, recalls Carcillo. "We have a team that transports more than 1,000 patients every year from outside hospitals," he shares. "When they arrive, they go to the ICU, the ED, the floor whatever is appropriate. We used the system for all ordering for all of these patients."
Carcillo has some strong suspicions as to why the system did not save lives. "If you write an order normally, it takes seconds," he notes, "But the way the system is set up, you have to make multiple clicks on the computer. I thought we would just go to the screen and type in the order, but in fact that’s not the way it worked at all."
The system, he continues, was made for use in a general med/surg ward and not for kids. "For kids coming into the ICU, you might have to do 10 to 20 clicks, which represents a significant time impairment," he explains.
In addition, says Carcillo, in a situation where a patient needs meds rapidly, the physician may not know immediately all the meds that are needed. "Let’s say you type in a medication, click, and the kid goes the wrong way,’" he posits. "You can’t go back in the system, because it is locked; the pharmacist on the other end is using it. So, for a period of time you can’t put more orders in."
This defeats the purpose of preventing errors, he stresses. "Before, a nurse at the bedside could go to a Pyxis machine and make up meds for us right away," he notes. "Now, we can only get it if we put the order in the computer and it goes through this system."
It would be ideal if the physician were able to use alternative methods if a child needed medications rapidly, says Carcillo, but in reality that’s not how things work in a hospital setting. "The hospital would say, If that’s the case, then we shouldn’t have the system at all,’" he says.
The other difficulty with a CPOE system, notes Carcillo, is that computers often don’t work. "This is a Windows program, and computers freeze up or go down; and it takes a tremendous support structure for these things to work." The bottom line, he says, is that "I don’t think you can use these systems in patients who would need meds quickly."
Not ready for prime time?
Carcillo stresses that he’s not opposed to the CPOE concept. "You want to eliminate errors and improve outcomes," he says. "Those most at risk are those who do not need meds to save their lives, and having a program that prevents errors for them makes a lot of sense — and that’s how it’s been designed. My guess is they work fine on someone in that setting, but when you try to apply it to people who need many, many meds ordered rapidly, I don’t think this technology can work."
Ideally, he says, you would need different programs for each specific setting or application, and those programs should be separately evaluated. Unfortunately, he says, "I don’t think administrators will stop using a system they paid a lot of money for unless some agency tells them they have to."
That leads to what Carcillo considers to be the most significant message of the study. "This cautionary tale tells us we have to evaluate the process," he observes. "The reason our findings are significant is that they are saying you have to look at the application of IT the same way we look at a lot of medicines; it can have unseen effects. The FDA came into being because meds were being given to kids and they were dying; there also has to be some quality control in the implementation of these programs."
Until then, he warns, "If I had the power over it, I’d say it’s not ready for prime time."
For more information, contact:
Joseph A. Carcillo, MD, Associate Professor of Critical Medicine, Pediatrics, University of Pittsburgh School of Medicine. Phone: (412) 420-5054. E-mail: [email protected].
Reference
- Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116:1506-1512.
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