Types of Unintended Consequences Related to Computerized Provider Order Entry

ObjectiveTo identify types of clinical unintended adverse consequences resulting from computerized provider order entry (CPOE) implementation.DesignAn expert panel provided initial examples of adverse unintended consequences of CPOE. The authors, using qualitative methods, gathered and analyzed additional examples from five successful CPOE sites.MethodsUsing a card sort method, the authors developed a categorization scheme for the 79 unintended consequences initially identified and then iteratively modified the scheme to categorize 245 additional adverse consequences resulting from fieldwork. Because the focus centered on consequences requiring prevention or remedial action, the authors did not further analyze reported unintended beneficial (positive) consequences.ResultsUnintended adverse consequences (UACs) fell into nine major categories (in order of decreasing frequency): 1) more/new work for clinicians; 2) unfavorable workflow issues; 3) never ending system demands; 4) problems related to paper persistence; 5) untoward changes in communication patterns and practices; 6) negative emotions; 7) generation of new kinds of errors; 8) unexpected changes in the power structure; and 9) overdependence on the technology. Clinical decision support features introduced many of these unintended consequences.ConclusionIdentifying and understanding the types and in some instances the causes of unintended adverse consequences associated with CPOE will enable system developers and implementers to better manage implementation and maintenance of future CPOE projects.     

Evaluation and Certification of Computerized Provider Order Entry Systems

Computerized physician order entry (CPOE) is an application that is used to electronically write physician orders either in the hospital or in the outpatient setting. It is used in about 15% of U.S. Hospitals and a smaller percentage of ambulatory clinics. It is linked with clinical decision support, which provides much of the value of implementing it. A number of studies have assessed the impact of CPOE with respect to a variety of parameters, including costs of care, medication safety, use of guidelines or protocols, and other measures of the effectiveness or quality of care. Most of these studies have been undertaken at CPOE exemplar sites with homegrown clinical information systems. With the increasing implementation of commercial CPOE systems in various settings of care has come evidence that some implementation approaches may not achieve previously published results or may actually cause new errors or even harm. This has lead to new initiatives to evaluate CPOE systems, which have been undertaken by both vendors and other groups who evaluate vendors, focused on CPOE vendor capabilities and effective approaches to implementation that can achieve benefits seen in published studies. In addition, an electronic health record (EHR) vendor certification process is ongoing under the province of the Certification Commission for Health Information Technology (CCHIT) (which includes CPOE) that will affect the purchase and use of these applications by hospitals and clinics and their participation in public and private health insurance programs. Large employers have also joined this focus by developing flight simulation tools to evaluate the capabilities of these CPOE systems once implemented, potentially linking the results of such programs to reimbursement through pay for performance programs. The increasing role of CPOE systems in health care has invited much more scrutiny about the effectiveness of these systems in actual practice which has the potential to improve their ultimate performance.     

The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry

Background

Computerized provider order entry (CPOE) systems can help hospitals improve health care quality, but they can also introduce new problems. The extent to which hospitals experience unintended consequences of CPOE, which include more than errors, has not been quantified in prior research.

Objective

To discover the extent and importance of unintended adverse consequences related to CPOE implementation in U.S. hospitals.

Design, Setting, and Participants

Building on a prior qualitative study involving fieldwork at five hospitals, we developed and then administered a telephone survey concerning the extent and importance of CPOE-related unintended adverse consequences to representatives from 176 hospitals in the U.S. that have CPOE.

Measurements

Self report by key informants of the extent and level of importance to the overall function of the hospital of eight types of unintended adverse consequences experienced by sites with inpatient CPOE.

Results

We found that hospitals experienced all eight types of unintended adverse consequences, although respondents identified several they considered more important than others. Those related to new work/more work, workflow, system demands, communication, emotions, and dependence on the technology were ranked as most severe, with at least 72% of respondents ranking them as moderately to very important. Hospital representatives are less sure about shifts in the power structure and CPOE as a new source of errors. There is no relation between kinds of unintended consequences and number of years CPOE has been used. Despite the relatively short length of time most hospitals have had CPOE (median five years), it is highly infused, or embedded, within work practice at most of these sites.

Conclusions

The unintended consequences of CPOE are widespread and important to those knowledgeable about CPOE in hospitals. They can be positive, negative, or both, depending on one’s perspective, and they continue to exist over the duration of use. Aggressive detection and management of adverse unintended consequences is vital for CPOE success.     

Time-dependent Drug-Drug Interaction Alerts in Care Provider Order Entry: Software May Inhibit Medication Error Reductions

Time-dependent drug-drug interactions (TDDIs) are drug combinations that result in a decreased drug effect due to coadministration of a second drug. Such interactions can be prevented by separately administering the drugs. This study attempted to reduce drug administration errors due to overridden TDDIs in a care provider order entry (CPOE) system. In four periods divided over two studies, logged TDDIs were investigated by reviewing the time intervals prescribed in the CPOE and recorded on the patient chart. The first study showed significant drug administration error reduction from 56.4 to 36.2% (p < 0.05), whereas the second study was not successful (46.7 and 45.2%; p > 0.05). Despite interventions, drug administration errors still occurred in more than one third of cases and prescribing errors in 79-87%. Probably the low alert specificity, the unclear alert information content, and the inability of the software to support safe and efficient TDDI alert handling all diminished correct prescribing, and consequently, insufficiently reduced drug administration errors.     

计算机医嘱输入系统对用药错误的助长作用

背景：医院的计算机医嘱输入（computerized physician order entry，CPOE）系统被广泛认为能从技术上解决用药错误，后者是最常见的可以预防的医院诊疗错误的来源。已发表的研究表明，CPOE可减少高达81％的用药错误。然而，很少研究关注CPOE助长用药错误作用的范围或类型。     

Medication-related Clinical Decision Support in Computerized Provider Order Entry Systems: A Review

While medications can improve patients’ health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs.To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand what classes of CDS their CPOE systems can support, assure that clinical knowledge underlying their CDS systems is reasonable, and appropriately represent electronic patient data. These issues often influence to what extent an institution will succeed with its CPOE implementation and achieve its desired goals.Medication-related decision support is probably best introduced into healthcare organizations in two stages, basic and advanced. Basic decision support includes drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug–drug interaction checking. Advanced decision support includes dosing support for renal insufficiency and geriatric patients, guidance for medication-related laboratory testing, drug-pregnancy checking, and drug–disease contraindication checking. In this paper, the authors outline some of the challenges associated with both basic and advanced decision support and discuss how those challenges might be addressed. The authors conclude with summary recommendations for delivering effective medication-related clinical decision support addressed to healthcare organizations, application and knowledge base vendors, policy makers, and researchers.     

Viewpoint: Controversies Surrounding Use of Order Sets for Clinical Decision Support in Computerized Provider Order Entry

Order sets provide straightforward clinical decision support within computerized provider order entry systems. They make “the right thing” easier to do because they are much faster than writing single orders; they deliver real-time, evidence-based prompts; they are easy to update; and they support coverage of multiple patient problems through linkages among order sets. This viewpoint paper discusses controversies surrounding use of order sets—advantages and pitfalls, decision-making criteria, and organizational considerations, including suggestions for vendors. Order sets have the potential to improve clinician efficiency, provide real-time guidance, facilitate compliance with Joint Commission on Accreditation of Healthcare Organizations and Centers for Medicare & Medicaid Services performance measure sets, and encourage overall acceptance of computerized provider order entry, but may not do so unless these controversies are addressed.     

The Impact of Computerized Provider Order Entry Systems on Inpatient Clinical Workflow: A Literature Review

Previous studies have shown the importance of workflow issues in the implementation of CPOE systems and patient safety practices. To understand the impact of CPOE on clinical workflow, we developed a conceptual framework and conducted a literature search for CPOE evaluations between 1990 and June 2007. Fifty-one publications were identified that disclosed mixed effects of CPOE systems. Among the frequently reported workflow advantages were the legible orders, remote accessibility of the systems, and the shorter order turnaround times. Among the frequently reported disadvantages were the time-consuming and problematic user-system interactions, and the enforcement of a predefined relationship between clinical tasks and between providers. Regarding the diversity of findings in the literature, we conclude that more multi-method research is needed to explore CPOE's multidimensional and collective impact on especially collaborative workflow.     

A Cognitive Task Analysis of Information Management Strategies in a Computerized Provider Order Entry Environment

Objective

Computerized Provider Order Entry (CPOE) with electronic documentation, and computerized decision support dramatically changes the information environment of the practicing clinician. Prior work patterns based on paper, verbal exchange, and manual methods are replaced with automated, computerized, and potentially less flexible systems. The objective of this study is to explore the information management strategies that clinicians use in the process of adapting to a CPOE system using cognitive task analysis techniques.

Design

Observation and semi-structured interviews were conducted with 88 primary-care clinicians at 10 Veterans Administration Medical Centers.

Measurements

Interviews were taped, transcribed, and extensively analyzed to identify key information management goals, strategies, and tasks. Tasks were aggregated into groups, common components across tasks were clarified, and underlying goals and strategies identified.

Results

Nearly half of the identified tasks were not fully supported by the available technology. Six core components of tasks were identified. Four meta-cognitive information management goals emerged: 1) Relevance Screening; 2) Ensuring Accuracy; 3) Minimizing memory load; and 4) Negotiating Responsibility. Strategies used to support these goals are presented.

Conclusion

Users develop a wide array of information management strategies that allow them to successfully adapt to new technology. Supporting the ability of users to develop adaptive strategies to support meta-cognitive goals is a key component of a successful system.     

Evaluation of Outpatient Computerized Physician Medication Order Entry Systems: A Systematic Review

This paper provides a systematic literature review of CPOE evaluation studies in the outpatient setting on: safety; cost and efficiency; adherence to guideline; alerts; time; and satisfaction, usage, and usability. Thirty articles with original data (randomized clinical trial, non-randomized clinical trial, or observational study designs) met the inclusion criteria. Only four studies assessed the effect of CPOE on safety. The effect was not significant on the number of adverse drug events. Only one study showed a significant reduction of the number of medication errors. Three studies showed significant reductions in medication costs; five other studies could not support this. Most studies on adherence to guidelines showed a significant positive effect. The relatively small number of evaluation studies published to date do not provide adequate evidence that CPOE systems enhance safety and reduce cost in the outpatient settings. There is however evidence for (a) increasing adherence to guidelines, (b) increasing total prescribing time, and (c) high frequency of ignored alerts.     

Using Computerized Provider Order Entry and Clinical Decision Support to Improve Referring Physicians' Implementation of Consultants' Medical Recommendations

Objectives

Only half of consultants' medical recommendations are implemented. We created a tool that lets referring providers review and implement electronic recommendations made by consultants, with the hypothesis that facilitation with our tool could improve implementation.

Measurements

The tool was piloted among geriatrics consultants and hospitalists. Pre-post evaluation was done with control (before pilot; N = 20) and intervention (after pilot; N = 20) patients. Consultants wrote notes containing recommendations for all study patients, and entered electronic recommendations only for intervention patients. We analyzed all recommendations and surveyed hospitalists.

Results

A total of 249 recommendations were made for intervention patients versus 192 for controls (p < 0.05). Of all recommendations about intervention patients, 78% were implemented, compared to 59% for controls (p = 0.01). Of the intervention recommendations, 77% were entered electronically using our tool; of these, 86% were implemented. All 24 survey respondents indicated that the system improved quality, saved time, and should be expanded.

Conclusion

Consultant recommendations were implemented 30% more often when there was electronic facilitation of recommendations.     

Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors

Context.— Adverse drug events (ADEs) are a significant and costly cause of injury during hospitalization. Objectives.— To evaluate the efficacy of 2 interventions for preventing nonintercepted serious medication errors, defined as those that either resulted in or had potential to result in an ADE and were not intercepted before reaching the patient. Design.— Before-after comparison between phase 1 (baseline) and phase 2 (after intervention was implemented) and, within phase 2, a randomized comparison between physican computer order entry (POE) and the combination of POE plus a team intervention. Setting.— Large tertiary care hospital. Participants.— For the comparison of phase 1 and 2, all patients admitted to a stratified random sample of 6 medical and surgical units in a tertiary care hospital over a 6-month period, and for the randomized comparison during phase 2, all patients admitted to the same units and 2 randomly selected additional units over a subsequent 9-month period. Interventions.— A physician computer order entry system (POE) for all units and a team-based intervention that included changing the role of pharmacists, implemented for half the units. Main Outcome Measure.— Nonintercepted serious medication errors. Results.— Comparing identical units between phases 1 and 2, nonintercepted serious medication errors decreased 55%, from 10.7 events per 1000 patient-days to 4.86 events per 1000 (P=.01). The decline occurred for all stages of the medication-use process. Preventable ADEs declined 17% from 4.69 to 3.88 (P=.37), while nonintercepted potential ADEs declined 84% from 5.99 to 0.98 per 1000 patient-days (P=.002). When POE-only was compared with the POE plus team intervention combined, the team intervention conferred no additonal benefit over POE. Conclusions.— Physician computer order entry decreased the rate of nonintercepted serious medication errors by more than half, although this decrease was larger for potential ADEs than for errors that actually resulted in an ADE.      

Improving Acceptance of Computerized Prescribing Alerts in Ambulatory Care

Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. Our objective was to improve clinician acceptance of drug alerts by designing a selective set of drug alerts for the ambulatory care setting and minimizing workflow disruptions by designating only critical to high-severity alerts to be interruptive to clinician workflow. The alerts were presented to clinicians using computerized prescribing within an electronic medical record in 31 Boston-area practices. There were 18,115 drug alerts generated during our six-month study period. Of these, 12,933 (71%) were noninterruptive and 5,182 (29%) interruptive. Of the 5,182 interruptive alerts, 67% were accepted. Reasons for overrides varied for each drug alert category and provided potentially useful information for future alert improvement. These data suggest that it is possible to design computerized prescribing decision support with high rates of alert recommendation acceptance by clinicians.     

Overriding of Drug Safety Alerts in Computerized Physician Order Entry

Many computerized physician order entry (CPOE) systems have integrated drug safety alerts. The authors reviewed the literature on physician response to drug safety alerts and interpreted the results using Reason's framework of accident causation. In total, 17 papers met the inclusion criteria. Drug safety alerts are overridden by clinicians in 49% to 96% of cases. Alert overriding may often be justified and adverse drug events due to overridden alerts are not always preventable. A distinction between appropriate and useful alerts should be made. The alerting system may contain error-producing conditions like low specificity, low sensitivity, unclear information content, unnecessary workflow disruptions, and unsafe and inefficient handling. These may result in active failures of the physician, like ignoring alerts, misinterpretation, and incorrect handling. Efforts to improve patient safety by increasing correct handling of drug safety alerts should focus on the error-producing conditions in software and organization. Studies on cognitive processes playing a role in overriding drug safety alerts are lacking.     

Integrating “Best of Care” Protocols into Clinicians' Workflow via Care Provider Order Entry: Impact on Quality-of-Care Indicators for Acute Myocardial Infarction

ObjectiveIn the context of an inpatient care provider order entry (CPOE) system, to evaluate the impact of a decision support tool on integration of cardiology “best of care” order sets into clinicians' admission workflow, and on quality measures for the management of acute myocardial infarction (AMI) patients.DesignA before-and-after study of physician orders evaluated (1) per-patient use rates of standardized acute coronary syndrome (ACS) order set and (2) patient-level compliance with two individual recommendations: early aspirin ordering and beta-blocker ordering.MeasurementsThe effectiveness of the intervention was evaluated for (1) all patients with ACS (suspected for AMI at the time of admission) (N = 540) and (2) the subset of the ACS patients with confirmed discharge diagnosis of AMI (n = 180) who comprise the recommended target population who should receive aspirin and/or beta-blockers. Compliance rates for use of the ACS order set, aspirin ordering, and beta-blocker ordering were calculated as the percentages of patients who had each action performed within 24 hours of admission.ResultsFor all ACS admissions, the decision support tool significantly increased use of the ACS order set (p = 0.009). Use of the ACS order set led, within the first 24 hours of hospitalization, to a significant increase in the number of patients who received aspirin (p = 0.001) and a nonsignificant increase in the number of patients who received beta-blockers (p = 0.07). Results for confirmed AMI cases demonstrated similar increases, but did not reach statistical significance.ConclusionThe decision support tool increased optional use of the ACS order set, but room for additional improvement exists.