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.     

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。     

CPOE在韩国教学医院和普通医院使用情况的调查

本文介绍了调查CPOE在韩国的使用情况。原文曾在美国医学信息学协会杂志刊登。     

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.      

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.     

Computerized Physician Order Entry in U.S. Hospitals: Results of a 2002 Survey

Objective: To determine the availability of inpatient computerized physician order entry in U.S. hospitals and the degree to which physicians are using it.Design: Combined mail and telephone survey of 964 randomly selected hospitals, contrasting 2002 data and results of a survey conducted in 1997.Measurements: Availability: computerized order entry has been installed and is available for use by physicians; inducement: the degree to which use of computers to enter orders is required of physicians; participation: the proportion of physicians at an institution who enter orders by computer; and saturation: the proportion of total orders at an institution entered by a physician using a computer.Results: The response rate was 65%. Computerized order entry was not available to physicians at 524 (83.7%) of 626 hospitals responding, whereas 60 (9.6%) reported complete availability and 41 (6.5%) reported partial availability. Of 91 hospitals providing data about inducement/requirement to use the system, it was optional at 31 (34.1%), encouraged at 18 (19.8%), and required at 42 (46.2%). At 36 hospitals (45.6%), more than 90% of physicians on staff use the system, whereas six (7.6%) reported 51–90% participation and 37 (46.8%) reported participation by fewer than half of physicians. Saturation was bimodal, with 25 (35%) hospitals reporting that more than 90% of all orders are entered by physicians using a computer and 20 (28.2%) reporting that less than 10% of all orders are entered this way.Conclusion: Despite increasing consensus about the desirability of computerized physician order entry (CPOE) use, these data indicate that only 9.6% of U.S. hospitals presently have CPOE completely available. In those hospitals that have CPOE, its use is frequently required. In approximately half of those hospitals, more than 90% of physicians use CPOE; in one-third of them, more than 90% of orders are entered via CPOE.In an editorial in American Medical News, legibility, remote access, and the potential “to make users better doctors” were described as the upsides of computerized physician order entry (CPOE) use, but the downsides of typing, system rigidity, and time were cited as making implementation of CPOE systems a highly controversial topic.¹ We define CPOE as a process that allows a physician to use a computer to directly enter medical orders. Physicians are not the only members of the health care team who might enter orders into a computerized system, but they are the focus of this particular study. Hospitals are being encouraged by outside forces to implement CPOE in an effort to reduce medical errors. We conducted a survey in 1997, with results published in 1998,² to discover what percentage of U.S. hospitals had CPOE at that time and to determine how heavily used it was in hospitals that had it. We found that one-third of hospitals claimed to have CPOE available but that it was little used at these sites. An earlier survey with a small response rate had found that 20% of surveyed institutions had CPOE,³ and a study published in 2000 that was limited to inpatient medication ordering by physicians reported that less than 10% of hospitals or health systems had such systems.⁴ A survey of hospital information systems in Japan discovered that order-entry systems for laboratory, imaging, and pharmacy were available at fewer than 20% of reporting hospitals, but this was not necessarily physician order entry.⁵ A 2003 report by the Leapfrog Group (a coalition of public and private organizations founded by the Business Roundtable, which is an association of chief executive officers of Fortune 500 companies) stated that 4.1% of the reporting hospitals in a recent survey had CPOE fully implemented,⁶ but the sample was primarily limited to certain demographics. During the five years since the results of our last survey were published, there have been numerous publications about the benefits of CPOE^7,8,9,10 and about some of the difficulties encountered by hospitals implementing it.^11,12,13 Several governmental agencies and other bodies such as the Leapfrog Group have made efforts to encourage CPOE use.^14,15,16 To aid organizations during planning and implementation, a number of guides and manuals have been published as well.^{17,18,19,20,21} Although much attention is being focused on CPOE, no recent nationwide figures on hospital installations have been published. Therefore, we decided to send the same survey to the same sample population in 2002 that we did in 1997. The questions to be addressed here are: how widespread is the implementation of CPOE in hospitals across the United States, where is it available, and how much is it used?     

Key Attributes of a Successful Physician Order Entry System Implementation in a Multi-hospital Environment

The benefits of computerized physician order entry have been widely recognized, although few institutions have successfully installed these systems. Obstacles to successful implementation are organizational as well as technical. In the spring of 2000, following a 4-year period of planning and customization, a 9-month pilot project, and a 14-month hiatus for year 2000, the Ohio State University Health System extensively implemented physician order entry across inpatient units. Implementation for specialty and community services is targeted for completion in 2002. On implemented units, all orders are processed through the system, with 80 percent being entered by physicians and the rest by nursing or other licensed care providers. The system is deployable across diverse clinical environments, focused on physicians as the primary users, and accepted by clinicians. These are the three criteria by which the authors measured the success of their implementation. They believe that the availability of specialty-specific order sets, the engagement of physician leadership, and a large-scale system implementation were key strategic factors that enabled physician-users to accept a physician order entry system despite significant changes in workflow.The benefits of physician order entry (POE) and the barriers to its realization have been well documented.¹ To date, the barriers appear to dominate. Less than 2 percent of U.S. hospitals have POE completely or partially available and require its use by physicians.² There is renewed interest in POE as a result of the Institute of Medicine report To Err is Human.³ For example, the Leapfrog Group, a consortium of Fortune 500 companies and other large health care purchasers, selected POE as the basis for one of its first safety standards. Before such initiatives bear fruit, the health care and information technology industries need to develop and share successful implementation practices.Ohio State University Health Systems (OSUHS) is a large health care system that includes the Ohio State University (OSU) Hospital, a tertiary medical–surgical care facility; the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, a National Cancer Institute comprehensive cancer center; Dodd Hall, an acute rehabilitation facility; OSU and Harding Behavioral Health, a neuropsychiatric hospital; and OSU Hospitals East, a recently acquired community hospital; and numerous clinics and physician offices. The system is organized along the traditional clinical services of an academic medical center, including medical and surgical subspecialties, obstetrics and gynecology, burn treatment, bone marrow transplant, physical rehabilitation, and psychiatry. In addition, OSUHS is the primary site for education and training for the College of Medicine and Public Health, the School of Allied Health Professions, and the Colleges of Dentistry, Nursing, Optometry, and Pharmacy. This breadth of services, with budgeted revenues in excess of $600 million, classifies OSUHS as a comprehensive integrated health care delivery system. Table 1 Table 1 Statistics for Ohio State University Health Systems (OSUHS) Inpatient Hospitals, 2000At OSUHS, information technology is viewed as a critical element to support clinical and business initiatives and the growth of the health system. Physician order entry is viewed as a logical extension of the OSUHS strategic plan. Implementation strategies adopted to facilitate achievement of our measures of successes include 1) development of a portable and scalable system that could be implemented across diverse and physically distinct clinical environments; 2) identification of the physician as the primary user, and customization of the system to meet physicians'' needs; and 3) clinical acceptance. This paper describes the processes that OSUHS used to plan, customize, and implement a POE system that meets these criteria.     

User Satisfaction with Computerized Order Entry System and Its Effect on Workplace Level of Stress

To evaluate the impact of Computerized Provider Order Entry (CPOE) on workplace stress and overall job performance, as perceived by medical students, housestaff, attending physicians and nurses, after CPOE implementation at Penn State—Milton S. Hershey Medical Center, an academic tertiary care facility, in 2005. Using an online survey, the authors studied attitudes towards CPOE among 862 health care professionals. The main outcome measures were job performance and perceived stress levels. Statistical analyses were conducted using the Statistical Analytical Software (SAS Inc, Carey, NC). A total of 413 respondents completed the entire survey (47.9 % response rate). Respondents in the younger age group were more familiar with the system, used it more frequently, and were more satisfied with it. Interns and residents were the most satisfied groups with the system, while attending physicians expressed the least satisfaction. Attending physicians and fellows found the system least user friendly compared with other groups, and also tended to express more stress and frustration with the system. Participants with previous CPOE experience were more familiar with the system, would use the system more frequently and were more likely to perceive the system as user friendly. User satisfaction with CPOE increases by familiarity and frequent use of the system. Improvement in system characteristics and avoidance of confusing terminology and inconsistent display of data is expected to enhance user satisfaction. Training in the use of CPOE should start early, ideally integrated into medical and nursing school curricula and form a continuous, long-term and user-specific process. This is expected to increase familiarity with the system, reducing stress and leading to improved user satisfaction and to subsequent enhanced safety and efficiency.     

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.     

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.     

推进医生电子医嘱 优化临床工作流程

电子医嘱应用对提升医疗质量、防止医疗差错有重要作用。电子医嘱系统的开发与实施使医院临床医疗的操作以及医护沟通出现了新的问题,因此,正确的实施策略和流程分析重组是推进临床电子医嘱的基础。在我院临床病区电子医嘱应用推进的基础上,总结了医院临床流程重组优化的原则和方法,分析了医院临床流程优化对提升医疗质量管理的推进作用,指出临床流程优化对临床电子医嘱应用效果有关键性影响。     

计算机化医生医嘱录入系统对医护合作性沟通的影响研究

在介绍计算机化医生医嘱录入系统(CPOE)以及医护合作性沟通的基础上,结合中国知网(CNKI)和PubMed数据库的相关文献进行回顾研究。从CPOE的影响及医护沟通自身组织模式的影响两方面进行分析,结果表明CPOE的引入对医护合作沟通的影响是多方面的,不能单纯评论其利弊。     

Adoption of Order Entry with Decision Support for Chronic Care by Physician Organizations

Objective

This study sought to explore physician organizations’ adoption of chronic care guidelines in order entry systems and to investigate the organizational and market-related factors associated with this adoption.

Design

A quantitative nationwide survey of all primary care medical groups in the United States with 20 or more physicians; data were collected on 1,104 physician organizations, representing a 70% response rate.

Measurements

Measurements were the presence of an asthma, diabetes, or congestive heart failure guideline in a physician organization’s order entry system; size; age of the organization; number of clinic locations; type of ownership; health maintenance organization market penetration; urban/rural location; and presence of external incentives to improve quality of care.

Results

Only 27% of organizations reported access to order entry with decision support for chronic disease care. External incentives for quality is the only factor significantly associated with adoption of these tools. Organizations experiencing greater external incentives for quality are more likely to adopt order entry with decision support.

Conclusion

Because external incentives are strong drivers of adoption, policies requiring reporting of chronic care measurements and rewarding improvement as well as financial incentives for use of specific information technology tools are likely to accelerate adoption of order entry with decision support.     

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.