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== Evaluating public health uses of health information exchange ==
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'''Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors'''
'''Jason S. Shapiro'''
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Ross Koppel, Joshua P. Metlay, et al.
----
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The potential of health information exchange (HIE) to improve the public health and public health activities may seem obvious, but current literature provides little evidence proving these effects. This article provides general evaluation methods for measuring the impact of HIE on public health in six use cases. For each use case the author gives a brief description for the case then discusses potential approaches to the evaluation of these use cases.
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Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors, the largest identified source of preventable hospital medical error. Published studies report that CPOE reduces medication errors up to 81%. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE. The authors undertook a comprehensive, multimethod study of CPOE-related factors that enhance risk of prescription errors.
----
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'''1. Mandated reporting of laboratory diagnoses.'''
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'''METHODS'''
Measuring the volume of relevant data transmitted using Electronic laboratory reporting directly to health departments would be a primary measure of success in this use case
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(i.e. recall):    relevant ∩ retrieved/relevant.
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'''Design'''
If feasible, a pre- and post-implementation study, could be conducted to demonstrate any change in the frequency of mandated reporting of laboratory diagnoses using HIE laboratory data.
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They performed a quantitative and qualitative study incorporating structured interviews with house staff, pharmacists, nurses, nurse-managers, attending physicians, and information technology managers. The Qualitative research was iterative and interactive
Additional metrics of interest could look at changes in efficiency, completeness and timeliness of reporting.
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'''Setting'''
----
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They studied a major urban tertiary-care teaching hospital with 750 beds, 39000 annual discharges, and a widely used CPOE system (TDS) operational there from 1997 to 2004.  
'''2. Mandated reporting of physician-based diagnoses'''
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'''Data Collection'''
Recall would be difficult to measure in this use case since measuring all relevant cases for the denominator would be time consuming and expensive. Another measure of interest is to evaluate the performance of the system
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1-Intensive One-on-One House Staff Interviews. 2-Focus Groups.3-Expert Interviews.4-Shadowing and Observation.5-Survey.
(i.e. the precision): relevant ∩ retrieved/retrieved.
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Measurement of precision would require a log file capturing all potential clinician reportable diseases detected by the system, followed by manual review to determine which cases are relevant.  
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'''RESULTS'''
Another useful evaluative measure might be to determine the volume of reporting pre- and post-implementation in much the same way that was suggested above for mandated reporting of laboratory diagnoses, as well as the efficiency, completeness and timeliness of reporting.
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----
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The study identified 22 previously unexplored medication-error sources that users report to be facilitated by CPOE. They group these as:
'''3. Public health investigation'''
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Because implementation of this use case will vary depending on the extent to which the HIE incorporates clinical data, recommendation of a specific evaluation is difficult. One possibility is to do a qualitative or semi-qualitative study of the public health investigator’s experience through surveys, semi-structured interviews or observational techniques. In addition if this were done across multiple HIE projects, analysis might permit the development of a set of standard practices for HIE implementations to help identify the data elements and user interface features that are most essential to this use case.
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'''A-Information Errors: Fragmentation and Systems Integration Failure.'''
----
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'''4. Disease-based non-reportable laboratory data'''
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'''1- Assumed Dose Information.'''
Because this use case will rely on the development of faster, less expensive, and more accessible assays to clinicians, and these are being developed and deployed in parallel with HIE systems, they will likely act as a confounder, making it difficult to construct an evaluation plan that incorporates a pre-implementation phase.  
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House staff often rely on CPOE displays to determine minimal effective or usual doses. The dosages listed in the CPOE display, however, are based on the pharmacy’s warehousing and purchasing decisions, not clinical guidelines.
Of most interest here is the gathering and analysis of empirical data to make new discoveries regarding the epidemiology of these common pathogens.
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'''2-Medication Discontinuation Failures'''
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Ordering new or modifying existing medications is usually a separate process from canceling (“discontinuing”) an existing medication. Without discontinuing the current dose, physicians can increase or decrease medication, add new but duplicative medication, and add conflicting medication.  
'''5. Antibiotic-resistant organism surveillance'''
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'''3-Procedure-Linked Medication Discontinuation Faults.'''
Since the intervention here is the dissemination of a community-wide antibiogram, A study evaluating the rates of local antibiotic resistance patterns before and after the implementation of a community- wide antibiogram would be of interest. Similarly, studies could be done pre- and post-implementation on a hospital level to see if an antibiotic-resistant organism (ARO) notification system leads to earlier identification and isolation of ARO-infected patients, and to see if hospital rates of nosocomial ARO infections decrease.
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Procedures and certain tests are often accompanied by medications. If procedures are canceled or postponed, no software link automatically cancels medications.
----
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'''4-Immediate Orders and Give-as-Needed Medication Discontinuation Faults.'''
'''6. Population-level quality monitoring'''
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NOW (immediate) and PRN (give as needed) orders may not enter the usual medication schedule. Failure to chart or cancel can result in unintended medications on subsequent days or reordering (duplications) on the same day.
Again, this use case would require a pre- and post implementation study. A number of organizations have developed, or are developing, standard sets of quality measures that could be used for evaluation.
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'''5-Antibiotic Renewal Failure'''
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Antibiotics are generally approved for 3 days. Before the third day, house staff should request continuation or modification. No warning is integrated into the CPOE system, and ordering gaps expand until noticed. Some unintentional “gaps” continue indefinitely because it is unknown whether antibiotics were intentionally halted.
'''Conclusion'''
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'''6-Diluent Options and Errors'''
This paper describes preliminary suggestions for measuring the impact of HIE on public health in specific use cases. There are other secondary and tertiary benefits to improved public health that would be much more difficult to measure.  
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A recent CPOE innovation requires house staff to specify diluents (e.g., saline solution) for administering antibiotics. Many house staff are unaware of impermissible combinations.  
During the early phases of development of regional HIE, the projects will be limited in scope due to only partial penetration of local markets and therefore only partial data capture. Measures likely to be affected during this early phase are efficiency measures and costs. These early measures may be used to calculate a return on investment of the initial implementation costs.
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'''7-Allergy Information Delay'''
As these HIE systems mature and begin to share data with one another, and a truly interoperable nationwide health information network (NHIN) begins to coalesce, quality and safety effects will begin to accrue and be measurable.
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CPOE provides feedback on drug allergies, but only after medications are ordered.
----
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'''8-Conflicting or Duplicative Medications'''
'''Limitations and Strengths'''
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The CPOE system does not display information available on other hospital systems. For example, only the pharmacy’s computer provides drug interaction and lifetime limit warnings.
This article provides general evaluation methods for measuring the impact of HIE on public health in only six use cases and in two of this six cases , the author mention that it is difficult to construct an evaluation plan.
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The good thing here is that he describe the use cases in some details and he also states some other benefits of the suggested evaluation measures in guiding and encouraging the process of  HIE development and implementation.
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'''B-Human-Machine Interface Flaws: Machine Rules That Do Not Correspond to Work Organization or Usual Behaviors'''
--[[User:Dr a hegab|Dr a hegab]] 22:01, 22 March 2008 (CDT)<nowiki>by Ahmed Mahmoud
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</nowiki>
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'''1-Patient Selection'''
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It is easy to select the wrong patient file because names and drugs are close together, the font is small, names are grouped alphabetically and most critical here, patients’ names do not appear on all screens.
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'''2-Wrong Medication Selection.'''
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A patient’s medication information is seldom synthesized on 1 screen. Up to 20 screens might be needed to see all of a patient’s medications, increasing the likelihood of selecting a wrong medication.
 +
'''3-Unclear Log On/Log Off'''
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Physician scan order medications at computer terminals not yet “logged out” by the previous physician, which can result in either unintended patients receiving medication or patients not receiving the intended medication.
 +
'''4-Failure to Provide Medications After Surgery.'''
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When patients under go surgery, CPOE cancels their previous medications. When surgeons order new or renewed medications, however, the orders are “suspended” (not sent to the pharmacy) until “activated” by postanesthesia-care nurses. But these “activations” still do not dispense medications. Physicians must reenter CPOE and reactivate each previously ordered medication.
 +
'''5-Postsurgery “Suspended” Medications.'''
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Physicians ordering medications for postoperative patients whom they actually observe on hospital floors can be deceived by patients’ real location vs. patients’ computer-listed location. If patients were not logged out of postanesthesia care, the CPOE will not process medication orders, labeling them “suspended.” Physicians must renegotiate the CPOE and resubmit orders for patients to receive postsurgical medications.
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'''6-Loss of Data, Time, and Focus When CPOE Is Nonfunctional.'''
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CPOE is shutdown for periodic maintenance, and crashes are common. Backup systems prevent loss of data previously entered. However, orders being entered when the system crashes are lost and cannot be reentered until the system is restarted. House staff reported that the
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'''7-Sending Medications to Wrong Rooms When the Computer System Has Shut Down.'''
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When a patient is moved within the hospital during the system downtime.
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'''8-Late-in-Day Orders Lost for 24 Hours.'''
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When patients leave surgery or are admitted late in the day, medications and laboratory orders might be requested for “tomorrow” at, for example, 7 AM. By the time the intern enters the orders, however, it might already be “tomorrow” (i.e., after midnight). Therefore, patients do not receive medications or tests for an extra day.
 +
'''9-Role of Charting Difficulties in Inaccurate and Delayed Medication Administration.'''
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Nurses are required to record (chart) administration of medications contemporaneously. However, this requires time.
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'''10-Inflexible Ordering Screens, Incorrect Medications.'''
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 +
'''Conclusions'''
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In this study, it was found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently. As CPOE systems are implemented, clinicians and hospitals must attend to errors that these systems cause in addition to errors that they prevent.
 +
 
 +
'''Limitations'''
 +
 
 +
The study conducted at only 1 hospital, examined only 1 CPOE system and the finding are not t from random house staff samples. So the errors discussed here may not be widely generalizable. Most of these CPOE facilitated errors can be easily corrected and avoided during the development and implementation of the system.  
 +
 
 +
reviewed by Ahmed Mahmoud

Latest revision as of 22:01, 30 March 2008

Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors Ross Koppel, Joshua P. Metlay, et al.

Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors, the largest identified source of preventable hospital medical error. Published studies report that CPOE reduces medication errors up to 81%. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE. The authors undertook a comprehensive, multimethod study of CPOE-related factors that enhance risk of prescription errors.

METHODS

Design They performed a quantitative and qualitative study incorporating structured interviews with house staff, pharmacists, nurses, nurse-managers, attending physicians, and information technology managers. The Qualitative research was iterative and interactive Setting They studied a major urban tertiary-care teaching hospital with 750 beds, 39000 annual discharges, and a widely used CPOE system (TDS) operational there from 1997 to 2004. Data Collection 1-Intensive One-on-One House Staff Interviews. 2-Focus Groups.3-Expert Interviews.4-Shadowing and Observation.5-Survey.

RESULTS

The study identified 22 previously unexplored medication-error sources that users report to be facilitated by CPOE. They group these as:

A-Information Errors: Fragmentation and Systems Integration Failure.

1- Assumed Dose Information. House staff often rely on CPOE displays to determine minimal effective or usual doses. The dosages listed in the CPOE display, however, are based on the pharmacy’s warehousing and purchasing decisions, not clinical guidelines. 2-Medication Discontinuation Failures Ordering new or modifying existing medications is usually a separate process from canceling (“discontinuing”) an existing medication. Without discontinuing the current dose, physicians can increase or decrease medication, add new but duplicative medication, and add conflicting medication. 3-Procedure-Linked Medication Discontinuation Faults. Procedures and certain tests are often accompanied by medications. If procedures are canceled or postponed, no software link automatically cancels medications. 4-Immediate Orders and Give-as-Needed Medication Discontinuation Faults. NOW (immediate) and PRN (give as needed) orders may not enter the usual medication schedule. Failure to chart or cancel can result in unintended medications on subsequent days or reordering (duplications) on the same day. 5-Antibiotic Renewal Failure Antibiotics are generally approved for 3 days. Before the third day, house staff should request continuation or modification. No warning is integrated into the CPOE system, and ordering gaps expand until noticed. Some unintentional “gaps” continue indefinitely because it is unknown whether antibiotics were intentionally halted. 6-Diluent Options and Errors A recent CPOE innovation requires house staff to specify diluents (e.g., saline solution) for administering antibiotics. Many house staff are unaware of impermissible combinations. 7-Allergy Information Delay CPOE provides feedback on drug allergies, but only after medications are ordered. 8-Conflicting or Duplicative Medications The CPOE system does not display information available on other hospital systems. For example, only the pharmacy’s computer provides drug interaction and lifetime limit warnings.

B-Human-Machine Interface Flaws: Machine Rules That Do Not Correspond to Work Organization or Usual Behaviors

1-Patient Selection It is easy to select the wrong patient file because names and drugs are close together, the font is small, names are grouped alphabetically and most critical here, patients’ names do not appear on all screens. 2-Wrong Medication Selection. A patient’s medication information is seldom synthesized on 1 screen. Up to 20 screens might be needed to see all of a patient’s medications, increasing the likelihood of selecting a wrong medication. 3-Unclear Log On/Log Off Physician scan order medications at computer terminals not yet “logged out” by the previous physician, which can result in either unintended patients receiving medication or patients not receiving the intended medication. 4-Failure to Provide Medications After Surgery. When patients under go surgery, CPOE cancels their previous medications. When surgeons order new or renewed medications, however, the orders are “suspended” (not sent to the pharmacy) until “activated” by postanesthesia-care nurses. But these “activations” still do not dispense medications. Physicians must reenter CPOE and reactivate each previously ordered medication. 5-Postsurgery “Suspended” Medications. Physicians ordering medications for postoperative patients whom they actually observe on hospital floors can be deceived by patients’ real location vs. patients’ computer-listed location. If patients were not logged out of postanesthesia care, the CPOE will not process medication orders, labeling them “suspended.” Physicians must renegotiate the CPOE and resubmit orders for patients to receive postsurgical medications. 6-Loss of Data, Time, and Focus When CPOE Is Nonfunctional. CPOE is shutdown for periodic maintenance, and crashes are common. Backup systems prevent loss of data previously entered. However, orders being entered when the system crashes are lost and cannot be reentered until the system is restarted. House staff reported that the 7-Sending Medications to Wrong Rooms When the Computer System Has Shut Down. When a patient is moved within the hospital during the system downtime. 8-Late-in-Day Orders Lost for 24 Hours. When patients leave surgery or are admitted late in the day, medications and laboratory orders might be requested for “tomorrow” at, for example, 7 AM. By the time the intern enters the orders, however, it might already be “tomorrow” (i.e., after midnight). Therefore, patients do not receive medications or tests for an extra day. 9-Role of Charting Difficulties in Inaccurate and Delayed Medication Administration. Nurses are required to record (chart) administration of medications contemporaneously. However, this requires time. 10-Inflexible Ordering Screens, Incorrect Medications.

Conclusions

In this study, it was found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently. As CPOE systems are implemented, clinicians and hospitals must attend to errors that these systems cause in addition to errors that they prevent.

Limitations

The study conducted at only 1 hospital, examined only 1 CPOE system and the finding are not t from random house staff samples. So the errors discussed here may not be widely generalizable. Most of these CPOE facilitated errors can be easily corrected and avoided during the development and implementation of the system.

reviewed by Ahmed Mahmoud

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