Using a computerized provider order entry system to meet the unique prescribing needs of children: description of an advanced dosing model
Background: It is well known that the information requirements necessary to safely treat children with therapeutic medications cannot be met with the same approaches used in adults. Over a 1-year period, Duke University Hospital engaged in the challenging task of enhancing an established computerized provider order entry (CPOE) system to address the unique medication dosing needs of pediatric patients. Methods: An advanced dosing model (ADM) was designed to interact with our existing CPOE application to provide decision support enabling complex pediatric dose calculations based on chronological age, gestational age, weight, care area in the hospital, indication, and level of renal impairment. Given that weight is a critical component of medication dosing that may change over time, alerting logic was added to guard against erroneous entry or outdated weight information. Results: Pediatric CPOE was deployed in a staggered fashion across 6 care areas over a 14-month period. Safeguards to prevent miskeyed values became important in allowing providers the flexibility to override the ADM logic if desired. Methods to guard against over- and under-dosing were added. The modular nature of our model allows us to easily add new dosing scenarios for specialized populations as the pediatric population and formulary change over time. Conclusions: The medical needs of pediatric patients vary greatly from those of adults, and the information systems that support those needs require tailored approaches to design and implementation. When a single CPOE system is used for both adults and pediatrics, safeguards such as redirection and suppression must be used to protect children from inappropriate adult medication dosing content. Unlike other pediatric dosing systems, our model provides active dosing assistance and dosing process management, not just static dosing advice.
Children are inherently different than adults due to childhood being such a dynamic period during ones lifetime. The abrupt changes in weight and physiological characteristics are a major cause in children being placed at a higher risk for incorrect dosing. Most pediatricians need to calculate doses based a wide array of information such as weight, age, gestational age, and indication, the slightest mistake in calculations or due to improper system design can cause significant morbidity and mortality. This is why the American Academy of Pediatrics states that the use of a computerized system should be used whenever possible. One study has even shown that a pediatric CPOE will reduce medication errors by 95%, and adverse drug events by 40%.
Duke Children's Hospital (DCH) is a component of Duke University Hospital (DUH), and serves as a tertiary pediatric referral center that has an average of 7000 pediatric admissions per year. DUH maintains a Horizons Expert Orders CPOE system. DCH introduced the Advanced Dosing Model (ADM) CPOE over a 14-month period. Before the ADM system was put into place a needs assessment was preformed by an advisory workgroup made up of physicians, nurses, pharmacists, and safety directors that defined the requirements for a pediatric CPOE. A major requirements of the system was that multiple broad patient criteria could be incorporated into the dosing decision assistance at the time of order entry.
The ADM CPOE system uses a content table with the information provided by the physician at the time of order entry to determine if pediatric medication dosing is required. This then gives a maximum and minimum amount of medication that can be given unlike other CPOE systems that will show the ordering physician all possible choices. Using this new system has decreased ADE rates by 42.9% and 46.4% in the PICU and NICU, respectively. While there is a decreases in ADE rates, these could be due to limited data and reporter bias.￼
This study described an implementation of the ADM CPOE system at DCH. While there were favorable results, they may have been biased due to reporter bias and limited data. The system also has limitations due to the fact that ADM was studied on a sub-population which may in the long run require significant resources management, implementation, and maintenance trade-offs between over and under defining dosing regions. There is also the problem of specific drugs not being able to be suggested due to the lack of over lap between the larger and smaller populations. Though even with these limitations ADM offers a powerful tool for use in children wards and hospitals that not only better treats the patients but gives them better outcomes.
I found this study to be very interesting. The fact that Duke was able to take their existing CPOE system and then add the advanced dosing model to lower ADE rates in their children hospital was quite amazing. I also found that the fact that children are so underserved to be a large problem, it is not as if children are not treated in hospitals every day and the fact that there is not an efficient way to dose children's medications at this point actually scares me. I think if other hospitals were to take ADM and implement it into their systems we would see a large decrease in morbidity and mortality.
- Using a computerized provider order entry system to meet the unique prescribing needs of children: description of an advanced dosing model (Ferranti 2011)