Difference between revisions of "Han YY, Carcillo JA, Venkataraman ST, Clark RSB, Watson RS, Nguyen TC, Bayir H, Orr RA. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005 Dec; 116(6): 1506-12"

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The authors report that in response to the IOM To Err Is Human: Building a Safer Health System report and the Leapfrog Group patient safety standard bechmarks, the Children’s Hospital of Pittsburgh implemented a hospital-wide commercially sold CPOE system in October of 2002. CHP was one of the first children’s hospitals in the United States to attain 100% electronic physician order entry. They also note that there is increasing discussion in the medical literature of  unintended consequences and impacts of CPOE on patient outcomes. They proposed to evalute mortality rates of a specific group of  high risk patients before and after instituting CPOE, the null hypothesis being that patient outcome would improve after this implementation.
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Han YY, Carcillo JA, et al. Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System. Pediatrics. 2005 Dec; 116(6):1506-12.
  
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The study population was all children admitted to CHP by interfacility transport during an 18 month period extending from October, 2001 to March 2003. CHP comprehensively implemented the CPOE system simultaneouly with its complementary clinical applications platform in October, 2002. It was felt that this patient population represented a first-encounter cohort to the CHP system that required urgent processing of admitting and treatment orders.  Additionally, each patient’s presentation was assigned a Pediatric Risk of Mortality (PRISM) score which was used to calculate predicted mortality rates for the study population. The authors also noted  “Changes to health care team dynamics and the manner by which bedside care was delivered ...”.
 
  
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A total of 1942 children were admitted to CHP via interfacility transport during the study perod, 1394 before and 548 after CPOE implmentation. The most common primary presentations were for respiratory/airway issues (42.6%), infectious disease (34.9%) and CNS/neuromuscular problems (19.4%).  1102 (56.7%) of patients were admitted to the ICU.  There were no essential differences in the clinical and demographic characteristics of the two groups.  The overall unadjusted mortality rate was 3.86% (75 patients) but was 2.80% before CPOE implementation and 6.57% after.  Based on PRISM scores observed mortality was better than predicted before CPOE implementation but worse than predicted after. In a regression model adjusted for PRISM score CPOE was independently associated with an increased risk of mortality (OR = 3.71, 95% CI 2.13 – 6.46), second only to shock (OR = 6.24) as an independent predictor of mortality in the study population.  The same analysis not adjusted for PRISM score still resulted in a mortality OR of 3.28 for CPOE.
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    The authors of this article describe their experience with PowerOrders (Cerner) at Children’s Hospital of Pittsburgh.  The system was “implemented hospital-wide over 6 days”.  The mortality rates were compared 13 months before and 5 months after CPOE (computerized physician order entry) activation .
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    The methods section notes that they studied all children admitted to their hospital “via interfacility transport for specialized, tertiary-level care during an 18 month period”. Severity of illness was assessed by the PRISM (Pediatrics Risk of Mortality) score.  This population is equivalent to pediatric intensive care unit (PICU) /critical care patients.
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    The methods section further discusses the use of the CPOE system.  The staff had a 3-hour teaching/practice session roughly 3 months prior to the system activation.  The system provides decision support related to drugs.  The orders must be activated by nursing prior to processing by the pharmacy.
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    The results section outlines the patient characteristics in table 1.  There was no significant difference in the pre and post CPOE patients except that there were more patients with central nervous system disease prior to the CPOE implementation.  The mortality rate was 2.8% (39 of 1394) prior to CPOE and 6.57% (36 of 548) after CPOE.  The P value was less than 0.001.  There were multiple factors that were independently associated with risk of mortality including CPOE.
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    The authors contrast their experience with other staff at their hospital (1) who noted a decrease in adverse drug events. This type of improvement has been noted by other groups (2). The authors also note that entering orders by CPOE takes more time and suggest that this may have adverse consequences in their group of acutely ill patients. Bergeron (3) has raised similar concerns about time. They also note changes in the dynamics of interaction among the staff, i.e. less face-to-face physician-nurse communication.
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    This article raises a number of important issues regarding CPOE.
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[1] Direct measurement of actual adverse events (death) may have greater validity than measuring potential adverse drug events.
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[2] The amount of training that the staff received (3 hours) was probably inadequate for most of the staff.
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[3] The amount of time after CPOE implementation may have been too short.  It would be worthwhile to re-examine this issue 2-3 years post CPOE implementation.
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[4] Improvement in the user-system interface may decrease some of the time problems.  The intensive care unit is especially problematic in the time area.
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[5] Ongoing training is important in ensuring optimum use of CPOE. This could be a situation where a biomedical informatician could be helpful in seeing the problems and suggesting possible solutions.  The use of custom order sets would be one possible suggestion for the time problem.
  
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The authors document a number of  observations.  The standard admission and order implementaion process was significantly changed after CPOE implementation.  In the ICU setting, the electronic order process was less efficient, more time consuming and more labor intensive, resulting in delays in diagnostic testing and initiation of therapies.  The organization of bedside care was significantly altered as one physician had to be exclusively doing order entry and a nurses had to computer activate all orders, resulting in less bedside personnel deliviering actual patient care.  Centralization of medications in the pharmacy and the need for pharmacy processing of all orders, a primary component of the ADE function of the PCS, resulted in serious delays in medication administration.  The number of patients who received antibiotics and vasoactive drugs within national guideline-recommended timelines was decreased by greater than 50% after CPOE implemetation.  Finally, direct physician-nurse interaction, deemed crucial to patient care and management in a critical care time-dependent setting, was fundamentally and negatively impacted by CPOE.
 
  
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The authors conclude that implementaions of CPOE systems “are typified by contingencies and proceed in a far from linear manner. They are part and parcel of organizational dynamics that ... cannot be foreseen, let alone predicted” (1).  They make a number of associated observations. This is a retrospective study and definitive statements about causal relationships cannot be made. The study population may be unique and different subpopulations may demonstrate differing results. The study period included the CPOE/clinical applications implementation period and may represent findings associated with institutional change, not necessarily CPOE intrinsically. The results may be due to the imbalance in the two study periods. The findings may be secondary to  issues with the clinical application system and not specifically CPOE  and finally, the observed association between CPOE implementaion and increased mortality could be due to an unidentified confounding variable.
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Gregory Griffin 10/21/06; 9:26 pm--[[User:Ggriffin|Ggriffin]] 20:36, 21 October 2006 (CDT)
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Comment
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The extrapolation of  ADE and medical error reduction by CPOE to improved patient outcomes is unproved.  CPOE is a tool that holds great potential promise for improving health care delivery.  More outcomes based research, however, is needed to assess the impact of CPOE on the delivery of clinical care.
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1. Aarts J, Doorewaard H, Berg M.  Understanding omplemantation:  The case of a computerized physician order entry system in a large Dutch university medical center.  J AM Med Inform Assoc.  2004; 11: 207 – 216.
 
  
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[[Category:OHSU-SP-06]]
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1. Upperman JS, Staley P, et al.  The introduction of computerized physician order entry and change management in a tertiary pediatric hospital.  Pediatrics. 2005 Nov;116(5):e634-42.
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[[Category:Reviews]]
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2. Potts AL, Barr FE, et al.  Computerized Physician Order Entry and Medication Errors in a Pediatric Critical Care Unit.  Pediatrics.  2004 Jan;113(1):59-63.
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3. Bergeron BP.  Medical Errors: Computers Are No Panacea.  J Med Pract Manage. 2005 Jul-Aug;21(1):31-4.

Revision as of 01:36, 22 October 2006

Han YY, Carcillo JA, et al. Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System. Pediatrics. 2005 Dec; 116(6):1506-12. 


    The authors of this article describe their experience with PowerOrders (Cerner) at Children’s Hospital of Pittsburgh.  The system was “implemented hospital-wide over 6 days”.  The mortality rates were compared 13 months before and 5 months after CPOE (computerized physician order entry) activation .
    The methods section notes that they studied all children admitted to their hospital “via interfacility transport for specialized, tertiary-level care during an 18 month period”.  Severity of illness was assessed by the PRISM (Pediatrics Risk of Mortality) score.  This population is equivalent to pediatric intensive care unit (PICU) /critical care patients.
    The methods section further discusses the use of the CPOE system.  The staff had a 3-hour teaching/practice session roughly 3 months prior to the system activation.  The system provides decision support related to drugs.  The orders must be activated by nursing prior to processing by the pharmacy.
    The results section outlines the patient characteristics in table 1.  There was no significant difference in the pre and post CPOE patients except that there were more patients with central nervous system disease prior to the CPOE implementation.  The mortality rate was 2.8% (39 of 1394) prior to CPOE and 6.57% (36 of 548) after CPOE.  The P value was less than 0.001.   There were multiple factors that were independently associated with risk of mortality including CPOE.
    The authors contrast their experience with other staff at their hospital (1) who noted a decrease in adverse drug events.  This type of improvement has been noted by other groups (2).  The authors also note that entering orders by CPOE takes more time and suggest that this may have adverse consequences in their group of acutely ill patients.  Bergeron (3) has raised similar concerns about time.  They also note changes in the dynamics of interaction among the staff, i.e. less face-to-face physician-nurse communication.
    This article raises a number of important issues regarding CPOE.

[1] Direct measurement of actual adverse events (death) may have greater validity than measuring potential adverse drug events. [2] The amount of training that the staff received (3 hours) was probably inadequate for most of the staff. [3] The amount of time after CPOE implementation may have been too short. It would be worthwhile to re-examine this issue 2-3 years post CPOE implementation. [4] Improvement in the user-system interface may decrease some of the time problems. The intensive care unit is especially problematic in the time area. [5] Ongoing training is important in ensuring optimum use of CPOE. This could be a situation where a biomedical informatician could be helpful in seeing the problems and suggesting possible solutions. The use of custom order sets would be one possible suggestion for the time problem.


Gregory Griffin 10/21/06; 9:26 pm--Ggriffin 20:36, 21 October 2006 (CDT)


1. Upperman JS, Staley P, et al. The introduction of computerized physician order entry and change management in a tertiary pediatric hospital. Pediatrics. 2005 Nov;116(5):e634-42. 2. Potts AL, Barr FE, et al. Computerized Physician Order Entry and Medication Errors in a Pediatric Critical Care Unit. Pediatrics. 2004 Jan;113(1):59-63. 3. Bergeron BP. Medical Errors: Computers Are No Panacea. J Med Pract Manage. 2005 Jul-Aug;21(1):31-4.

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