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

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.