The Challenges and Promise of Computerized Physician Order Entry CPOE Systems:

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The Challenges and Promise of Computerized
Physician Order Entry (CPOE) Systems
Reexamination and New Data

• Ross Koppel, Ph.D. Sociology Department and
  Center for Clinical Epidemiology Biostatistics,
  University of Pennsylvania
• AHRQ Conference on Healthcare Information
  Technology, June, 2005

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Our Study

• Role of Computerized Physician Order Entry
  Systems in Facilitating Medication Errors
• JAMA, March 9, 2005
• Koppel, Metlay, Cohen, Abaluck, Localio, Kimmel,
  Strom

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Reaction to Our Article

• Thousands of articles, comments, press releases,
  attacks, and support
• J. of Biomedical Informatics 4 papers on our
  work JAMA 6 letters
• Informatics community Of course, just good
  data.
• Vendor community Irrelevant because it was old
  system

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Our Studys Genesis

• The role of hospital workplace stressors (e.g.,
  shifts, sleeplessness, new rotations) on
  housestaff medication prescribing errors.
• The CPOE system emerged as a study focus when
  housestaff repeatedly told us it caused stress
  and error

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Findings 22 medication error risks facilitated
by CPOE

• I. Information Errors generated by fragmentation
  of data and failure to integrate the hospitals
  several computer and information systems
• II. Human-Machine Interface Flaws Reflecting
  machine rules that do not correspond to work
  organization or usual behaviors

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Ex Assumed Minimum Dose Assumed Dose Range
Information

• 73 of housestaff use CPOE displays to determine
  low doses 82 used CPOE displays to determine
  range of doses. 40 used CPOE to determine
  dosages at least a few times weekly 10 to 14
  daily. New Systems Differences

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Ex Medication Discontinuation Failures for
several hours Not canceling medication because
of fragmented CPOE

• Reported by 51. 22 indicated this occurs a few
  times weekly, daily or more frequently.

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Ex Antibiotic Renewal Failure--Therapy Gaps

• 83 of housestaff observed gaps in antibiotic
  therapy because of unintended re-approval delays.
  27 reported this occurs a few times weekly 13,
  once daily or more frequent. New System RNs
  save us

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Patient Selection--Screen Design Inconsistent
Color/Font Coding

• 55 of housestaff Difficulty identifying the
  patient they were ordering for because of
  fragmented CPOE displays 23 say this happened a
  few times weekly or more frequently. New
  system Foolish Observation

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Ex Wrong Medication SelectionMultiple Screens

• 72 of housestaff report they were often
  uncertain about medications and dosages due to
  difficulty in viewing all the medications on one
  screen

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Our RECOMMENDATIONS Concentrate on Organizational
Factors (1-3 of 5)

• 1. Focus primarily on the organization of work
  not on technology. CPOE must only determine
  clinical actions if they improve care.
• 2. Aggressively examine the technology in use.
  Problems obscured by workarounds, medical problem
  solving ethos, and low housestaff status.
• 3. Substitution of technology for people is a
  misunderstanding of both. Aggressively fix
  technology when shown to be counter-productive.
  Failure to do so engenders alienation and
  dangerous workarounds.

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Our RECOMMENDATIONS Concentrate on Organizational
Factors (4-5)

• 4. Episodic and incomplete error reporting are
  standard. Management belief in these reports
  obfuscates and compounds problems. Pursue errors
  second stories.
• 5. Plan for continuous revisions and quality
  improvement recognizing that all changes
  generate new error risks.

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Preview of New Findings

• Have studied NEW system (SCM) in same hospital
  with same and new cohorts
• Asked same questions in same format
• Few improvements surprise to us
• 1. fewer crashes
• 2. lack of guidance on dosages (sic)
• 3. Others No improvement or worse

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Coda Questions and Issues

• New Research still to be explored
• Response by IT vendors and friends
• Increasing Acceptance New articles within past
  few weeks
• Your questions?
• Ross Koppel, Ph.D. Sociology Dept. and Center
  for Clinical Epidemiology Biostatistics, Univ
  of Penn. rkoppel_at_sas.upenn.edu