Outcomes%20on%20Implementation%20of%20Electronic%20Medication%20Administration%20Records%20and%20CPOE

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Outcomes on Implementation of Electronic
Medication Administration Records and CPOE

• Alan Chan, MD
• Internal Medicine-Pediatrics

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Mentors

• Michael Huke, Pharm D.
• Melissa Gabriel, Pharm.D., BCPS
• Jeff Hackman, MD Emergency Dept.

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Disclaimer

• I was working on the CDC Universal Data
  Collection project for hemophilia and other blood
  disorders for adult and pediatrics.
• A couple months ago, the project was shelved due
  to funding cuts and delays.
• Im not sure if I should blame the federal budget
  cuts
• Full statistical analysis is not completed.

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Background

• Something big happened at the end of August 2010!

• Cerner GO-Live/Q6 for the CPOE (or Computer
  Physician Order entry) !!!
• This will be referred to as the start date.

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The Institute of Medicine

• In 1999 article, notes 44,000 to 98,000 deaths
  due to medical errors.
• To what extent these are directly related are
  debatable.
• Computer physician order entry is one of the
  benchmarks for patient safety.
• Defined by Leapfrog Group along with ICU
  staffing, High risk treatments/procedures, and
  Safe Practices Score
• Also part of HITECH Act of 2009.
• http//www.leapfroggroup.org/for_consumers/hospita
  ls_asked_what accessed 4/1/2011

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University HealthSystem Consortium (UHC)

• Consists of 113 academic medical centers and
  affialiated hospitals 90 of nations
  non-profits academic medical centers
• Patient Safety Net (PSN) is a real time,
  Web-based event reporting system.
• At Truman Medical Center (TMC), events can be
  logged into the system by any health care
  provider.
• https//www.uhc.edu/11851.htm accessed 4/1/2011

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Objective

• We believe that the initiation of the CPOE and
  electronic medication administration record
  (eMAR) would decrease total errors.
• What new errors might be introduced?
• Few studies exist to track these changes.

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Methods

• Search on PubMed limited to past 5 years, English
  print journals, and Humans.
• Terms included electronic medical records and
  patient safety for 228 results and Adverse drug
  events computer physician order with 51
  results.
• Some immediate references and citations to these
  results were used, which could include older
  articles.
• http//www.ncbi.nlm.nih.gov accessed 4/1/2011

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Methods (cont)

• TMC all areas (inpatient, outpatient, ER, BH)
• CPOE system Powerchart Cerner
• A retrospective review of PSN results were used
  these are self reported.
• Time frame of 1, 3, and 6 months pre and post
  implementation were used.
• A random sampling of 1 and 3 month windows were
  done to ensure similar number of reports.

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Variables

• Looked at ALL medications errors (med errors)
• Sub groups of wrong medication and incorrect
  medication list separately and also together.
• Looked at Adverse Drug Reactions (ADR), but not
  medication errors.
• In these Med errors, looked at the type of
  outcome, whether it created an Unsafe, No Harm,
  or Harmful Event.

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Medication errors 9 types

1. Dose omission
2. Extra dose given
3. Wrong medication
4. Prescription/refill delay
5. Medication list was incorrect
6. Monitoring error (includes contraindications)
7. Unauthorized drug
8. Inadequate pain management
9. Other

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Harm Score or Category of Events

• Unsafe conditions (A)
• Event, but no Harm
• B1 near miss from chance
• B2 near miss because of recovery efforts
• C reached patient (pt), but no harm
• D reached pt, and required additional
  monitoring to prevent harm
• Event, but Harm
• E pt temporary harm, and required treatment
• F pt temporary harm, and required more
  hospitalization
• G permanent harm
• H harm and required intervention to sustain
  life like ICU transfer
• Death (I) one case, but unique circumstance.
• Undetermined (X) - no cases

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Results 1 month window
PRE before start date POST after start
date ARR is the Absolute risk reduction RRR
is the relative risk reduction
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Results 3 month window
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Results 6 month window
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Results

• A few single months were checked before and after
  start date, and the overall results number of
  reported events are similar
• The overall number of reports have been
  increasing over the past few years, so difficult
  to access much before the start date.
• Overall, all types of errors are lower.

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Results Harm score
These are number of medication errors
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More errors?

• Why more Unsafe errors?
• More wrong med errors (from 5 to 10)
• New type of error delay in getting med
• A contraindication was displayed and noted
• Other types
• Why More Harmful errors?
• Actually less Omission errors
• More wrong med errors (from 5 to 7)
• Other types
• The other types may be mislabeled.

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Discussion

• User generated reports, although members of the
  PSN team here review reports as they are
  generated in real-time.
• Some other reports may not have been correctly
  classified.
• New unintended consequences one study at a
  tertiary pediatric center actually noted
  increased mortality.
• Might affect time sensitive therapies like
  critical care settings.
• Han YY, Carcillo JA, Venkataraman ST, et al.
  Unexpected increased mortality after
  implementation of a commercially sold
  computerized physician order entry system

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Next steps

• Review 1 year data
• Evaluate whether this represents a fair sample of
  the cases.
• Review the other category to make sure properly
  labeled cases
• Look at ADR and mortality, latter difficult to
  evaluate with this.

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Notable thoughts.

• It takes time for providers to adopt
• Pharmacy centralizes many medications
• Providers may spend more time away from bedside
• Physician workload will increase, but uncertain
  amount
• Is this trade off worth the better documentation
  and e-paper trail?
• More order set would decrease click through
  time
• Delays in opening electronic charts during heavy
  work times
• Self reported events and ADR may not correlate
  with true rate.

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Other thoughts

• One study at a pediatric hospital saw overall
  decrease in hospital wide mortality with CPOE and
  electronic nursing documentation.
• Studies at ICU areas show decrease in risk of
  medication errors, but no significant reduction
  in ADR or mortality.
• Many studies have not been fully powered to
  detect the small number of ADR or mortality
  though.
• We can look at 1 year data from start date.

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References

• http//www.leapfroggroup.org/for_consumers/hospita
  ls_asked_what accessed 4/1/2011
• Han YY, Carcillo JA, Venkataraman ST, et al.
  Unexpected increased mortality after
  implementation of a commercially sold
  computerized physician order entry system
  published correction appears in Pediatrics.
  2006117(2)594. Pediatrics. 2005116(6)1506151
  2.
• Van Rosse F, Maat B, Carin MA, et al. The Effect
  of CPOE on Medication Prescription Errors and
  Clinical Outcome in Pediatric and Intensive Care
  A Systemic Review. Pediatrics. 2009 123(4)
  1184-1190.
• Sittig DF, Ash JS, Zhang J, et al. Lessons From
  "Unexpected Increased Mortality After
  Implementation of a Commercially Sold
  Computerized Physician Order Entry System.
  Pediatrics. 2006 118 797-801.
• Longhurst CA, Parast L, Sandbord CI, et al.
  Decrease in Hospital-wide Mortality Rate After
• Implementation of a Commercially Sold
  Computerized Physician Order Entry System.
  Pediatrics. 2010 126 14-21.
• Kaushal R, Shojania KG, Bates DW. Effects of
  Computerized Physician Order Entry and Clinical
  Decision Support Systems on Medication Safety.
  Arch Intern Med. 2003 163 1409-1416.
• http//www.cpoe.org/ From Oregon Health and
  Sciences University. Accessed 4/1/2011

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