Saturday, January 12, 2008

Computerized physician order entry (CPOE)

This is one of a series of blogs on hospital information technology, emphasizing its limitations and pitfalls.

The following is a short excerpt from Biomedical Informatics.

One of the most challenging features of many HISs is computerized physician order entry (CPOE). The intent of CPOE is to eliminate the wasteful hand-written (often illegible) doctor's orders that may need to be transcribed by nurses, pharmacists, and laboratory personnel before finally entered into the HIS. Having the physicians directly enter their orders into the HIS has been a long-awaited dream for many hospital administrators. In a fascinating report, patient mortality was shown to increase after implementation of CPOE.

[Han YY, Carcillo JA, Venkataraman ST, Clark RS, Watson RS, Nguyen TC, Bayir H, Orr RA. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 116:1506-1512, 2005. text of article]

In this study, having CPOE was a strong, independent predictor of patient death. Somehow, a computerized service intended to enhance patient care had put patients at increased risk.

Without commenting on this particular study, it may be useful to review some factors that transform CPOE, and other well-intended medical informatics efforts, into destructive technologies.

Reasons why hospital informatics projects, such as CPOE, may fail.

-Tasks that were traditionally accomplished through intepersonal communication may be replaced by solitary entry sessions with HIS computer terminals. Opportunities to share helpful explanations and patient status updates may be lost.

-Computer entry tasks may be tedious, time-consuming, and repetitive. Harried staff, under these circumstances, may do an incomplete or sloppy job.

-Computer orders, once entered, may have no mechanism for correcting entry errors, leading to miscommunications.

-The asynchronous nature of multi-user entries into the HIS may cause havoc in a system that depends on coordinated workflow. For instance a prescription may not be filled by pharmacy until an order entered by a clerk-typist is released by a physician. If there is no system to ensure that each entry occurs in a timely and coordinated manner, workflow is halted.

Beyond informatics issues lie all-important social issues. High-tech medical solutions seldom achieve a desired effect for low-tech medical staff. Introducing complex informatics services, such as CPOE, requires staff training. There needs to be effective communication between the clinical staff and the hospital IT staff and between the hospital IT staff and the HIS vendor staff. Everyone involved must cooperate until the implemented system is working smoothly.

-Jules Berman

In June, 2014, my book, entitled Rare Diseases and Orphan Drugs: Keys to Understanding and Treating the Common Diseases was published by Elsevier. The book builds the argument that our best chance of curing the common diseases will come from studying and curing the rare diseases.

I urge you to read more about my book. There's a generous preview of the book at the Google Books site. If you like the book, please request your librarian to purchase a copy of this book for your library or reading room.

tags: common disease, orphan disease, orphan drugs, rare disease, subsets of disease, disease genetics, genetics of complex disease, genetics of common diseases, cryptic disease