Published in the December 2011 issue of Today’s Hospitalist
CONSIDER IT A DILEMMA of the computerization of health care. While electronic medical records need physician input via computerized provider-order entry (CPOE), doctors are having a tough time figuring out how to navigate systems that are being rushed to market.
A case in point: A recent study revealed that introducing a CPOE system with clinical decision-support actually increased the number of duplicate medication orders. The irony is that CPOE is supposed to prevent that exact problem.
The study, which was published online in July by the Journal of the American Medical Informatics Association, found that after CPOE was implemented, duplicate medication orders jumped from 2.6% of all orders to 8.1%. The study looked at drug orders in two ICUs (adult and cardiac) at a 400-bed community teaching hospital.
Lead author Tosha B. Wetterneck, MD, MS, a hospitalist and researcher in the Center for Quality and Productivity Improvement at the University of Wisconsin-Madison, says it’s no surprise that introducing CPOE leads to duplicate order entries. That’s because many systems come with design flaws “and because physicians may need to change how they work to accommodate the new technology.
Dr. Wetterneck and her colleagues suggested specific steps that hospitals “and hospitalists “can take to address problems with systems. She spoke with Today’s Hospitalist about how duplicate orders happen and how systems should be redesigned to make them safer.
Why did your study focus on the ICU?
We know there are higher usages of meds, especially high-risk meds, in the ICU setting. We were looking for a more-bang-for-your-buck study, so we chose to do this study in ICUs.
How does CPOE with clinical decision-support lead to duplicate orders?
Instead of one way to order medications, there are now multiple ways. We have a laptop or four or five computers on wheels, and people stand in a circle in the ICU. Each person can look at data at the same time, and everyone can see what I see with a shared understanding of what’s going on. But each resident, intern, pharmacist or attending standing behind a computer can enter an order then or later. When we used paper charts, only one person wrote an order. If the plan that day was to replace potassium, we never had to say, “Who’s going to do that?” We could see the chart and know if somebody had done it.
How do duplicate orders play out during handoffs?
We did see the same exact orders written around shift changes. That leads to an obvious question: Why isn’t the person coming on aware that an order based on labs was already written? The answer is that the information isn’t commonly given during handoffs.
Also, it’s sometimes hard to tell on the computer which orders are recently placed; you have to click to a different screen. The system didn’t allow side-by-side screens, and there are no pop-up windows. When a nurse completes an order, it’s not active so you don’t get a duplicate alert even if the drug is given for one-time meds or doses. Once that drug is administered, that information is sent to the system’s discontinued medication bin.
What finding was most disturbing?
Many duplicate orders were placed within an hour of each other, sometimes by the same provider, sometimes by different providers.
Why didn’t the warning systems work?
There was a problem with how the algorithms were designed. Duplicate order checking is based on identifying similar medications, which includes both the medication name and the route of administration. If I said, “Replace potassium,” but one person ordered it by IV and one ordered it orally, the system doesn’t issue a duplicate med alert because the routes of administration are not the same. That needs to be changed.
The alert picked up three different kinds of duplicates: the same order, the same medication and the same drug class. Many duplicate alerts for drugs in the same class are false positives because we use a lot of meds in the same therapeutic class. Plus, we found that the content of the alerts that popped up was very complex.
How did physicians react?
We know from the literature that people tend to ignore alerts when false positive rates are above 15%. When you get alerts so frequently, it’s like crying wolf, and physicians just click through them. The ICU has such a high workload and high distraction rate that it’s easy to see why alerts are frequently overridden. It also explains why a lot of organizations turn alarms off.
Do duplicate orders lead to medical mistakes?
Most hospital systems have pharmacists and nurses reviewing orders so they can catch mistakes. In an upcoming study, we’ll report that the majority of these duplicate orders are caught.
You suggest ways to improve CPOE system design. (See “CPOE and duplicate orders.”) What else do you consider critical?
We need to design computers to give people information that they need. For example, systems should have a split screen showing orders placed in the last two hours or the last 20 orders.
What changes can physicians make?
There are some system fixes we can make ourselves: assigning who’s actually going to write orders, having maybe just one designated order writer. At handoffs, we may need to say, “I replaced this” or “I ordered the potassium.”
How can these systems be made to work better?
We should use a holistic approach by looking at the entire system.
What is the design of the computer system? What can I control?
We need to involve human factors engineers who understand system design.
Companies are rushing to release these systems because millions of dollars are at stake. With federal legislation providing financial incentives to implement EHRs, you want to be out there now.
Because of this, we are going to have technology introduced that won’t meet all of our needs. It’s up to us to understand the limitations.
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.