# Presentation: 043320

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

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

-   Reexamination and New Data

## Our Study

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

## 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

## Our Study’s 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

## Findings:   22 medication error risks facilitated by CPOE  

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

## 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]

| Assumed Minimum Dose & Assumed Dose Range Information             In the past three months... have you... | Never% | < 1/ week % | About a few times/
wk % | About once a day % | >once per day % |
| --- | --- | --- | --- | --- | --- |
| Used CPOE to determine low dose for infrequently used medications... | 27.3 | 34.6 | 28.5 | 7.3 | 2.3 |
| Used CPOE to determine the range of doses for infrequently used medications... | 18.5 | 40.4 | 27.3 | 10.8 | 3.1 |

## 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.

| Medication Discontinuation Failures            
In the past three months... have you... | Never% | < 1/
week % | About a few times /wk % | About once a day % | >once per day % |
| --- | --- | --- | --- | --- | --- |
| Delayed for several hours canceling medication because of fragmented CPOE display... | 48.6 | 29.0 | 12.0 | 6.2 | 4.2 |

## 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”]

| Antibiotic Renewal Failure Therapy Gaps.   In the past 3 mos... have you... | Never% | < 1/week % | About a few times /wk % | About once a day % | >once per day  % |
| --- | --- | --- | --- | --- | --- |
| Observed a gap in antibiotic therapy because of unintended delay in re-approval of antibiotic.  | 16.9 | 43.5 | 26.9 | 6.9 | 5.8 |

## 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]

| Patient Selection--Screen Design; & Inconsistent Color/Font Coding 
In the past 3 mos...have you.. | Never % | < 1/week % | About a few times /wk % | About once a day % | >once per day % |
| --- | --- | --- | --- | --- | --- |
| Not been able to quickly tell which patients you are ordering for because of poor CPOE display... | 45.4 | 32.3 | 12.3 | 5.0 | 5.2 |

## Ex: Wrong Medication Selection—Multiple Screens 

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

| Wrong Medication Selection—Multiple Screens.   In the past   
3 mos have you... | Never% | < 1/
week % | About a few times /wk % | About once/ day % | >once per day % |
| --- | --- | --- | --- | --- | --- |
| Been uncertain about patients’ medications because of multiple CPOE displays... | 28.5 | 25.4 | 23.4 | 11.7 | 10.9 |

## 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.**

## 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.**

## 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*

## 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@sas.upenn.edu*