Deborah Murray

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Critical Literature Review

A HIT Evaluation: Reduction of medication errors through CPOE use

I certify that my work in this course will be entirely my own work. I will not quote the words of any other person from a printed source or a website without indicating what has been quoted and providing an appropriate citation. I will not submit my work in this course to satisfy the requirements of any other course. Name/Signature: ___Deborah Murray______________________

Deborah Murray

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Nearly more than 7000 patients per year in the United States die due to sloppy handwriting of Physicians. From a clinical perspective there is a definite need for improvement of illegible physician writing as it is a risk to patient care. From a patient perspective, numerous injuries and law suits speak loudly that correction of poor physician penmanship is eminent. Lastly, the bad handwriting of physicians can be attributed to medication errors. The means to correct this issue facing the healthcare community and the public is to implement technology in the form of Computerized Physician Order Entry (CPOE). It is the purpose of this presentation to review current literature and evaluate the reduction of medication errors due to poor handwriting of the physician by addition of a CPOE system.

Deborah Murray

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Illegible physician handwriting is an age-old issue that is long overdue for extinction. With medication orders that look like hieroglyphics more than a spoken language, clinicians try desperately to translate, magnify, and breakdown physician handwritten prescriptions. While clinicians frustration with this issue is real, some physicians view bad handwriting as a badge of honor. After all, the physician is a busy, productive, and essential part of the clinical team. More often than not, a physicians time is his most valuable commodity. This commodity can sometimes be paid for in sloppiness, medication errors, and even death.

Illegible physician handwriting is sufficiently documented in both the medical community as well as public forums. (Moore 2010, Stross 2012,ASHP, Sokol 2006) The effects of poor physician penmanship can bog down workers and interrupt patient care. Research confirms that handwritten prescriptions are several times more likely to result in medication errors (Stross 2012, ASHP, Sokol 20060).

The literature reviewed offered two different solutions for illegible physician handwriting. The call for physician penmanship classes (Science Daily 2000, Sokol 2006) was initiated by the medical staff at Cedars-Sinai Medical Center in 2000. This shows the early recognition of the issue and willingness to correct, however, with modern technology this solution is no longer a viable one. Conversely, Kaushal 2010 and ASHP advocate the use of CPOE to enable automated checking for doses, strength, allergies, and drug interactions. Another alternative

solution would be the use of preprinted physician orders, however this will be explored later.

There is obvious quantitative data to support that poor physician handwriting exist. There is also supporting qualitative data that support solutions to eradicate poor penmanship if not abolish it altogether. These next pages will be dedicated to exploring CPOE effects.

Deborah Murray

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Historically, the eariliest existance of a successful CPOE program was in the early 1970s.(Bates, 1994). The addition of CPOE opened the door for opportunity for clinicians and allowed researchers to study the many potential advantages and improvements it could provide.

A 2006 report by the Institute of Medicine estimated that a hospitalized patient is exposed to a medication error each day of his or her stay . These medication error risks included those due to illegible writing by physicians. This risk is greatly dimished by the addition of CPOE (Ammenwerth 2008, Bates 1999, Yu 2009). These studies quantitavtively evaluated the reduction of medication errors. While Ammenwerth et al. found that overall 23 of 25 studies showed a significant medication error rate reduction of 13% to 99%, Yu et al. found that 264 institutions using CPOE reported improvement in medication-related outcomes in hospitals. The value of Yu et al. research is that it was a study of both qualitative and quantivative responses to CPOE. Another type of qualitative study was a time series analysis with three period of time (Bates 1999). This type of study has its advantages in that small adjustments could be made to the CPOE systems as the study progressed in time. The downside to this method could be biased results and lack of randomization. Never the less, Bates et al. results report significant reductions in medication errors.

The type of CPOE system was also evaluated generically (Yu 2009, Leonard Davis Institue of Health Economics 2011). Ammenwerth et al. provided a more detailed evaluation of several CPOE systems. In all cases, the hardware and software of the CPOE systems was discussed, but not the focus of the results.

The Leonard Davis Institue of Health Econmics admitted that CPOE can eliminate medication errors due to bad handwriting (2011). However, they are the only researchers to admit that this elimination is dependent on physicians use of CPOE. While the LDI does offer some how tos with CPOE, it is beyond the scope of this literature review.

MedicExchange Directory of Computerized Physician Order Entry (CPOE) Companies

Computerized physician order entry (CPOE) is a procedure of electronic entry of medical practitioner orders for patient treatment. Physician orders are conveyed through a computer network to varied medical staff and health departments, radiology, pharmacy, laboratory etc. accountable for carrying out the order. CPOE systems replace conventional methods of order entry, and ascertain that the orders are comprehensible - it trims down readability errors, and enhances patient safety. (Source mediexchange)

There were quite a bit of COPE systems reviewed in Ammenwerth.( 2008 ) A basic review of systems is as follows: System 1- EmSTAT, Cyber Plus (1997) Commercial Prescription writing module with display of patient name, age, sex, patient weight, patient allergies. NO Decision Support Focus- conversion of handwritten prescriptions System 2- BICS, home grown system (1993). CPOE with limited Decision Support of renal insufficiency dosing. System 3-Invision 24, Siemens (2000)-Commercial- CPOE with best practice based order sets, drug-allergy checks, drug-drug interactions, order duplication, corollary orders, weight based dosing, drug route restriction. Advanced Decision Support.

SYSTEM EmSTAT

AVAILABILITY commercial

CPOE COMPONENT yes

YEAR INCEPT 1997

CLIN DECSION SUPPORT no

BICS

home grown

yes

1993

limited

Invision 24

commercial

yes

2000

advanced

Deborah Murray Benefits of CPOE

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The addition of a CPOE system can be an intimidating and costly event for any hospital. The amount of work and research is daunting no matter how prepared the facility is for this event. Even with this in mind, the many benefits of a functional CPOE system can be cost efficient and patient beneficial. First and foremost, the Healthcare Information Technology for Economic and Clinical Health Act (HITECH) of 2009, per the Health and Human Services Department U.S. set forth a provision that Healthcare Information Technology (which includes CPOE) was passed by President Obama. Under this act, healthcare organizations reaching meaningful use status as of the year 2011 could qualify for government incentive payments, while those medical practices that have not met the standards set forth by 2015 will be penalized monetarily (HHS 2009). The benefits of CPOE as presented by Tierny (1993) and Amarasingham (2009) may have occurred at vastly different times but deliver the same message. This message is that CPOE is not only cost effective but reduces patient complications, length of hospital stay and lower mortality rates. While using a randomized controlled trial (RTC), Tierney (1993) concluded that significant lowered patient charges in addition to total hospital costs, resulted in a $3 million surplus in a fiscal year. In addition, Amarashingham (2009) confirmed this age old benefit by conducting a lengthy, multi hospital crosssectional study. They noted that CPOE was associated with a 9% to 55% cost reduction rate. This type of study allowed for the authors to specifically note that higher scores on order entry, test results, and decision support were associated with lower costs for all hospital admissions. It must be noted that some bias existed in Amarashingham et al. due to the fact that the study only used patients 50 years old or greater. While this population tends to have more health issues, this only substantiates the benefits of CPOE. Future studies should include all ages. None of the articles reviewed mentions the cost savings involved with time management reductions. This author believes that perhaps positive results in this area of study have failed. This issue also needs further study perhaps with a cost benefit type of evaluation. Alternatives to CPOE As discussed previously, preprinted physician orders are an alternative to CPOE technology and physical handwriting. These preprinted physician orders usually pertain to a standard set of orders in specialty healthcare (i.e. Coronary Care medications). The physician then just checkmarks the medications he wishes the patient to have. The drawbacks to this type of system is that more often than not, additional technology is needed to write the standardized orders, alert fatigue can occur, and physicians can alter the orders via penmanship at any given time (Ehringer 2009).

Deborah Murray Unintended Consequences of CPOE

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The addition of CPOE or any technology is not without its misgivings. The development of CPOE and HIT would not be as advanced if failure, massive research, and time were not a part of the process. Therefore, the unintended consequences of CPOE do occur and are addressed as follows. In qualitative studies, unintended consequences of CPOE included fragmentation (Koppel 2005, Campbell 2006). This fragmentation could cause an incoherent view of the patients electronic medical record. This fragmentation maybe a cause for medication errors but involvement with physician illegible handwriting is highly unlikely. In Campbell et al. this is confirmed by a theoretical framework evaluation that found the most unintended consequence of CPOE was more or new work for clinicians (20%) whereas medication errors were only (7%). While this result can impact patient care, the question of evaluation method leaves this author to ponder the values. Power loss was also an issue in both studies. Koppel et al. also identified quantitative unintended consequences of CPOE. These included 22 incidents of fragmentation and 1 of power loss. This study was conducted in only one hospital and is not representative of a majority. This author feels that future studies of a quantitative nature could best serve the healthcare community. Both studies did not acknowledge a specific CPOE system associated with these unintended consequences. It must be noted that many factors can influence unintended consequences; however this author is confident that medication errors due to physician handwriting is low on the factor list. Summary The results of this evaluation confirm that CPOE is an import tool that can be utilized by hospitals to decrease medications errors by eliminating physician writing altogether. Poor penmanship was clearly established as a problem to healthcare providers. Medication errors overall were shown to be reduced when the technology of CPOE was introduced. A small system review, provided information on CPOE systems available for purchase. A cost analysis of the savings to a CPOE aided hospital was evaluated and shown to increase savings to the institution and better patient outcomes. Lastly, unintended consequences of CPOE were addressed, but the methods used left this author to question the quantity of results. The undertaking of implementation of any technology system in healthcare takes many resources. It must be noted that many factors can also influence the successful implementation of CPOE. It must be stressed that each institution assess its individual needs and install a CPOE system that will give them the best benefits.

Amarashingham, R., Plantinga, L., & West, M. (2009). Clinical information technologies and inpatient outcomes. Archives of Internal Medicine, 169(28), 110-114. Armstrong, E. (2010, February). Electronic prescriptions more reliable than handwritten ones. Retrieved from www.news.cnet American Society of Hospital Pharmacist. Medication Misadventures Guidelines. (ASHP) Ammenwerth, E., Inderst, P., & Machan, C. (2008). The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. Journal of the American Medical Informatics Association, 15(5), 585-595. Bates, D., Stead, W., & Sittig, D. (1994). Computer based physician order entry: the state of art. Journal of the American Medical Information Association, 1(2), 108-123. Bates, D., Teich, J., & Lee, J. (1999). The impact of cpoe on medication error prevention. Journal of the American Medical Informatics Association, 8(4), 313-321. Campbell, E., Sittig, D., & Ash, J. (2006). Types of unintended consequenes related to cpoe. Journal of the American Medical Association, 13(5), 547-553. Department of Health and Human Services. HITECH Act 2009. Ehringer, G., & Duffy, B. (2009). Promoting best practice and safety through preprinted physician orderswww.ahrq.gov. Hackmeyer, P. (2000, April 27). Handwriting challenged doctors to take penmanship class at cedars-sinai medical cener [Online forum comment]. Retrieved from www.sciencedaily.com Kaushal, A. (2010). The comparative effectiveness of 2 electronic prescribing systems. Unpublished manuscript, Weill Cornell Medical College, . Koppel, R., Metlay, J., & Cohen, A. (2005). Role of cpoe in facilitating medication errors. Journal of the American Medical Association, 293(10), 1197-1203. Sokol, D., & Hetige, S. (2006). Poor handwriting remains a significant problem in medicine. Journal of the Royal Society of Medicine, 99(12), 645-646. Stoss, R. (2012, April 28). Chicken scratchesvs. electronic prescriptions. New York Times Strom, B. (2011, February). Leonard davis institute. Retrieved from www.ldi.com Tieney, W., Miller, M., & Overhage, M. (1993). Physician inpatient order writing on microcomputer workstations. Journal of the American Medical Infomatics Associaton, 269(3), 379-383. Yu, F., Menachemi, N., & Berner, E. (2009). Full implementation of cpoe and medication related quality outcomes. American Journal of Medical Quality, 24(4), 278-286.