At Blount Memorial Hospital in Maryville, Tenn., a seriously ill patient typically has 15 to 20 orders active at any time, a total of 70 during a hospital stay. Compared with a decade ago, "things are a lot more complex. The pace is so fast," says Jeanne Ezell, director of pharmacy.
"Medication is very complex-lots of places for things to go wrong," Ezell says. Vigilant checking of multiple medications and doses should be automatic, but "humanly it is just not possible to do all those checks."
As everywhere, Blount's inpatients are much sicker, on average, than they were 10 years ago. Success in moving treatment to outpatient settings has increased the average acuity of the remaining inpatients. But in this era of managed care, hospital stays are shorter and more intense, giving nurses and pharmacists little down time, Ezell says. "Everyone is constantly working because of the pressure to get people out of here."
Welcome to the clinical reality of patient care in 2001. It's a setting ripe for medical errors.
An error could be as simple as illegible handwriting or as complex as failure to adjust a dosage because no one picked up on a patient's deteriorating capacity to handle a drug. Information systems that prevent such errors are pricey, and industry leaders wonder where the cash would come from.
But proponents of making patient safety a higher priority in healthcare say the medical sophistication of hospitals has risen to the point that clinician skill and experience alone cannot keep track of all possibilities for error.
"Humans are inherently fallible information processors," says Brent James, M.D., vice president for medical research at Intermountain Health Care, Salt Lake City.
"It doesn't matter how smart you are, how careful or conscientious you are, how well-rested you are. As a human being handling data, you will make mistakes-it's a demonstrable fact," James says. "And the way you really solve that is to build robust systems that make it hard to do it wrong, easy to do it right."
The fierce pace of hospital work, combined with an accelerating rate of medical innovation and medication therapy, have introduced layer upon layer of details to keep straight, healthcare experts say.
Physicians who are charged with keeping the details straight also are faced with changing economics and resulting pressure to move faster, "and that increased pace increases the likelihood of error," says Terry Williams, vice president of the business solutions group at Eclipsys Corp., a Delray Beach, Fla.-based healthcare information services company.
Although breakthrough drugs can greatly improve care for certain conditions, "the strength and potency of the pharmaceuticals is so much more so than in the past," he says. The stronger drugs, combined with their possible bad effect on a patient's concurrent health problems, increase the potential for danger arising from even small miscalculations.
In addition, the pace of pharmaceutical change is so great that the drug databases Eclipsys uses are updated every few weeks, Williams says. The overall complexity of medicine makes so many more drugs available that incomplete or scattered medical records become serious safety issues, "increasing the chance of making a decision that's not fully informed," Williams says.
Meanwhile, healthcare executives are under the gun from payers to cut costs, and that often means laying off staff, says Robert Cook, director of loss prevention and program services for Ascension Health, a Catholic-sponsored healthcare system based in St. Louis.
"Payers' demands have eroded the level of quality of care," Cook says. "Healthcare is very much a humanistic industry. It really takes people to take care of other people." Pressure to cut costs has resulted in "a diminution of the workforce to the extent that it's affected quality," he says.
But the care process in healthcare facilities is "not very well planned out or thought about," he adds. In particular, coordination of information about a patient's condition is minimal or absent, especially during transitions from one care location to another within a hospital as well as transfers in or out of the hospital, Cook says.
Impetus for action
The general lack of a systematic approach to preventing missteps in this stressed climate was a focus of the Institute of Medicine's galvanizing report on medical errors, To Err is Human, published in late 1999. Widely referenced for its estimate that as many as 98,000 Americans are killed annually by hospital medical errors, the report was more about organizing to prevent injuries than about errors, most of which do not result in harm, says James, a member of the IOM Committee on Quality Health Care in America.
The committee's report played up errors because it would attract attention and provide impetus for change, James says. "Inside the group we understood errors to mean system errors," he says. "Even in that small subset that were human errors, the solutions were the same. They were system fixes."
Last March the IOM's 335-page sequel, Crossing the Quality Chasm, drove the point home by declaring that "healthcare should be supported by systems that are carefully and consciously designed to produce care that is safe, effective, patient-centered, timely, efficient and equitable." The report asserted that information technology "has enormous potential" to further all six of those aims and that it "must play a central role in the redesign of the healthcare system."
Industry representatives agreed with the findings but said money was an issue in the call to upgrade computer systems and implement new clinical software advances at healthcare facilities (Modern Healthcare, March 5, p. 4). "A lot of this came at a time when the Balanced Budget Act (of 1997) has put these facilities in a situation where fiscal prudence is a mandate," says Kevin Scheckelhoff, regional vice president for consulting in the MedManagement division of McKesson HBOC, a San Francisco-based healthcare products and information services supplier.
And it has forced executives to justify committing millions of dollars in capital funds on purely clinical management objectives that don't easily translate to dollars and cents.
"You'll never meet a senior administrator who will say he's not in favor of clinical quality. But it's not real tangible either," says Scheckelhoff, who advises healthcare facilities on how to find procedural weaknesses in pharmacy operations and devise improvements. "One thing you can say about financial issues is, they're tangible."
Some providers who have pioneered clinical information management in their facilities say the prevention of medical errors is enough of a return. When systems prevent adverse drug events, along with resulting extra days in an intensive-care unit and legal liability, "the best financial (return) is patient safety," says Robert Raschke, a critical-care physician at Good Samaritan Regional Medical Center in Phoenix.
"I don't have the numbers to show that," says Raschke, who is instrumental in the facility's development of computerized feedback to physicians based on the condition of their patients. But he says financial officers at Samaritan and its parent company, Phoenix-based Banner Health Arizona, "understand the logic, even without objective numbers."
Room for improvement
If healthcare organizations are serious about preventing errors, they'll have to grow into a new role of marshaling information for management of care delivery, says James of Intermountain Health Care, which has turned out volumes of research on the subject for two decades.
"Information is perhaps not the lifeblood but more the central nervous system of the way that we deliver care," he says. "I know as a physician that the better information I have, the better I can diagnose illness, the better options I can offer my patients, the better treatments I can apply and, ultimately, the better outcomes I can achieve."
An early study on the impact of Good Samaritan's system demonstrates both the hidden danger of information shortcomings and the ability of error-prevention systems to supply the necessary details in time. The study was published in a 1998 issue of the Journal of the American Medical Association.
Of 9,306 hospital admissions during a six-month period, the system generated 1,116 alerts of potentially dangerous clinical situations, and 794 of them were determined to be valid dangers. In 596 cases, doctors changed their orders consistent with the alert's recommendations, and 44% of time the ordering physician had not recognized the danger at the time the alert was delivered.
(There was some lag time: Pharmacists first evaluated alerts printed out in the pharmacy and contacted the ordering physician only when the alert was judged to be well-founded.)
Most of the situations flagged by the system can be understood by reviewing lab results and applying them to other important medical issues affecting a patient. But that requires a doctor with many patients and duties to check on the lab values "when it occurs to him" and see them early enough to do the right thing, Raschke says. "Now the computer does it automatically," he says of operations at Good Samaritan.
Sometimes a problem can't be picked up unless a physician knows of some recent changes in the function of a patient's kidneys, which can become stressed during hospitalization and take longer to filter a drug out of the body, James says.
Drugs are prescribed based on a formula that takes a lot of factors into account: height, weight, body mass, age, how long it takes to absorb the drug into the body and then to clear it out. But declining kidney function can raise the peak blood level of the drug higher than it should be.
"I could give a patient the appropriate recommended dose of the drug, just as I'm supposed to-but over time, because of declining renal function, that appropriate dose could turn into an overdose," James says. "And I could have a full adverse drug event, an overdose reaction, even though I thought that I'd done everything right."
At Intermountain's LDS Hospital in Salt Lake City, a computer system that can estimate kidney function checks every dose of every drug at the time it's given for the likely peak level of the medication in a patient's bloodstream. The analysis includes not only whether the dose might be an inadvertent overdose but also a possible underdose, in which a medication would not have the therapeutic effect for which it was prescribed, James says.
A medication improvement team at Blount Memorial didn't have such computer sophistication at its disposal, but it pursued the same general objective of "automating all the places we could" to make it easier to do things right, says Ezell, the pharmacy director.
The hospital three years ago instituted automated drug-dispensing machines on all medical/surgical nursing units as well as the emergency department and operating rooms, "to better control narcotics and cut down on the paperwork involving narcotics," Ezell says.
Next the facility installed a medication-order "robot," which receives prescriptions directly from the pharmacy information system and dispenses bar-coded packages of medication by patient for delivery to nursing stations.
Early next year, the hospital will gear up for automating the administration of medications at the bedside, using bar codes produced by the robot and matched against patient identification bracelets.
It's the final step in a three-stage automation approach marketed by McKesson HBOC.
Ezell says the error incidence in pharmacy was not out of line before the automation, but the machines reduced the error rate by 40%. "Even though it's not a large amount of error, that's a significant decrease," she says.
The automation came at an opportune time, because Blount experienced a sudden increase in average patient census to 170 from 110. Order volume jumped 50% between June and September 1998. But the hospital was able to handle it without hiring any more people, Ezell says.
Other hospital initiatives concentrate on the process of getting orders more quickly to the pharmacy through automation, which eliminates several time-consuming and error-prone steps in the process and expedites medication therapy.
At Montefiore Medical Center in New York, an average of 109 minutes was saved by a computer system that physicians use to enter orders. At Alamance Regional Medical Center in Burlington, N.C., a computerized order-entry system trimmed an average of 86 minutes off the previous manual process (See charts, p. 5 and 6).
Montefiore experienced a 50% reduction in prescribing errors compared with the nonelectronic methods it used before instituting physician order entry, says John Manzo, director of pharmacy. A clinical study is validating those findings, he says.
Alamance reduced redundant and duplicative tests by 72% using a checking feature of the order-entry process, says Terri Andrews, manager of clinical applications.
The facility hasn't specifically studied the impact on avoided costs or reductions in full-time-equivalent positions, but Andrews says cutting out that much duplication logically means an end to most duplicative expense, "plus patient inconvenience and unnecessary pain."
External pressure: How real?
Though Alamance Regional started using technology as far back as the mid-1990s to increase efficiency, "we never approached automation as a way to reduce FTEs here," she says. "Our (return-on-investment) studies have focused on patient-care improvement."
In 1996, "fear of managed care" drove automation efforts, she says. Now the emphasis has shifted to the ability to respond to scrutiny and expectations raised by the IOM reports and by other external forces such as the Leapfrog Group, a coalition of large U.S. corporations that wants to set quality-related prerequisites for doing business with healthcare providers (See special report in this week's Modern Healthcare).
One objective of the Leapfrog Group is to require the use of computerized physician order-entry systems. That's because of mounting recognition that these systems eliminate transcribing errors and call attention to dangerous prescribing situations before they can affect patient safety.
But the approaches can cost $3 million or more per healthcare organization and entail 18 to 24 months of drastic change, not to mention a significant give-and- take with the medical staff, says Scheckelhoff of McKesson HBOC. Given that charged situation, "the fact that people are waiting to see what they have to do before they institute some of these changes is understandable," he says. "They want a confidence level that if they make that commitment, there's a very high likelihood of success."
Even among organizations aggressively applying automation to the improvement of patient safety, there is disagreement over whether physician order entry should be enlisted at the start or only after a host of other areas ripe for improvement are tackled first (See related article, p. 24).
Instead of arguing over where to start, healthcare organizations have to declare a resolve to start making medical error prevention a higher priority, says Tina Shapleigh, M.D., who heads up the Eclipsys business solutions division. "The whole topic of patient safety has not been talked about in the forefront," she says. Instead of burying discussion of errors in medical peer review committees, providers "need to put in place a culture that says patient safety is at the top of our list."
The main issue, Shapleigh says, is that faulty processes have to be changed; information systems are just the tools to achieve the change. "The computer helps you and says, 'What do you think about this?' "
If the benefits of making healthcare processes safer aren't enough, the consequences of higher public expectations might tip the scale, says Cook of Ascension Health.
The healthcare industry has quietly absorbed evidence in medical journals and elsewhere about the prevalence of errors, he says, but now the issue has been elevated to a public forum by "a new generation of consumers that are much more informed and wanting to know about their specific providers." The IOM reports and other publicity "have created a hype and awareness about medical errors, and that will continue."
"There are so many factors that have contributed to the awareness of patient safety," Cook says. "The more awareness there is, perhaps it will lead to better recognition of the importance of information management."