Healthcare computerization proponents last week asserted that a new study of automation fails to prove that information technology is a major cause of medical errors rather than the solution to such mistakes.
The study's findings run counter to the conventional wisdom that automating healthcare processes will reduce medical errors. Researchers looked at the use of an early computerized physician order-entry system at the Hospital of the University of Pennsylvania in Philadelphia from 1997 to 2004 and discovered that the system facilitated 22 types of medication-error risks.
The Pennsylvania survey "does provide useful information about categorizing errors," said David Bates, medical director of clinical quality and analysis in information systems at Partners HealthCare System, Boston. "The important point is this study did not evaluate whether or not CPOE reduced the medication-error rate."
Bates expressed concern that the Pennsylvania study, published in the March 9 issue of the Journal of the American Medical Association, might cloud the picture at a time when hospital officials are deciding whether to invest huge sums in CPOE and other clinical IT systems.
22 types of errors
The study's authors note that by some estimates, 770,000 people are injured or killed by adverse drug events in hospitals annually and that "CPOE systems are widely viewed as crucial for reducing prescribing errors." But after using questionnaires, interviews and focus groups to query 261 users of an early CPOE system at the teaching hospital, researchers "identified 22 previously unexplored medication-error sources that users report to be facilitated by CPOE."
The results echo those of a December 2004 U.S. Pharmacopeia report. While not exclusively examining CPOE, that group found in looking at its drug-error reporting data from 570 hospitals and healthcare systems that one in five medication errors involved some sort of CPOE system.
But neither study measured the net effect of CPOE on the volume of errors because they didn't take note of error rates before the systems were introduced, Bates said.
Suzanne Delbanco, chief executive officer of the Leapfrog Group, said she, too, was concerned that the Pennsylvania study would confuse some people. The business healthcare coalition has championed CPOE as one way to reduce medical errors and improve quality.
The study centers on users' impressions "of quite an old system," Delbanco said, adding, "No system is any better than how it is designed and improved.
"What confuses me was why weren't there feedback systems? If the clinical staff was finding problems, why weren't they resolved? It points to not only the design of the system but the upkeep."
"What this demonstrated is what we have said all along-having a system is not the same thing as intercepting serious medication errors," Delbanco said.
The Pennsylvania researchers placed CPOE errors in two categories: information errors generated by fragmentation of data, principally caused by poorly integrating the CPOE with other hospital record-keeping systems; and flaws that occurred because the software didn't match the way physicians, nurses and others provided care.
One example of data fragmentation problems cited in the report was that the Pennsylvania CPOE system forced physicians to view up to 20 screens of information to see one patient's medication record. And crashes causing order delays were "common," according to the report. A third of physicians surveyed indicated these delays occurred a few times a week, while nearly 9% reported they happened daily.
`It's not a panacea'
"I'm not saying we should not be doing CPOE," said study co-author Brian Strom, associate vice president of strategic integration at the Hospital of the University of Pennsylvania and associate vice dean of the University of Pennsylvania School of Medicine. "It certainly has shown to have some benefit. The point is, it's not a panacea. It's not a one-shot deal. ... It needs to be continually evaluated, changed and reviewed."
Researchers, while blaming some of the problems on the system itself, also noted that during the 2002 to 2004 study period, the Eclipsys TDS computerized order-entry system used at the Pennsylvania hospital was the market leader.
Thus, the report contends, "There was no reason to suspect that TDS is inferior to any other CPOE system." Strom also noted that the hospital has since upgraded to the next generation of Eclipsys system, Sunrise Clinical Manager, and so some of the problems encountered before may have been eliminated.
Bates and his colleagues published a landmark article in JAMA in 1998 on CPOE's impact on patient safety at Brigham and Women's Hospital in Boston. The study used data gleaned before and after the system was implemented. "We looked at the errors that were present with paper ordering and at both the errors created and eliminated with CPOE and there was a more than an 80% reduction," Bates said.
Rick Mansour, chief medical information officer of Eclipsys Corp., released a prepared statement responding to the article, noting that the study focused on a "first-generation system deployed in a single setting." He said the company has made improvements in its latest system that are designed to "minimize or eradicate" errors documented in the study.