From PDAs to CPOE to e-mail, information technology is seeping its way into the practice of medicine despite any reluctance from physicians, so much so that a cottage industry has sprung up to measure the effects of such IT use by physicians on patient care. The following stories by Andis Robeznieks report on three recent studies that attempt to learn whether those effects have been positive or negative. -- David Burda, Editor
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High rates of adverse drug events related to medication selection, dosage and monitoring were recorded at the Veterans Affairs Department Medical Center in Salt Lake City even though the facility used a computerized physician order-entry system that checked prescriptions for drug allergies and interactions, according to a study in the May 23 issue of the Archives of Internal Medicine.
The center experienced 483 clinically significant adverse drug events -- defined as events that required a change in treatment plan -- in 937 hospital admissions studied over the final 20 weeks of 2000. The number of patients experiencing at least one adverse drug event was 241 (26%) and many experienced more than one, according to the report. Of the 483 events, 45 (9%) were classified as serious. Some 27% of the events were the result of errors, with the most frequent being failure to provide prophylaxis for expected adverse drug reactions. Nevertheless, the report's lead author, Jonathan Nebeker, M.D., an attending physician at the VA's Salt Lake City Health Care System, says the study was not about medication errors but the need to develop computerized decision support that targets the most troublesome types of adverse drug events.
"Many studies have shown that human beings can only simultaneously consider four independent factors in decisions," Nebeker says in an e-mail interview. "It is common to have to consider 10 to 20 simultaneous factors in patient medication decisions."
PDAs help lower medication errors
Even in primary-care physician offices where health information technology has seldom been used, introducing personal digital assistants, or PDAs, as prescribing tools can help lower the potential for medication errors, according to a study by Kimberly Galt, associate dean for research and professor of pharmacy practice, and her colleagues at Creighton University in Omaha, Neb.
Using PDAs led to significant reductions in errors of legibility and omissions and less use of abbreviations and symbols, the report said. The report was included in a four-volume set of articles published by the U.S. Agency for Healthcare Research and Quality. The findings also were presented at the National Patient Safety Foundation Congress recently in Orlando, Fla.
In a three-year study funded by a $900,000 AHRQ grant, Galt's team first analyzed the hand-written orders generated by 78 prescribers at 31 physician offices in eastern Nebraska and western Iowa from June to December 2002. Half of the physicians were randomly selected to be trained in using PDAs for writing prescriptions.
Data were collected on the 14,378 prescriptions they wrote, both by hand and with the PDA, from March to August 2003 and were compared with the 19,372 prescriptions previously written.
Omission of patient age or birth date on prescriptions fell from 95.5% to 59.2%, and significant declines were also seen in omitting refill status and indication for use. The use of symbols also declined from 76.7% to 47.4%, while illegible prescriptions decreased from 9.1% to 2.7%.
The physician offices chosen for the study all used computers for billing, but none had computers in patient-care rooms. The physicians randomly chosen for the PDA intervention were given training on using the devices to write prescriptions and to use drug-information software for decisionmaking support.
Galt says that although a free-standing PDA could be seen as a "suboptimal model," there were still meaningful reductions in error rates. Use of the PDAs, however, varied widely.
Nine of the 39 physicians were considered "adopters" and used the PDAs to write 88% to 100% of prescriptions; 13 were identified as "potential adopters" who used the PDA for 16% to 61% of prescriptions. The remaining 17 physicians were classified as "nonadopters" and included the "techno-terrified" group that didn't generate any prescriptions via the PDA.
E-mail pleases patients, aids docs
Using e-mail is a convenient way to boost patient satisfaction and improve physician efficiency, according to Pennsylvania State University College of Medicine researcher Shou Ling Leong, M.D., the lead author of a report on doctor-patient communication in the May/June issue of the Journal of the American Board of Family Practice.
"E-mail is an important tool," says Leong, an associate professor of family and community medicine at the university. "Patients like it, physicians like it, and it should be part of the redesign to make healthcare more efficient."
The study compared communication between patients and four doctors who used e-mail for nonurgent messages and four who did not use e-mail to communicate with patients. Because of its small size, Leong says the study was more useful for identifying trends than for generating statistics.
She says the most important of the trends were that patient satisfaction increased and that it took physicians less time to reply to e-mails than telephone messages.
Leong says her own patients regularly send e-mails giving a few weeks' worth of blood pressure or blood glucose readings. This allows her to fine-tune their medications while saving patients a visit to the doctor's office, she says. She adds that e-mail is helpful in managing the multiple conditions of her elderly patients who e-mail updates about their visits to specialists.