Talk about your good news-bad news situations. Three recent pediatric medical journals have studied the implementation of computerized physician-order entry at Children's Hospital of Pittsburgh and have linked the process to a reduction in harmful medication errors and an increase in mortality.
But the one with negative findings received the most attention. A report in the December issue of Pediatrics said that mortality rates for patients transferred to Children's Hospital for specialized, tertiary-level care increased to 6.57% for the five months after CPOE implementation, from 2.8% for the 13 months before that. The study began Oct. 1, 2001, with implementation occurring near the end of October 2002, and ended March 31, 2003.
The negative findings contrast with a report that appeared in the January issue of the Journal of Pediatric Surgery, which found that transcription errors were eliminated and harmful adverse drug events dropped to 0.03 per 1,000 doses from 0.05 per 1,000 doses. This equals the prevention of one harmful adverse drug event every 64 patient days. Children's Hospital is a 260-bed facility with 12,000 annual admissions, including about 3,000 annual intensive-care unit admissions. And a report in the November issue of Pediatrics described the planning and preparation that Children's Hospital underwent before implementation and concluded that "CPOE is an invaluable resource for supporting patient safety."
"When our staff reported their findings two years ago, we carefully reviewed their data and did not come to the same conclusions. The study provides a brief snapshot of a small subset of patients over a very limited timeframe," said Eugene Wiener, M.D., medical director of Children's, in an e-mailed statement. "Since there is a significant variability in mortality over time in Children's ICU, we believe the findings have no correlation to the implementation of CPOE."
On health information technology Web logs, however, commentary is being generated fast and furiously on the issue. "There has been a boatload of cyberspace discussion," said Jim Fackler, M.D., a pediatric intensive-care physician and critical-care director for IT vendor Cerner Corp., whose Millennium system went live at Children's Hospital in October 2002. "It's true CPOE went in. It's true mortality went up. It remains my opinion that the two aren't causally related," Fackler said.
The December Pediatrics report noted that there were several problems that may have led to the mortality increase. There was a lack of communication bandwidth that sometimes "froze" the computers. In situations when patients needed to be stabilized, two physicians were often needed, with one directing care and the other working the computer. A satellite ICU medication dispenser was removed in order to centrally locate all the hospital's pharmacy services.
"Nothing in the article points to it being the CPOE technology itself that was at fault," said Suzanne Delbanco, executive director of the Leapfrog Group, which has been a strong promoter of CPOE. "It was the implementation and surrounding infrastructure that caused the problems."
Fackler was also highly critical of the study's design, which compared 13 months before implementation with just five months after. The researchers appear to have anticipated this criticism and said in their report that the study was cut off after five months because that was when the 80-hour limit for resident work hours was initiated. This was considered to be a "potential confounder" of the results, so the study was terminated when the limit was imposed.