August 2, 2007

Ordering CPOEs

Two studies in the current issue of Journal of the American Medical Informatics Association (JAMIA) highlight the current frustration with, and potential importance of, computerized physician (provider) order entry (CPOE) systems. The electronic entry of physician instructions for patient care has been touted by the government as a way to reduce medication errors and improve safety, although studies to date have shown mixed results. CPOE has the potential to change patient care, for better or worse, particularly when the ordering process is linked to clinical decision support software, clinical guidelines, and alerts.

Joan Ash, PhD, Department of Medical Informatics and Clinical Epidemiology at Oregon Health & Science University’s School of Medicine, and colleagues followed up their earlier work on unintended consequences of CPOE use at five selected hospitals, with this current study, The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry. Here, they sought to measure the extent and importance of eight of these previously identified types of unintended consequences at every US hospitals with a CPOE system. A total of 176 hospitals completed the telephone survey, a response rate of 47%. Six of the eight types of unintended consequences previously identified by the five hospitals were also considered important by the majority of these 176 hospitals: workflow issues; communications issues; overdependence on technology; never-ending system demands; emotions (usually negative); and more/new work issues. The remaining two types—changes in power structure, and new kinds of errors—identified as important in the preliminary study were not regarded as important with the majority of these hospitals. The authors note an important limitation of their study: they queried individuals who “might have given answers biased in a positive way because they believe in CPOE’s benefits. This might help explain why the two categories of power shifts and new kinds of errors did not rank highly…” The authors’ recommend that hospital leaders charged with implementing CPOE consider each of the eight types of unintended adverse consequences carefully during their planning. “Implementation success depends on managing the unintended, as well as the intended, consequences of CPOE…Unless we make a concerted effort to avoid, manage, and/or overcome unintended consequences, the implementation of clinical information systems may lead to detrimental results.”

Evaluation of Outpatient Computerized Physician Medication Order Entry Systems: A Systematic Review provides a literature review of outpatient CPOE evaluation studies to determine if outcomes exist related to improved patient care. The authors identified 30 such studies, a relatively small number with few if any of them deemed to be well designed. The study’s main finding was that the available evidence does not demostrate that CPOE enhances safety or reduces medication costs, although they did find an increased adherence to clinical guidelines. The outpatient setting presents challenges to CPOE research because inpatient orders tend to be more easily collected and reviewed due to centralized hospital information systems.

As technology advances and the applied research aspects of medical informatics matures, we can hope for better, more clinically relevant studies on software and best-of-breed applications directed at evidence-based practices.

July 24, 2007

Sweet IT report

Not surprisingly, a recent report from the Center for Information Technology Leadership (CITL) takes a very favorable view of using information technology to combat diabetes. The report, The Value of Information Technology-Enabled Diabetes Management,” published last month online but summarized earlier this year in a Diabetes Care article, reviewed the benefits, costs, and quality implications of IT-enabled diabetes management programs, such as electronic diabetes registries and clinical decision support software. It found that all forms of IT-enabled disease management improved patients’ health and reduced costs. Regarding the report’s observed use of HIT in disease management by government/insurance/managed care (payers) more than physicians (providers): “Because cost savings from improved care are largely reaped by payers, many diabetes-management programs are implemented by payers rather than providers. Furthermore, providers have been slow to adopt health information technologies that underpin diabetes management programs. Yet while implementation of payer technologies does improve the health of patients with diabetes and results in cost-of-care savings, providers are in the best position to improve care and control medical costs. This misalignment of incentives may be causing the market to pursue suboptimal interim solutions.” CITL is a nonprofit research center for those who, according to their Web site, “need evidence about the value of specific health information technologies.” It is based at Partners HealthCare System in Boston and is headed by a prestigious high-powered executive committee

July 15, 2007

Quality Care by MDs, not EHRs

According to “Electronic Health Record [EHR] Use and the Quality of Ambulatory Care in the United States” from the July 9th issue of Archives of Internal Medicine, using EHRs in the out-patient setting does not appear to improve quality of care (as measured by compliance with 17 ambulatory care quality indicators developed at Stanford University). The retrospective study analyzed data drawn from the 2003 and 2004 National Ambulatory Medical Care Survey, an annual survey conducted by the CDC’s National Center of Health Statistics. During these two years, 18% of physician visits used EHRs and, when compared to physician visits without EHRs, the investigators found no statistical difference among the outcomes in 14 of 17 indicators.  
          Jeffrey Linder, MD, lead author and general internist at Harvard’s Brigham and Women’s Hospital, explained in an associated iHealthBeat article that, “…other studies have shown that [EHRs] are not much more than a replacement for the paper chart. In light of those findings, this is not that surprising…” Randall S. Stafford, MD, PhD, senior author and associate professor of medicine at the Stanford Prevention Research Center, offers his theories on why EHRs were not found to improve quality care: the study looked at older systems that probably lacked clinical decision support, and that “No matter how sophisticated the system, it can’t dictate a course of action to a physician…” For more on how the authors interpreted their study, see Stanford University’s press release. (Ed. note 07/19/07: For a different spin, see WSJ Health Blog’s Computerized Medical Files Not Much Better Than Paper, and the comments that follow.—ML)

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