Impact of electronic prescribing in a hospital setting: A process-focused evaluation

doi:10.1016/j.ijmedinf.2007.10.008

International Journal of Medical Informatics

Volume 77, Issue 8, August 2008, Pages 546-554

https://doi.org/10.1016/j.ijmedinf.2007.10.008 Get rights and content

Abstract

Objective

To evaluate effects of a natural CPOE implementation in a hospital setting and inform the efficacy of using CPOE rather than traditional paper medication orders.

Design

A multiple-baseline, quasi-experimental study of a naturally occurring CPOE intervention, with a non-equivalent control site.

Measurements

Compliance with medication-ordering protocols and time to first dose of antibiotics.

Results

Medication orders placed using CPOE were significantly more compliant than paper-based medication orders, and first doses of antibiotics were delivered significantly faster when ordered with CPOE than when placed using the standard paper-based system (p < .01).

Conclusion

Findings support the use of CPOE and justify the need for interventions to increase CPOE adoption and consistent use among physicians.

Section snippets

Background

Medication errors alone are estimated to be responsible for 7000 deaths annually in the U.S. [1]. This is higher than the number of Americans who die annually as the result of workplace injuries (i.e., 5575 in 2003 [2]). The total national cost associated with preventable adverse medical events is estimated to be between $17 and $29 billion [1], and the increased U.S. healthcare costs attributable to preventable adverse drug events (ADEs) are estimated to be around $2 billion [1].

In an era of

Method

This study was IRB approved by both hospitals and Virginia Tech. All three institutions approved retrospective review of medication order forms and informed consent requirements were waived due to de-identification of all ordering physicians and use of group data methods.

Inter-rater reliability

To obtain measures of rater reliability, two research assistances collected information independently on the same medication orders. For each type of data collected, the frequency that two independent observers agreed and disagreed was totaled and a percentage of agreement was calculated. Inter-rater reliability data were gathered on 32.5% (n = 2050) of the order sets used for collecting compliance data and 53% (n = 173) of paper-based antibiotic orders. Overall inter-rater agreement was 89.9% for

Discussion

This study demonstrated clear improvements in key patient-safety variables as a function of using a CPOE system for ordering medications in a hospital setting. Prior research has shown CPOE orders to be significantly safer and more effective than traditional paper orders [11], [12], [13], [14], [15], [16]; the findings of this study provide additional evidence for the benefits of CPOE. The majority of previous studies measured CPOE's impact with self-report of medication errors and ADEs [11],

Conclusion

The process of conducting an initial evaluation comparing the results of two types of medication-ordering behavior, although somewhat cumbersome, is absolutely necessary prior to intervening to increase CPOE adoption and use. Without evidence supporting CPOE's added benefits from the hospital in which it has been implemented, blindly intervening to increase CPOE use could actually increase the likelihood of ordering errors.

Summary points

What was known before this study?

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Medication errors remain

Acknowledgements

The authors thank the undergraduate research assistants from the Center for Applied Behavior Systems for their contribution in collecting the data published in this study, particularly Patrick A. Rhodes and David M. Harris. Additionally, the authors specially thanks George Grayson, Matt Chisholm, and the pharmacy staff of Lewis-Gale Medical Center in Salem, VA for their collaborative efforts on this project. This research served as partial fulfillment of the senior author's M.S. degree in

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Medication orders not using CPOE were approximately 8 times more likely to require pharmacist intervention (2.26% versus 0.29%; P < 0.001), with the majority of pharmacist interventions performed to prevent medication errors. The overall mean TAT for medication orders was significantly shorter in the CPOE group in comparison with the non-CPOE group (22.2 ± 86.5 min versus 81 ± 256.7 min; P < 0.001). CPOE orders nearly eliminated medication errors with wrong dosage forms and formulary issues.
Medication orders entered via CPOE are associated with a significant reduction in medication TAT and less likely to require pharmacist intervention. Use of CPOE may improve quality of patient care and efficiency of health care delivery.
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The medical application domain has been a great challenge for information technology solutions for decades, especially when the target process has been complex and multidisciplinary such as chemotherapy processes.
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The implementation of the system improved the process by removing repetition and sequencing of the tasks. Following the implementation, chemotherapy postponing decreased by 17.2% (Z = −4.723, P = .000) and there were 5.7% less records with missing administration time (Z = −3.047, P = .002). The admission rate increased 1.9 patient per working day (t(94) = −5.974, P = .000). The overall turn-around-time reduced 18.9 min following the implementation (t(169) = 3.48, P = .001). In a multivariate multiple regression model the reduction in turn-around time was related to the implementation of the system (Pillai's Trace = 0.159, F(4,161) = 7.613, P = .000).
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Other studies have evaluated the impact of CPOE on antibiotic administration timing. Cunningham et al. [12] found that CPOE decreased the time to the first dose of antibiotics (326 vs. 185 min) at two hospitals where the expected time to the first dose of antibiotics was 4 h. Our study addressed the impact of an electronic medication-management system including order entry, pharmacy order processing and eMAR in an adult medical/surgical ICU where the sepsis (SSC) guidelines were followed and the expected time to the first dose of antibiotic was one hour.
To examine the effect of implementing electronic order management on the timely administration of antibiotics to critical-care patients.
We used a prospective pre-post design, collecting data on first-dose IV antibiotic orders before and after the implementation of an integrated electronic medication-management system, which included computerized provider order entry (CPOE), pharmacy order processing and an electronic medication administration record (eMAR). The research was performed in a 24-bed adult medical/surgical ICU in a large, rural, tertiary medical center. Data on the time of ordering, pharmacy processing and administration were prospectively collected and time intervals for each stage and the overall process were calculated.
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The implementation of an electronic order-management system improved the timeliness of antibiotic administration to critical-care patients. Additional system changes are required to further decrease the turnaround time.
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Table 1 summarizes the potential benefits of CPOE. The motivations of introducing CPOE include reducing medication errors (Anderson et al., 2002), decreasing medical costs through better decision making (Mekhjian et al., 2002), obtaining better quality of care, and increasing compliance of healthcare professionals (Cunninghan et al., 2008). With CPOE, illegible handwriting, incomplete documentation, and loss of documents are unlikely to occur (Hwang et al., 2002).
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View full text

Impact of electronic prescribing in a hospital setting: A process-focused evaluation

Abstract

Objective

Design

Measurements

Results

Conclusion

Section snippets

Background

Method

Inter-rater reliability

Discussion

Conclusion

Acknowledgements

J. Am. Med. Inform. Assoc.

J. Am. Med. Inform. Assoc.

Int. J. Med. Inform.

To Err is Human: Building a Safer Health System

Medication errors in nursing homes and small hospitals

Am. J. Hosp. Pharm.

Medication errors observed in 36 healthcare facilities

Arch. Intern. Med.

Communication failures: an insidious contributor to medical mishaps

Acad. Med.

Medication error prevention: progress of initiatives

JONAS Healthc. Law Ethics Regul.

Discrepant attitudes about teamwork among critical care nurses and physicians

Crit. Care Med.

Role of computerized physician order entry systems in facilitating medication errors

JAMA

Extending the understanding of computerized physician order entry: implications for professional collaboration, workflow, and quality of care

Int. J. Med. Inform.

The impact of computerized physician order entry of medication error prevention

J. Am. Med. Inform. Assoc.

The impact of hospital wide computerized physician order entry on medical errors in a pediatric hospital

J. Pediatr. Surg.

The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients

Pediatrics

Effect of computerized physician order entry and a team intervention on prevention of serious medication errors

JAMA