Electronic entering may end healthcare's reign of error

The Institute of Medicine's 1999 report To Err Is Human charged that as many as 98,000 people die every year from medical errors that occur in hospitals. Soon after publication of the report, more than 100 organizations joined under the banner of the Leap Frog Group for Patient Safety to help find industrywide solutions to avoidable medical errors. Computerized physician order entry (CPOE) quickly emerged as a lynchpin for such solutions.

"Today, the number of people who interact with any clinical process, when coupled with the number of steps involved, creates a prescription for problems," said Stephanie L. Reel, CIO at Johns Hopkins University.

An effective CPOE solution as a component of a strategic portfolio that is tightly integrated into the care process can be instrumental in reducing the opportunity for error, Reel said. CPOE systems feature two principal attractions. They encourage physicians to order electronically rather than through handwritten or oral instructions, and they provide a high level of information about patients by combining clinical information from a variety of sources, most notably pharmacy, laboratory, and radiology.

The impact on radiology may at first seem transparent because physicians will order imaging exams whether or not they can do it on a computer. One of the virtues of computerization, however, is that it introduces a measure of discipline.

"Radiologists complain that ordering physicians frequently omit the reason they are ordering the exam, denying to radiologists clinical clues that might change their a priori probabilities for certain findings," said Philip Drew, Ph.D., president of Concord Consulting Group.

As a result, radiologists' accuracy, both for finding diseases that are present and for ruling out those that are absent, suffers. A computerized order entry system can force the ordering physician to fill in all fields, including the reason for the exam, before it will accept the order, and thus, perhaps improve the practice of medicine, Drew said.

Improving patient safety is the real intent of CPOE, and radiology has a role in attaining this goal. CPOE can reduce or eliminate errors created when clerks transcribe imaging orders from written charts, said Deniese Chaney, a consultant at San Diego research company SAIC Healthcare. With a manual system, clerks transcribe chart orders to radiology requisitions, which are sent to radiology for processing. With CPOE, physicians enter orders directly, eliminating clerical intervention and transcription errors.

Using CPOE functionality from IDX Systems, Montefiore Medical Center in New York City has eliminated the multiple handoffs associated with getting those orders to the radiology department, as well as numerous clarifying phone calls and conversations.

"While the extent of any improvement depends on the system, we've measured between 0.5 and one FTE saving in radiology from eliminating re-keying of orders from physicians," said Rick Taylor, an accountant at IDX Systems.

CPOE could also help determine the efficacy of certain imaging studies. While it is the radiologist's responsibility to determine if contrast is indicated or contraindicated, if referring physicians are allowed to order CT studies with contrast, CPOE could screen for out﷓of﷓range renal function studies, use of Glucophage, and other red flags, said Dr. Steven Horii, clinical director of medical informatics at the University of Pennsylvania Medical Center.

CPOE software could also screen for appropriateness of or contraindications to certain examinations, such as abdominal CT immediately following a barium enema or upper GI series. Or CPOE could feed questions back to the ordering physician based, for example, on the patient's age or the possibility that the patient might be pregnant. CPOE software could also direct the requesting physician to call radiology in certain circumstances, such as the ordering of an examination the patient has already undergone in the past 24 hours, Horii said.

"CPOE is the logical place for radiology to provide point-of-presence decision support," said Dr. Paul Chang, director of radiology informatics at the University of Pittsburgh. "We will be able to educate and guide our clinical colleagues with respect to appropriate test selection. We will also be able to get access to more accurate clinical history and indications using CPOE. This is not only good medicine, but it increases the likelihood of accurate ICD-9 coding."

CPOE will be critical in alleviating overutilization of radiology services. The challenge will be to make the CPOE interface efficient and friendly enough that clinicians will accept it, Chang said.

"CPOE is a huge win for radiology," said Paul Nagy, Ph.D., an assistant professor of radiology at the Medical College of Wisconsin. "We spend so much time triple-checking the accuracy of an order. CPOE provides an awesome front end that can save radiology a lot of time."

Radiology can also use CPOE as a feedback mechanism to correct the poor ordering practices of certain physicians who ask for exams that are not in keeping with current best practices. It improves billing by forcing the use of accurate ICD-9 codes (or symptoms) that justify certain procedure codes.

"CPOE can be a challenge for clinician acceptance, but it is all gravy for radiology," Nagy said.

PATIENT SAFETY

"There is probably nothing that will challenge us as an industry as much as patient safety, and yet there is probably no greater way to make an impact in the macroeconomic future of healthcare than by addressing patient safety," Reel said.

Technology is not the complete answer. Low﷓tech solutions and fundamental attention to details are often equally important and are sometimes the differentiating factor between success and failure, according to Reel.

Two recent studies help confirm the impact of CPOE on radiology, care delivery, and patient safety. One paper (J Am Med Inform Assoc 2002;9[5]:529﷓539) suggests that hospitals implementing CPOE can substantially cut the time it takes to complete radiological studies, obtain lab tests, and deliver medications to patients by having doctors fill out orders by computer rather than by hand.

Aside from the obvious benefit of eliminating prescription drug errors associated with handwritten prescriptions, the study found that CPOE cut turnaround times for x﷓rays and other radiology procedures by 43% (from just over seven and a half hours to four hours and 21 minutes), cut medication turnaround times by 64% (from nearly five and a half hours to just under two hours), and reduced turnaround times for lab tests by 25% (from 31 to 23 minutes).

Another study, presented at the January meeting of the Society for Critical Care Medicine, reported that an order entry system implemented at Cincinnati Children's Hospital Medical Center significantly reduced the time it takes to obtain radiology film for patients in the pediatric intensive care unit and to receive oral reports from the radiologist.

CPOE reduced the time for arrival to take the x﷓ray from 18 to eight minutes (56% improvement) and the time for the x﷓ray to become available for viewing from 33 to 24 minutes (27% improvement).

All patient orders, including radiology studies, medications, special diets, laboratory studies, tests, and consultations are included in the system. Stat radiology orders are electronically routed to a pager carried by a radiology technologist.

The system also resulted in fewer phone calls between clinicians and radiologists to clarify or augment information. User satisfaction surveys indicated that physicians, radiologists, and radiology technologists are pleased with the new system.

ONE SURPRISE FITS ALL

Those contemplating CPOE can expect to be surprised, said Dr. Richard Dykstra, an assistant professor of medical informatics at Oregon Health & Science University.

"Every location we studied and almost all in the literature revealed serious challenges, among them communication problems," Dykstra said.

Over the past century, healthcare has developed communication channels from pneumatic tubes to fax, beepers, and e-mail. CPOE promises to replace most of these devices with "instant" communication, threatening to replace face﷓to﷓face communication in the process.

"It is in the face-to-face that the CPOE effect is felt the most," Dykstra said. "Without communication, care teams lose coordination and may cease to be teams."

This effect, though serious, is temporary, he said. Healthcare workers are remarkably resilient and always discover new ways to communicate.

Reel advises enterprises to leverage their strengths, encourage and celebrate the small victories, build on examples of success, listen carefully, and include clinicians in the process.

"Clinicians long to contribute to the solution, and failing to give them an opportunity to do so is wasteful," she said. "And be absolutely certain that you have created a reliable, robust technological and support environment that can support the people who must interact with the system."

Reel offers a final caveat. Top-down "big bang" approaches are almost always destined for failure.

To succeed in the challenging environment ahead, radiology departments must evaluate business and technology strategies against their ability to create a more efficient healthcare service delivery model, said Jim Bloedau, president of Information Advantage Group in San Francisco.

"Improving efficiency and safety means getting the right information to the right person at the right time, the Holy Grail of real-time computing," Bloedau said.

At the heart of this computing model will be the radiology information system and the integration of enterprise CPOE into it.

"The RIS is the brains of the radiology departmental operation. In the very near future it will look quite a bit different than it does in most places today," Bloedau said.