Monday, January 01, 2007

Top 10 issues in hospital medicine for 2006---issue 2: electronic medical records and computerized physician order entry

I elevated this topic from number 6 last year to number 2 due to increasing controversy and pressure for implementation. I sounded a cautionary note in last year's post, citing difficulties in physician acceptance and the potential for computerized physician order entry (CPOE) to increase certain types of errors.

Much more has been published this year including an insightful Medscape General Medicine Video Editorial by hospitalist thought leader and patient safety advocate Robert Wachter, M.D. Wachter sets out to temper irrational enthusiasm, pointing out that early studies which drove this enthusiasm took place in a select group of top notch institutions and looked only at “process” improvements. Until recently we had no data on patient outcomes. Wachter’s editorial reminds us of more recent papers showing a 3 fold increase in mortality in a pediatric hospital population following the implementation of a commercially available CPOE system and a powerful anecdote about a fatal insulin error related to bar code technology.

Issues regarding implementation are controversial. In another Medscape General Medicine Video Editorial AHRQ director Carolyn Clancy, M.D. thinks we should move full speed ahead and implies we should take advantage of readily available “off the shelf” systems. But Wachter warns that the systems that really seem to work are home grown and developed over years.

With the disasters in implementation and adverse patient consequences we’ve seen it would seem wise to move slowly.

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