Friday, May 28, 2010

Is there finally evidence that CPOE reduces mortality?

Online ahead of print in the journal Pediatrics:

PATIENTS AND METHODS We performed a cohort study with historical controls at a 303-bed,freestanding, quaternary care academic children's hospital. All nonobstetric inpatients admitted between January 1, 2001, and April 30, 2009, were included.

RESULTS After CPOE implementation, the mean monthly adjusted mortality rate decreased by 20% (1.008–0.716 deaths per 100 discharges per month unadjusted [95% confidence interval: 0.8%–40%]; P = .03). With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame.

It's not the greatest quality data but I don't know if we can expect much better. Reuters Health interviewed a health IT expert from UA Birmingham about the study:

"There have been a couple of studies previously that have taken a similar approach and have found the opposite result" of the current study, said Nir Menachemi, an expert in health information technology and policy at the University of Alabama at Birmingham. "I was more surprised by those studies."

The debate over whether CPOE is working as intended is hardly over, said Menachemi: "I think it would be foolish to believe that any one study can end the discussion."

Paul Levy at Running a Hospital thinks differently:

Let's go back to the basics. Hand-written drug orders are subject to transcription errors at both ends, the person writing them and the person reading them. Each time you add an intermediary in the drug ordering process, you add an opportunity for error. Also, unless there is real-time and accurate checking for drug-drug interactions, allergies, assessment of doses based on body weight and the like, there will be some percentage of preventable medication errors.

Maybe I live in a rarefied world of early CPOE adopters, but does anyone out there think this is still subject to debate?

Yes, I and a lot of other people do. Levy's problem in understanding this, I suspect, is not that he lives in the world of early adopters, but that he doesn't have experiential knowledge of what entering orders on the wards is really like in both systems, paper and electronic. Those intermediaries he's talking about are personnel who are trained in the secretarial skills of order entry and, by doing safety checks of their own, may actually reduce errors.

It cuts both ways. CPOE has theoretical advantages. There are also unintended consequences. The implementation of CPOE can be a mess. Take a bunch of time pressed doctors and suddenly add secretarial duties to their work flow. Not pretty.

The field of health information technology will mature. Doctors will gradually become more adept at the secretarial skills of order entry. Some day most practicing doctors will have grown up on CPOE, having never known any other system. By then maybe CPOE will have saved lives. I doubt that there will ever be a study to prove it. The debate about the risks and benefits of the electronic medical record is alive and healthy, and should go on.

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