PEDIATRICS Vol. 117 No. 4 April 2006, pp. 1451-1452 (doi:10.1542/10.1542/peds.2005-3116)
Perceived Increase in Mortality After Process and Policy Changes Implemented With Computerized Physician Order Entry
Brian R. Jacobs, MDRichard J. Brilli, MD
Kim Ward Hart, MA
Division of Critical Care Medicine
Cincinnati Children's Hospital
Cincinnati, OH 45229
To the Editor.—
The article by Han et al1 reports a "direct association" between increased mortality rate and the implementation of a commercial computerized physician order entry (CPOE) system in a tertiary care PICU. The Children's Hospital of Pittsburgh (CHP) investigators observed a significant increase in raw mortality and in severity-adjusted mortality rates. The investigators concluded that the problems they encountered were unanticipated and embedded in the CPOE system rather than being a result of choices in how this technology was adopted. Problems specifically mentioned were the inability to preregister patients, additional time needed to enter orders, the need for a second physician devoted solely to entering orders, nurses spending too much time at the computer and away from the bedside, delays in administration of critical medications, premature termination of standing medication orders, mistiming of medication administration, and using a generic platform in a highly specialized setting.
Many of the implementation strategies used by the CHP in their PICU have been identified previously as problematic, including (1) absence of active and meaningful involvement by critical care physicians in system design, decision-support tools, and implementation strategies, (2) use of an adult-based general medical ward platform not designed/redesigned for the organization's needs or the requirements of critical care practitioners, (3) a training period for clinicians ending a full 3 months before implementation rather than using just-in-time training, (4) absence of order sets (widely regarded as the single most important factor for enabling physician workflow), and (5) adoption of a slow and inefficient platform with inadequate performance during peak periods.2,3 In addition, decisions to move from a decentralized to a centralized pharmacy and acceptance of a CPOE platform that did not allow simultaneous users to enter/review medications were counterintuitive in a busy critical care unit. Furthermore, it seems that computer terminals were not optimally placed or were immobile and insufficient in number to allow nurses to carry on their work at the bedside, thus interfering with patient care.
Between April and December 2002, the Cincinnati Children's Hospital Medical Center (CCHMC) implemented CPOE throughout the institution. CCHMC is a 423-bed facility with 1045 physicians and 1750 nurses. The PICU has a capacity of 25 beds and an average daily census of 18 children. The CPOE application is part of a larger integrating clinical information system, the core applications of which include a Web-based portal, CPOE, clinical documentation, and a data repository (Invision; Siemens Medical Solutions, Malvern, PA). These core applications interface with other hospital-based information systems including radiology PACS, laboratory, pharmacy, admissions, and dietary. The CPOE platform is linked to numerous intranet- and Internet-based resources and clinical decision-support tools such as medication dose-range checking, hospital policies, the medication formulary, a discharge summary system, and an Internet search engine. The CPOE system is accessed through fixed and wireless workstations throughout the institution. Each week, 30000 orders are generated through the system, 90% of which are entered directly into the computer by physicians or advance practice nurses.
Our experience with implementing CPOE in a PICU setting was quite different from that noted by Han et al. Critical care physicians, nurses, and respiratory therapists were heavily involved in our CPOE system design before implementation. Pediatric-specific information (including critical care order sets, pathways for the entry of continuous infusions, and critical care–specific medication dose-range checking) was developed by critical care clinicians and incorporated into the system well in advance of implementation. Workflow incompatibility with the CPOE system was analyzed and deficiencies corrected in advance of implementation. The system was implemented in a stepwise fashion, with entry into the critical care unit only after a successful pilot in a medical unit. Live user support was offered 24 hours/day, 7 days/week, until no longer needed. Ongoing feedback was not only accepted, but was solicited. Other important issues such as optimal workstation (fixed and wireless) numbers and location and standardized nomenclature (ie, centigrade versus Fahrenheit) were addressed before implementation.
Unlike CHP, the CCHMC did not observe a rise in mortality rates in its critical care unit after implementing CPOE. In fact, the raw mortality rate has declined, and the severity-adjusted mortality ratio has remained stable (Fig 1).
|
The CHP is to be congratulated for adopting an important technology and persevering despite important challenges in their critical care setting. The pediatric community will benefit from the lessons they have learned. The study confirms the importance of having a well-supported plan for adopting and implementing CPOE. Our experience at the CCHMC validates the notion that CPOE can be implemented successfully with numerous benefits and without an adverse impact on mortality rates.
REFERENCES
- Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116
:1506
–1512
[Abstract/Free Full Text] - Ash JS, Stavri PZ, Kuperman GJ. A consensus statement on considerations for a successful CPOE implementation. J Am Med Inform Assoc. 2003;10
:229
–234
[Abstract/Free Full Text] - Ahmad A, Teater P, Bentley TD, et al. Key attributes of a successful physician order entry system implementation in a multi-hospital environment. J Am Med Inform Assoc. 2002;9
:16
–24
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
CiteULike 
Connotea 
Del.icio.us 
Digg 
Facebook 
Reddit 
Technorati 
Twitter What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
