On February 19th, 2005 the New York Times reports, in an article
called Health Industry Under Pressure to Computerize that our government
would like the health care industry to move towards electronic ordering of
medications and an electronic medical record. This needs to be done even
at the level of small and solo medical practices. The thinking is as 40 %
of the health industry becomes electronic; the society dividend will be a
10% reduction in medical errors. In fact, if steps are not taken soon to
make it happen, the government will probably impose a solution.”
On the one hand, the government is right. The Institute of Medicine
estimates that 98,000 deaths occur per year, in US hospitals, because of
medical errors, and most of the errors are from medication errors. In
fact, medication errors, according to one Harvard study, occur more in
Pediatrics than adult medicine, and the most in neonatology, where the
tiny patients demand the most precise attention to detail. (My specialty!)
It is not clear how this is going to be paid for, and I can relate my
experience for my specialty in my system. I learned, quickly, that many of
the electronic medical records (cost about 26 million dollars) would be
more suited to adult patients, rather than babies. In 1998, I looked at
specific charting for neonatology patients only because I wanted
electronic ordering for Total Parenteral Nutrition (TPN), but the cost was
120,000$ for the system, as the calculator was not sold as a separate,
stand alone software. For an additional 120,000$ , a perinatal database
could interface with neonatal electronic record interface? It was not
clear to me: how would the 26 million dollar electronic system record by a
different vendor interface with these other products? How could I justify
another ¼ million dollars on top of the 26 million our health system
already wanted to spend? On the other hand, JCAHO reminds physicians that
one adverse drug event cost $2000, and the average malpractice award for
medical errors $636,000 if it goes to a jury trial, and more importantly
we are talking patient safety, but what can a small town neonatologist do
if no stand alone commercial product exists? Let me tell you what my
partner Dr Jose Yuvienco and I did after we read the paper in Pediatrics
by Christoph U. Lehmann MD et al. Preventing Provider Errors Online Total
Parenteral Nutrition Calculator, with a little help from reference books,
and friends in our pharmacy (, Scott W. Mihalovic and John Johnson),
Information services department, (Gina L Howlett and, Jerrilyn R
Hendrickson).
(The article, Preventing Provider Errors Online Total Parenteral Nutrition
Calculator describes that the John Hopkins Medical Center was able to take
these complicated paper ordering of Neonatal Total Parenteral Nutrition
and make them electronic within 3 weeks! More importantly, they showed
what I suspected: value to patients. They were able to reduce errors from
10.8 per 100 TPN paper orders to 1.2 errors using this electronic format
or an 89% reduction.)
I made sure that our paper orders at Franciscan Skemp Healthcare in
LaCrosse were completely up-to-date. (This included my reading, carefully,
several hundred pages of a manual called the Pediatric Nutrition Handbook
5th Edition by the Academy of Pediatrics, a careful review of exactly what
commercial ingredients we use, and meetings with our nurse administrator
Karen Olson, and pharmacists to develop an Excel spreadsheet that did 90 %
of the work. Then, with my information services colleagues, we locked
formulae, made pop-ups if heparin was not added to central line TPN
orders, and made it compliant with our current charting.
In speaking to colleagues in different parts of the state, including
locally we are one of the few hospitals that have a TPN calculator, and
the hospitals outside of our state such as John Hopkins or Cornell
(personal communication with Professor Alfred N. Krauss as I did my
fellowship at Cornell), have calculators they created on their own TPN
calculators despite large investments into a general electronic medical
record.
Already the orders are more efficient; there are no handwriting
issues. When I fill out Total Parenteral Nutrition orders for a baby, I
now type in 10 boxes and the computer calculates the other 30 boxes with
no mathematical errors and also saves me laborious tedious calculations
that ordinarily I would have to do on several babies a day.
At Franciscan Skemp Healthcare of the Mayo Health System, there are
over 1000 baby Total Parenteral Nutrition orders per year. The pharmacy
told me it was the most complicated order the pharmacy does, and this new
program written was recently presented at the Mayo Clinic Formulary and
Pharmacy Retreat, as an example of technologic of technological
advancement.
In my attendance at the 2005 Pediatric Academic Society meeting in
Washington, DC, I asked a vendor of a new charting system for neonatology:
Does it include a TPN program or calculator? No.Why isn’t there a cheap,
but reliable commercial product? Does every hospital have to make their
own? Can our hospital share what we created?
I think, it would be terrific if the American Academy of Pediatrics,
would as part of it’s Pediatric Nutrition Handbook simply have a committee
of experts write a CD ROM program that could accompany their excellent
textbook to allow hospitals throughout the country to just have an
electronic TPN calculator. The program would have ranges for the
different elements and chemicals that need to be given to a baby by vein
where the individual physician could then print out TPN and intralipid
orders. If this is unlikely to happen being that there is so much
variability throughout the United States in the various specifics of this
TPN orders despite the fact that there are some well grounded rules on
what the ranges of nutrients are, then a solution at the Statewide level
or regional level is the next best solution.
In Wisconsin, Peridata, driven by a private public partnership
including the Wisconsin Association for Perinatal Care, is a web-based
perinatal database that allows electronic reporting of birth certificates,
in addition to the storage of perinatal data elements not required as part
of the birth certificate. This is going to allow almost all of the
Wisconsin Hospitals with Midwifery and Obstetrics to compare and benchmark
patient outcomes within the State of Wisconsin. In addition, to ideally,
developing a module that would let Wisconsin perinatal centers submit data
to Vermont-Oxford, I imagine the development of an electronic TPN
calculator . (This could happen because in our State, the experts convene
many times a year, at a large annual meeting, and in committees throughout
the year, never in the same corner of Wisconsin.)
Until then, medical centers such as the Mayo Health system that have
Neonatologist, pharmacists, and Information Services experts, can take
paper orders and make them electronic. Title 21 Code of the federal
regulations requires that any software systems ensure accuracy;
reliability and consistency intended performance by taking paper orders
and making them electronic. The John Hopkins study shows, as well as our
institutional experience, that the physician driven conversion of reliable
paper medical orders to electronic medical can save lives and money, and
may the solution to becoming electronic quicker at a much cheaper cost.
References:
1. Lohr, Steve Health Industry Under Pressure To Computerize New
York Times
February 19, 2005
2. Christoph U. Lehmann, MD, Kim G. Conner, RPh, MAc and Jeanne M.
Cox, MS, RD Preventing Provider Errors: Online Total Parenteral
Nutrition Calculator
PEDIATRICS Vol. 113 No. 4 April 2004, pp. 748-753
3. American Academy of Pediatrics. Nutritional needs of the preterm
infant. In: Kleinman RE, ed. Pediatric Nutrition Handbook. 5th ed.
Elk Grove, IL: American Academy of Pediatrics; 2004:36
4. The Computerized Database: Are the Data Reliable? Costakos, DT,
Love LA, Kirby R, manuscript. American Journal of Perinatology 1998 July
Volume 15, No. 7, 453-459.
Submitted and written by:
Dennis T Costakos, MD, FAAP
Director NICU
Franciscan Skemp ,
Mayo Health System
700 west ave south
LaCrosse , Wisconsin
Asst Prof of Pediatrics,
Mayo Clinic College of Medicine,
Rochester, MINN USA
Conflict of Interest:
AAP and WAPC member
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