MEDITECH's CPOE Beats Leapfrog Error Reduction Estimates in Burke Rehab Hospital Study
Two recent CPOE studies garnered a considerable amount of attention in the media. These research papers indicated that physician ordering software was not the panacea that many organizations -- including the United States government -- had claimed, but that it actually increased errors. The press seemed to suggest that CPOE is the software equivalent of "snake oil," disregarding the importance of an integrated HCIS designed in conjunction with physician workflow processes. Many smaller hospitals were left wondering if the only viable CPOE solution is the homegrown, prohibitively expensive system built by academic medical centers.
Could a small hospital find affordable, "off-the-shelf" CPOE software that works? Administrators and clinicians at Burke Rehabilitation Hospital, a 150-bed inpatient facility in White Plains, New York, asked themselves this question before selecting MEDITECH's solution in 2002. They implemented Pharmacy in 2002 and CPOE in 2003. By 2004, Burke's CPOE usage rate was already at 100%, enabling them to compare the number and severity of medication errors during the year prior to implementing CPOE and during the first year of CPOE's use. The results? Burke saw a 62% reduction in medication errors, a significantly greater number than the Leapfrog Group's estimate of 50%. Thomas Grandville, director of pharmacy at Burke, and several of his colleagues submitted these findings to the American Journal of Health-System Pharmacy (AJHP), which published the letter in its March 1, 2006 edition (and will be accessible on their Web site in April). MEDITECH recently spoke with both Grandville and Burke Rehab CIO Ken Kupetsky about these impressive results.
Q: It's interesting that your organization thought to measure CPOE's impact well before go-LIVE. What motivated you to perform the study and then to publicize its results?
Ken Kupetsky: We've always kept track of medication errors. When we transitioned from a paper-based system to CPOE, we wanted to see if our results were similar to the Leapfrog Group's claim of a 50% reduction in errors. So we've been measuring the system's effectiveness since day one.
Q: Data for your study was collected from medication error report summaries. Can you tell us a little more about the reports, both before and after CPOE went LIVE? How did you report on the data?
Thomas Grandville: Medication error data was reported exactly the same way both before and after CPOE implementation. We use the United States Pharmacopeia (U.S.P.) reporting program, MEDMARX, for error category classification.
Q: How does Burke's method of tracking medication errors compare to the industry norm?
TG: Health care facilities may adopt their own methods of medication error tracking.
Q: Your paper, Impact of Computerized Physician Order Entry on Medication Error Reduction (Using a Vendor-based System), was presented at the Institute for Healthcare Improvement (IHI) Forum on Quality Improvement, in December 2005. Were there any other incentives for doing the study and publishing the paper (i.e., funding, publicity, etc.)?
TG: There were no incentives -- financial or otherwise -- to publish the paper or to present the storyboard at the forum in December. We simply wanted to share information and experiences as well as lessons learned.
Q: How did the IHI forum's attendees react to your study?
TG: There was a lot of interest in the storyboard, because so many hospitals are either evaluating vendor-based systems or implementing them.
Q: Why did you submit the letter to AJHP?
TG: The letter was originally the five-page paper which I presented at the IHI Forum. I submitted it to AJHP because they are the premier journal for hospital pharmacy. They accepted it, but edited the study down to a "letter." Other journals probably would have published the entire paper, but I decided to stick to AJHP because of its broad reader base.
Q: Were there any reservations about publishing error rates?
KK: No, not at all. We were anxious to share our results.
Q: Because the study was conducted during the first year of CPOE usage, physicians were adjusting to different workflow processes, and your IS department was probably tweaking the system. Do you expect errors to continue to decline as providers get more accustomed to on-line ordering?
KK: As the physicians get more experienced and process improvements are made, I'm sure we'll see even better outcomes in the future.
Q: Some naysayers might think that, as a rehab facility, your providers are not using order sets as complicated as providers in acute care settings. How do your patients' medication therapies compare to those in an acute care setting?
KK: Because our facility is specifically designed for certain types of patients, many of the order sets are consistent with those issues. However, the order sets are often complex, so compared to an acute care setting it's similar.
Q: A couple of recent studies have claimed that CPOE introduces new kinds of medication errors. Did clinicians find themselves making different kinds of errors? To what would you attribute these errors (e.g., workflow process changes, skipped alerts, etc.)?
TG: CPOE systems do introduce new types of errors. Some of these are due to users' lack of familiarity with the system, as well as the limitations of software. However, illegibility errors are virtually eliminated, and errors are reduced across the board.
Q: Your study notes that the severity of the errors also decreased after implementing MEDITECH's CPOE system. Could you tell us a little more about how the system's safeguards helped to prevent errors from impacting the patient?
TG: The study did reveal a decrease in error severity based on the MedMARx (USP) error categories. I feel it would be safe to say that a decrease in the number of errors really matters only if you can have some corresponding decrease in error severity (or at least errors that are not more severe). The goal is always to achieve a zero error rate. That said, errors in Category C or less do not ordinarily require patient intervention.
Q: Will you continue to measure these types of errors in the year ahead to see if there is additional improvement?
KK: Yes. We will continue to measure medication errors, and expect the rates to continue to decline as physicians become more accustomed to the system.
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Do you have questions or comments about this article? Please e-mail them to Ann Marie Sennott. At the hospital's request, we ask that you refrain from contacting them directly, in the event that the same questions are raised by multiple readers.
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