Tuesday, December 30, 2008

The Pitfalls of Computerized Order Entry

CPOE (Computerized Provider Order Entry) is one of the center-pieces of the move to get health care into the digital age. Lots of folks are putting lots of time, money and effort into installing CPOE in hospitals, clinics, nursing homes and everywhere else doctors, nurses and patients interact. There are great expectations for big improvements in quality, costs and work flow.

Years ago, I managed a General Internal Medicine clinic that installed a new Electronic Medical Record and we had some pretty bad outcomes. The amount of work that doctors had to do to get all the data into the EMR was unreasonable. Unfortunately, a few providers tried anyway. They worked long hours, got exhausted and frustrated, and in once case, actually wound up in the hospital as a patient due to the strain of trying to keep up with a badly designed system.

I was hoping that more recent EMRs are more thoughtfully designed, but a recent study by Emily M Campbell, Kenneth P Guappone, Dean F Sittig, Richard H Dykstra and Joan S Ash in The Journal of General Internal Medicine paints a pretty dark picture. They reviewed the experience of five different hospitals that installed CPOE systems and collected a long list of the ways that the systems made things worse, not better, for the users and their patients. Problems included:
  • Inadequate desk space to accommodate charts near the computers
  • Long sequences of mouse clicks needed to do simple tasks
  • Order sets that force the users to change the way they work
  • Problems integrating clinical data and orders
  • Systems that force the nurses to give medications at specified times rather than the best time for the patient
  • Systems that force users to re-enter the orders when the patient is moved to another unit, even when this is not clinically necessary
  • Multiple providers entering conflicting orders simoultaneously
  • Decision support alerts that don't know enough about the clinical situation to give good advice, but can't be avoided
and many others.

All of these problems have been recognized for a long time. It is disturbing that they continue to appear in the most recent implementations of the systems. At least thoughtful observers like Campbell et al. are providing advice on how to do it better. Can our vendors and institutions learn from them?

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