Uh oh

Computerized physician order entry (CPOE) is looked on as a panacea which will decrease medical error, improve efficiemcy, and improve patient safety. Only it looks like it has some major, unintended consequences, like increasing death according to an article titled "Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System: in this months Pediatrics.

The authors, from my institution, studied the outcomes of kids who were transported to Children's Hospital of Pittsburgh (CHP) for care. Transport is used to move patients who need more specialized care than the referring institution can provide. In Western Pennsylvania, CHP is the primary site for tertiary (i.e. highly specialized) pediatric care, so many smaller hospitals will transport kids. Reasons can range from need for ICU level care (most outside hospitals don't have pediatric ICUs) to requirment for specialist input. Kids who are transported range from not that sick to in extremis, with the overall level of illness being less than you might expect. To be fair, community hospitals have a real range of expertise, so some just aren't comfortable with really sick kids. In addition, it is generally better to transport before someone is in extremis.

Anyway, the findings were suprising and alarming:

Among 1942 children who were referred and admitted for specialized care during the study period, 75 died, accounting for an overall mortality rate of 3.86%. Univariate analysis revealed that mortality rate significantly increased from 2.80% (39 of 1394) before CPOE implementation to 6.57% (36 of 548) after CPOE implementation. Multivariate analysis revealed that CPOE remained independently associated with increased odds of mortality (odds ratio: 3.28; 95% confidence interval: 1.94–5.55) after adjustment for other mortality covariables.

Put in plain English, kids transported after implementation of CPOE had a more than 3 fold increased risk of death. Ouch

The authors go on to speculate on what went wrong. They conclude that doctors and nurses spent more time sitting at the computer and less taking care of patients:

The usual "chain of events" that occurred when a patient was admitted through our transport system was altered after CPOE implementation. Before implementation of CPOE, after radio contact with the transport team, the ICU fellow was allowed to order critical medications/drips, which then were prepared by the bedside ICU nurse in anticipation of patient arrival. When needed, the ICU fellow could also make arrangements for the patient to receive an emergent diagnostic imaging study before coming into the ICU. A full set of admission orders could be written and ready before patient arrival. After CPOE implementation, order entry was not allowed until after the patient had physically arrived to the hospital and been fully registered into the system, leading to potential delays in new therapies and diagnostic testing . . . .

This initial time burden seemed to change the organization of bedside care. Before CPOE implementation, physicians and nurses converged at the patient's bedside to stabilize the patient. After CPOE implementation, while 1 physician continued to direct medical management, a second physician was often needed solely to enter orders into the computer during the first 15 minutes to 1 hour if a patient arrived in extremis. Downstream from order entry, bedside nurses were no longer allowed to grab critical medications from a satellite medication dispenser located in the ICU because as part of CPOE implementation, all medications, including vasoactive agents and antibiotics, became centrally located within the pharmacy department. The priority to fill a medication order was assigned by the pharmacy department's algorithm. Furthermore, because pharmacy could not process medication orders until they had been activated, ICU nurses also spent significant amounts of time at a separate computer terminal and away from the bedside. When the pharmacist accessed the patient CPOE to process an order, the physician and the nurse were "locked out," further delaying additional order entry.

Before CPOE implementation, the physician expressed an intended order either through direct oral communication or by writing it at the patient's bedside (often reinforced with direct oral communication), with the latter giving the nurse a visual cue that a new order had been placed. The nurse had the opportunity to provide immediate feedback, which sometimes resulted in a necessary revision of that order. In addition, these face-to-face interactions often fostered discussions that were relevant to patient care and management. After CPOE implementation, because order entry and activation occurred through a computer interface, often separated by several bed spaces or separate ICU pods, the opportunities for such face-to-face physician–nurse communication were diminished.

They go on to note that they've made some changes (orders can be entered before patient arrives), but many problems still remain. A second physician still needs to sit and enter orders and there remains an unacceptable lag in getting medications started.

In the past I've defended CPOE, but it is hard to do so after this study. Of course, many of the problems can be potentially overcome (e.g. by preentered "sets" of orders that often go together) and the centralization of pharmacy is really a separate issue, but I still find this article very troubling.