Re: Role of CPOE Systems in Facilitating medication Errors
On Fri, 2005-03-11 at 05:36, J. Antas wrote: The Journal of American Medical Association (JAMA) just published an article by Koppel et al. about the impact of a widely used computerized physician order entry (CPOE) system in facilitating medication errors at a hospital. CPOE increased the probability of 22 potential sources of prescribing error. Source URL: http://e-healthexpert.org/ http://jama.ama-assn.org/cgi/content/abstract/293/10/1197?etoc
Re: Role of CPOE Systems in Facilitating medication Errors
On Tue, 2005-03-15 at 10:17, Daniel L. Johnson wrote: On Fri, 2005-03-11 at 05:36, J. Antas wrote: The Journal of American Medical Association (JAMA) just published an article by Koppel et al. about the impact of a widely used computerized physician order entry (CPOE) system in facilitating medication errors at a hospital. CPOE increased the probability of 22 potential sources of prescribing error. Source URL: http://e-healthexpert.org/ http://jama.ama-assn.org/cgi/content/abstract/293/10/1197?etoc Actually, the best entry to this discussion is via the editorial: http://jama.ama-assn.org/cgi/content/full/293/10/1261 Some excerpts from this insightful editorial: Behind the cheers and high hopes that dominate conference proceedings, vendor information, and large parts of the scientific literature, the reality is that systems that are in use in multiple locations, that have satisfied users, and that effectively and efficiently contribute to the quality and safety of care are few and far between. ... The summary by Garg et al of 100 trials of clinical decision support systems over a 6-year span is critical. About two thirds of the studies claimed improved clinician performance, but these assessments were often biased; when the authors were not also the system developers, less than half of the systems showed an improvement. In fact, grading oneself was the only factor that was consistently associated with good evaluations. ... ...the study by Koppel et al of users of a single CPOE system in a large academic medical center identified 24 different types of failures of which users were aware; roughly half the participants said these faults occurred from several times per week to daily. ... These results are disappointing but should not be surprising. There is a long-standing, rich, and abundant literature on the problems associated with the introduction of computer technology into complex work in other domains, as well as occasional notes in health care. ... To begin to move forward, it is necessary to dispense with the commonly held notion that these problems are simply bits of bad programming or poor implementation that can easily be excised or avoided the next time around. ...these failures [involve] not developing the right systems due to widespread but misleading theories about both technology and clinical work. ... Simply having greater clinician participation in the design of these technologies will not fix this problem. Most domain experts have little insight into their own work processes or sources of expertise. ... ...this lack of self-insight is the fundamental reason why system developers cannot objectively evaluate the systems they have developed. No matter how much they may try to be objective, the very process of development and refinement has created in them hidden assumptions about the way things work that make it impossible for them to envision some of the ways in which things might go wrong when users who do not share those assumptions interact with the system. ... Useful information technology is a sine qua non to bridging the quality chasm that has been so clearly identified by the Institute of Medicine and others.32 Yet an information technology in and of itself cannot do anything, and when the patterns of its use are not tailored to the workers and their environment to yield high-quality care, the technological interventions will not be productive. This implies that any IT acquisition or implementation trajectory should, first and foremost, be an organizational change trajectory. This is true at both the organizational level and the national level; a national health IT infrastructure without a clear logic about how health care organizations will become engaged in this infrastructure is bound to fail.
RE: Role of CPOE Systems in Facilitating medication Errors
Sobering thoughts ...not at all surprising. I am struck by the degree of magical thinking that so many of us engage in around HIT solutions. Perhaps it will be the next generation who have lost our gee whiz naivety... David Derauf -Original Message- From: Daniel L. Johnson [mailto:[EMAIL PROTECTED] Sent: Tuesday, March 15, 2005 8:12 AM To: OpenHealth List Cc: Mark Deyo-Svendsen; Hank Simpson; Kathy Markham Subject: Re: Role of CPOE Systems in Facilitating medication Errors On Tue, 2005-03-15 at 10:17, Daniel L. Johnson wrote: On Fri, 2005-03-11 at 05:36, J. Antas wrote: The Journal of American Medical Association (JAMA) just published an article by Koppel et al. about the impact of a widely used computerized physician order entry (CPOE) system in facilitating medication errors at a hospital. CPOE increased the probability of 22 potential sources of prescribing error. Source URL: http://e-healthexpert.org/ http://jama.ama-assn.org/cgi/content/abstract/293/10/1197?etoc Actually, the best entry to this discussion is via the editorial: http://jama.ama-assn.org/cgi/content/full/293/10/1261 Some excerpts from this insightful editorial: Behind the cheers and high hopes that dominate conference proceedings, vendor information, and large parts of the scientific literature, the reality is that systems that are in use in multiple locations, that have satisfied users, and that effectively and efficiently contribute to the quality and safety of care are few and far between. ... The summary by Garg et al of 100 trials of clinical decision support systems over a 6-year span is critical. About two thirds of the studies claimed improved clinician performance, but these assessments were often biased; when the authors were not also the system developers, less than half of the systems showed an improvement. In fact, grading oneself was the only factor that was consistently associated with good evaluations. ... ...the study by Koppel et al of users of a single CPOE system in a large academic medical center identified 24 different types of failures of which users were aware; roughly half the participants said these faults occurred from several times per week to daily. ... These results are disappointing but should not be surprising. There is a long-standing, rich, and abundant literature on the problems associated with the introduction of computer technology into complex work in other domains, as well as occasional notes in health care. ... To begin to move forward, it is necessary to dispense with the commonly held notion that these problems are simply bits of bad programming or poor implementation that can easily be excised or avoided the next time around. ...these failures [involve] not developing the right systems due to widespread but misleading theories about both technology and clinical work. ... Simply having greater clinician participation in the design of these technologies will not fix this problem. Most domain experts have little insight into their own work processes or sources of expertise. ... ...this lack of self-insight is the fundamental reason why system developers cannot objectively evaluate the systems they have developed. No matter how much they may try to be objective, the very process of development and refinement has created in them hidden assumptions about the way things work that make it impossible for them to envision some of the ways in which things might go wrong when users who do not share those assumptions interact with the system. ... Useful information technology is a sine qua non to bridging the quality chasm that has been so clearly identified by the Institute of Medicine and others.32 Yet an information technology in and of itself cannot do anything, and when the patterns of its use are not tailored to the workers and their environment to yield high-quality care, the technological interventions will not be productive. This implies that any IT acquisition or implementation trajectory should, first and foremost, be an organizational change trajectory. This is true at both the organizational level and the national level; a national health IT infrastructure without a clear logic about how health care organizations will become engaged in this infrastructure is bound to fail.
Re: Role of CPOE Systems in Facilitating medication Errors
Really agree on these. I had a 'which EMR should I get?' call from a colleague yesterday. I told her that I still am not sure after all these years of search but one thing that I am pretty sure of is that the millions of federal grant dollars and high-end political attention currently being given to this is a positive development but the likely result is a whole lot of nothing to the average clinician. In the near (10 year) term. I hope I am wrong. -- IV On Tue, 15 Mar 2005 08:25:30 -1000 David Derauf [EMAIL PROTECTED] wrote: Sobering thoughts ...not at all surprising. I am struck by the degree of magical thinking that so many of us engage in around HIT solutions. Perhaps it will be the next generation who have lost our gee whiz naivety... David Derauf -Original Message- From: Daniel L. Johnson [mailto:[EMAIL PROTECTED] Sent: Tuesday, March 15, 2005 8:12 AM To: OpenHealth List Cc: Mark Deyo-Svendsen; Hank Simpson; Kathy Markham Subject: Re: Role of CPOE Systems in Facilitating medication Errors On Tue, 2005-03-15 at 10:17, Daniel L. Johnson wrote: On Fri, 2005-03-11 at 05:36, J. Antas wrote: The Journal of American Medical Association (JAMA) just published an article by Koppel et al. about the impact of a widely used computerized physician order entry (CPOE) system in facilitating medication errors at a hospital. CPOE increased the probability of 22 potential sources of prescribing error. Source URL: http://e-healthexpert.org/ http://jama.ama-assn.org/cgi/content/abstract/293/10/1197?etoc Actually, the best entry to this discussion is via the editorial: http://jama.ama-assn.org/cgi/content/full/293/10/1261 Some excerpts from this insightful editorial: Behind the cheers and high hopes that dominate conference proceedings, vendor information, and large parts of the scientific literature, the reality is that systems that are in use in multiple locations, that have satisfied users, and that effectively and efficiently contribute to the quality and safety of care are few and far between. ... The summary by Garg et al of 100 trials of clinical decision support systems over a 6-year span is critical. About two thirds of the studies claimed improved clinician performance, but these assessments were often biased; when the authors were not also the system developers, less than half of the systems showed an improvement. In fact, grading oneself was the only factor that was consistently associated with good evaluations. ... ...the study by Koppel et al of users of a single CPOE system in a large academic medical center identified 24 different types of failures of which users were aware; roughly half the participants said these faults occurred from several times per week to daily. ... These results are disappointing but should not be surprising. There is a long-standing, rich, and abundant literature on the problems associated with the introduction of computer technology into complex work in other domains, as well as occasional notes in health care. ... To begin to move forward, it is necessary to dispense with the commonly held notion that these problems are simply bits of bad programming or poor implementation that can easily be excised or avoided the next time around. ...these failures [involve] not developing the right systems due to widespread but misleading theories about both technology and clinical work. ... Simply having greater clinician participation in the design of these technologies will not fix this problem. Most domain experts have little insight into their own work processes or sources of expertise. ... ...this lack of self-insight is the fundamental reason why system developers cannot objectively evaluate the systems they have developed. No matter how much they may try to be objective, the very process of development and refinement has created in them hidden assumptions about the way things work that make it impossible for them to envision some of the ways in which things might go wrong when users who do not share those assumptions interact with the system. ... Useful information technology is a sine qua non to bridging the quality chasm that has been so clearly identified by the Institute of Medicine and others.32 Yet an information technology in and of itself cannot do anything, and when the patterns of its use are not tailored to the workers and their environment to yield high-quality care, the technological interventions will not be productive. This implies that any IT acquisition or implementation trajectory should, first and foremost, be an organizational change trajectory. This is true at both the organizational level and the national level; a national health IT infrastructure without a clear logic about how health care organizations will become engaged in this infrastructure is bound to fail.
Re: Role of CPOE Systems in Facilitating medication Errors
To All, It's interesting that the discussion of this article occurred last week on the Nursing Informatics lists I belong to. Most comments were centered on how the study was poorly designed. :-) I did see a couple of comments on how Nurses have been involved in implementations, noted problems like this article mentions and apparently were not listened too. Pat
Re: Role of CPOE Systems in Facilitating medication Errors
Without having read the study, as industry news it recalls Murphy's Law applied to complex information systems (i.e., Computerization enables you to make bigger mistakes faster). One e-Pharmacy presentation I attended last summer warned about the ability of e-Prescription systems to perfect the transmission of a prescribing error. This study does us the favor of trying to quantify that risk. [wr] - - - - - - - - On 15 Mar 2005, at 10:25 AM, David Derauf wrote: Sobering thoughts ...not at all surprising. I am struck by the degree of magical thinking that so many of us engage in around HIT solutions. Perhaps it will be the next generation who have lost our gee whiz naivety... David Derauf -Original Message- From: Daniel L. Johnson [mailto:[EMAIL PROTECTED] Sent: Tuesday, March 15, 2005 8:12 AM To: OpenHealth List Cc: Mark Deyo-Svendsen; Hank Simpson; Kathy Markham Subject: Re: Role of CPOE Systems in Facilitating medication Errors On Tue, 2005-03-15 at 10:17, Daniel L. Johnson wrote: On Fri, 2005-03-11 at 05:36, J. Antas wrote: The Journal of American Medical Association (JAMA) just published an article by Koppel et al. about the impact of a widely used computerized physician order entry (CPOE) system in facilitating medication errors at a hospital. CPOE increased the probability of 22 potential sources of prescribing error. Source URL: http://e-healthexpert.org/ http://jama.ama-assn.org/cgi/content/abstract/293/10/1197?etoc Actually, the best entry to this discussion is via the editorial: http://jama.ama-assn.org/cgi/content/full/293/10/1261 Some excerpts from this insightful editorial: Behind the cheers and high hopes that dominate conference proceedings, vendor information, and large parts of the scientific literature, the reality is that systems that are in use in multiple locations, that have satisfied users, and that effectively and efficiently contribute to the quality and safety of care are few and far between. ... The summary by Garg et al of 100 trials of clinical decision support systems over a 6-year span is critical. About two thirds of the studies claimed improved clinician performance, but these assessments were often biased; when the authors were not also the system developers, less than half of the systems showed an improvement. In fact, grading oneself was the only factor that was consistently associated with good evaluations. ... ...the study by Koppel et al of users of a single CPOE system in a large academic medical center identified 24 different types of failures of which users were aware; roughly half the participants said these faults occurred from several times per week to daily. ... These results are disappointing but should not be surprising. There is a long-standing, rich, and abundant literature on the problems associated with the introduction of computer technology into complex work in other domains, as well as occasional notes in health care. ... To begin to move forward, it is necessary to dispense with the commonly held notion that these problems are simply bits of bad programming or poor implementation that can easily be excised or avoided the next time around. ...these failures [involve] not developing the right systems due to widespread but misleading theories about both technology and clinical work. ... Simply having greater clinician participation in the design of these technologies will not fix this problem. Most domain experts have little insight into their own work processes or sources of expertise. ... ...this lack of self-insight is the fundamental reason why system developers cannot objectively evaluate the systems they have developed. No matter how much they may try to be objective, the very process of development and refinement has created in them hidden assumptions about the way things work that make it impossible for them to envision some of the ways in which things might go wrong when users who do not share those assumptions interact with the system. ... Useful information technology is a sine qua non to bridging the quality chasm that has been so clearly identified by the Institute of Medicine and others.32 Yet an information technology in and of itself cannot do anything, and when the patterns of its use are not tailored to the workers and their environment to yield high-quality care, the technological interventions will not be productive. This implies that any IT acquisition or implementation trajectory should, first and foremost, be an organizational change trajectory. This is true at both the organizational level and the national level; a national health IT infrastructure without a clear logic about how health care organizations will become engaged in this infrastructure is bound to fail. [wr] - - - - - - - - will ross technology project management 216 west perkins street, suite 206 ukiah, california 95482 usa 707.272.7255 [voice] 707.462.5015 [fax] - - - - - - - -
Re: Role of CPOE Systems in Facilitating medication Errors
when the authors were not also the system developers, less than half of the systems showed an improvement. In fact, grading oneself was the only factor that was consistently associated with good evaluations. Now I interpret this and the next quote differently. No matter how much they may try to be objective, the very process of development and refinement has created in them hidden assumptions about the way things work I suspect that if the people using the system are not (strongly influential in) developing it, it does not improve their performance. and... I think that as one develops (or perhaps extensively configures) software, in one's practice, the assumptions including values that one works on in clinical practice and administration are built into it, and feed back in their turn, in that sometimes choices in software objectify a choice between potential ways to do something, codify a practice, treat a condition. Thus the system shrinks and stretches onto the users like a pair of jeans in a bath. Later, it doesn't fit anyone else quite so well. -- Adrian MidgleyFLOSS regularly
Re: Role of CPOE Systems in Facilitating medication Errors
My department hosts a seminar series on clinical informatics with a focus on the electronic medical record. The videos are available online to the public at: http://clinicalinformatics.stanford.edu/scci_seminars/2004-05.html The last two discussions have focused on the quality benefits from CPOE. The recent article about medical errors caused by CPOE was discussed briefly. Feel free to take a look. -- Philip S. Constantinou Director of Systems Development and Data Management Information Resources and Technology (IRT) Stanford University, School of Medicine http://med.stanford.edu/irt/development t: 650-766-0645 f: 650-725-4415 e: [EMAIL PROTECTED] Calendar: Use SunDial to schedule meetings
Re: Role of CPOE Systems in Facilitating medication Errors
On Tue, 15 Mar 2005, Adrian Midgley wrote: ... No matter how much they may try to be objective, the very process of development and refinement has created in them hidden assumptions about the way things work I suspect that if the people using the system are not (strongly influential in) developing it, it does not improve their performance. Adrian, All software impose a particular model of the way things work upon their users. The issues is not the existence of this model but how easy it is for people using the system to understand and change the model to better fit their needs. ... Thus the system shrinks and stretches onto the users like a pair of jeans in a bath. Later, it doesn't fit anyone else quite so well. Why should we expect it to fit anyone else? Medical practice is heterogenious and rapidly changing. Until we recognize customizability/extensibility as a critical feature, we will continue to lament the need to buy a different jean for each clinical setting and re-purchase a pair of new jean every few years. Best regards, Andrew --- Andrew P. Ho, M.D. OIO: Open Infrastructure for Outcomes www.TxOutcome.Org
JAMA article on CPOE causing controversy
The recent JAMA article on Computerized Physician Order Entry (Role of Computerized Physician Order Entry Systems in facilitating Medication Errors) seems to have created controversy: Health-IT World, March 15, 2005 Debate Swirls Around JAMA Article Critical of CPOE http://tmlr.net/jump/?c=12208m=2795p=927207t=164a=296 Excerpts from Scot Silverstein's response to Health-IT World, March 15, 2005 Debate are at: http://hcrenewal.blogspot.com/2005/03/debate-swirls-around-jama-article.html Source URL: http://e-healthexpert.org/node/50
Re: Role of CPOE Systems in Facilitating medication Errors
On Tue, 2005-03-15 at 14:01, Andrew Ho wrote: Medical practice is heterogenious and rapidly changing. Until we recognize customizability/extensibility as a critical feature, we will continue to lament the need to buy a different jean for each clinical setting and re-purchase a pair of new jean every few years. Very true. Sounds like a promotion for openEHR http://www.openehr.org model. Cheers, -- Tim Cook Key ID 9ACDB673 @ http://www.keyserver.net/en/ signature.asc Description: This is a digitally signed message part
Re: Role of CPOE Systems in Facilitating medication Errors
On Tue, 15 Mar 2005, Tim Cook wrote: ... Sounds like a promotion for openEHR http://www.openehr.org model. Care to explain?
Re: Role of CPOE Systems in Facilitating medication Errors
On Tue, 2005-03-15 at 15:10, Andrew Ho wrote: On Tue, 15 Mar 2005, Tim Cook wrote: ... Sounds like a promotion for openEHR http://www.openehr.org model. Care to explain? Sure. I didn't intend to be cryptic. You comments: Medical practice is heterogenious and rapidly changing. Until we recognize customizability/extensibility as a critical feature, we will continue to lament the need to buy a different jean for each clinical setting and re-purchase a pair of new jean every few years. sounds to me like the background reasons for openEHR. See:http://www.openehr.org/getting_started/t_openehr_primer.htm A relevant excerpt: Health Information Systems today suffer from a number of key problems: * lack of interoperability and vendor lock-in; * cost and difficulty of maintenance, given the rate of change and sheer size of the information in the health domain; * lack of support for security, privacy and consent. These shortcomings are widely recognised, but doing something about them is not simple, because of the sheer volume of health data being produced, and the number and complexity of systems. There is no silver bullet fix, of course. However, the openEHR Foundation proposes solutions based on a reconceptualisation of the problem space not in narrow IT implementation terms, but in terms of an integrated framework of technical modelling, domain modelling, and software engineering. The following sections describe openEHR thinking in more detail. Cheers, -- Tim Cook Key ID 9ACDB673 @ http://www.keyserver.net/en/ signature.asc Description: This is a digitally signed message part
