Most hospitals don't use latest ordering technology

November 24, 2003

PORTLAND, Ore. -- Computers programmed to screen out errors and standardize physicians' orders for prescriptions, tests and other care have been a source of hope in reducing medical errors and improving patient safety. The problem is that most hospitals aren't using this technology, known as computerized physician order entry (CPOE).

Reducing medical errors gained a sense of urgency in 2000 when the Institute of Medicine reported on the issue. The institute found that medical errors may be responsible for up to 98,000 deaths in hospitals and cost the U.S. health care system approximately $38 billion per year.

Despite a wide array of quality, policy and financial incentives to use CPOE, fewer than 10 percent of American hospitals make it completely available to their physicians. This was among the findings of a study conducted by researchers in the Oregon Health & Science University School of Medicine and recently published in online edition of the Journal of the American Medical Information Association (JAMIA).

"CPOE reduces medical errors by eliminating illegible orders, improving communication and order tracking, checking for inappropriate orders, and providing reminders to carry out orders," said Joan Ash, Ph.D, M.L.S., M.B.A. "However, its use is not yet widespread because it has a reputation for being difficult to implement successfully." Ash is the study's lead author and associate professor of medical informatics and clinical epidemiology in the OHSU School of Medicine.

In a combined mail and telephone survey of 964 randomly selected hospitals, Ash's study examined the availability of inpatient CPOE in U.S. hospitals and the degree to which physicians are using it. The response rate was 65 percent. Researchers found that: In about half of hospitals that have CPOE, more than 90 percent of physicians use it, and in one-third of them, more than 90 percent of orders are entered using CPOE.

"So far the benefits for physicians have not outweighed the difficulties presented by the systems," Ash said. "However, the systems have improved and so have the payoffs."

Patient care information systems like CPOE also can create unintended or "silent" errors, according to a separate study conducted by Ash and colleagues in The Netherlands and Australia. This study also was published in the online version of JAMIA.

The study's authors divide these silent errors into two main types: errors during data entry and retrieval, and errors in the communication and coordination process. Both types of errors occur because the systems simply don't take into account the work atmosphere most health care professionals experience, according to Ash, also lead author of this study.

"Many information systems simply don't reflect the health care professional's hectic work environment with its all too frequent interruptions from phone calls, pages, colleagues and patients," Ash said. "Instead these are designed for people who work in calm and solitary environments. This design disconnect is the source of both types of silent errors."

The screen itself can cause errors. Choices that appear too close together result in ordering the wrong tests or sending orders for the wrong person. If a system is rigidly structured, it causes users to focus closely on entering details and switching from screen to screen to enter information.

"Some patient care information systems require data entry that is so elaborate that time spent recording patient data is significantly greater than it was with its paper predecessors," the authors wrote. "What is worse, on several occasions during our studies, overly structured data entry led to a loss of cognitive focus by the clinician."

Communication and coordination errors occur when systems don't take the fluid nature of a hospital's workflow into consideration. These include unsafe medication routines, difficulty in addressing urgent situations, clever routines to avoid system safeguards, and difficulties in promptly transferring patients.

The system itself can be a source of poor communication when its users replace old-fashioned written, face-to-face and telephone interactions with computerized order entry entirely. This loss of communication richness can lead to missed orders or appointments, delayed diagnostic tests and missed medication.

"We believe that with a heightened awareness of these issues, informaticians can educate, design systems, and conduct research in such a way that we may be able to avoid the unintended consequences of these subtle silent errors," the study's authors concluded.

For this article, separate studies were conducted in the United States, The Netherlands and Australia. The authors used similar qualitative methods to study patient care information systems. These systems include CPOEs and other applications that give health care professionals and patients direct access to medical records, and radiology and patient information systems, for example.
Both studies were funded in part by the National Library of Medicine.

To view all OHSU news releases, visit

Oregon Health & Science University

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