ZIFFPAGE TITLEA Price to PayBy Deborah Gage | Posted 2004-08-01 Email Print
Physicians at Cincinnati Children's Hospital figured if they picked the right technology and the right vendor, establishing an electronic means of ordering drugs and recording patient treatments would easily reduce mistakes and improve care. But there wasA Price to Pay
The first set of errors, in communications or coordination, can result if the system overwhelms a clinician with information. At Cincinnati Children's, a doctor examining a patient picked up an abnormal heart rhythm. One way to get the heart back to normal is to use a medication called Adenosine, a drug that if not administered carefully could stop a patient's heart. The doctor, who wanted a tiny dosea fraction of a cubic centimetermistakenly wrote into the system a prescription for a dose 10 times stronger than what he had intended. The computer system has alert messages that flash on the screen when an overdose is suspected, but this doctor ignored the warnings.
The drug was administered, but luckily that patient's body flushed the drug without suffering any harm. Dr. Craig Hallstrom, a physician at the hospital who tracked the unintended consequences of the patient care system, said one of the problems in this instance was that the system had too many alerts. Physicians were coming across warnings for allergies, drug interactions and other potential problems almost every time they ordered a drug. Before long, doctors become desensitized to the alerts.
Data entry and retrieval problems can result from something as simple as a poor screen design, such as those with "pick and click" interfaces that allow doctors to check boxes to order medications and tests.
These screens often cram too many options into too little space, making it easy for time-harried physicians to pick the wrong medicine or dosage. For instance, another Cincinnati Children's doctor, when ordering a mild pain reliever, was given the choice to order the medication in pill or liquid form. The physician mistakenly hit "tablets" instead of "milliliters" when clicking off dosage options, ignored subsequent warnings to reconsider, and ended up prescribing 325 tablets of Tylenol to be administered to a child. The amount of Tylenol ordered was a potentially harmful dose, but was so out-of-bounds that a pharmacist easily caught the error.
"The only people who think [this is] easy are the people who haven't done it," Johnson says.
The difficulties of electronic record-keeping and order-processing are so substantial that, to date, only 159 of 5,794 U.S. hospitalsaround 2.7%have live order entry systems that doctors use, according to KLAS Enterprises, a research company specializing in health-care information technology.
Yet early this year, ignoring the odds, President Bush won support from both Democrats and Republicans in Congress when he launched his own "moon shot" program: a call to create a national electronic health-records system within 10 years that would allow patients to own and share their medical information with hospitals and other health-care providers. He appointed a coordinator, Dr. David Brailer, and budgeted $150 million for research and development to get the job done.
So far, the various health-care constituenciesinsurers, hospitals, doctors, policy makershave agreed on what technical issues to address. Standards for recording and exchanging data, as well as federal certification of technologies and products, are on the list. But few, if any, details on what is specifically needed or how results will be achieved have been worked out. There have not even been any noticeable discussions during this initiative, which is led by the U.S. Department of Health and Human Services, of using technology to track and report medical errors. The project to unify record-keeping and exchange could cost as much as $1 trillion to install.
Yet it could promote a greater "culture of safety'' in the health-care industry. Advocates of increasing patient safety, such as David M. Lawrence, chairman emeritus of the Kaiser Foundation Health Plan, say the airline industry can be a model. From 1950 to 1990, fatalities in commercial aviation fell 80% after the industry began meticulously analyzing accidents and near-misses.
But while hospitals have leaped at the chance to invest in new technologies that they can charge for, such as whole-body scanners, they have been slow to invest in or fund the development of computer software and hardware that improve patient care and safety. In May, Forrester Research found that while organizations across the country plan to increase their information-system spending this year by 2.4%, hospitals will increase tech spending by only 1.9%. And last month, the Medical Records Institute, a group pushing for the adoption of electronic health-care records, found that 55% of the 800 health-care managers it surveyed cited a lack of funds as the biggest barrier to the adoption of electronic health records. As a result, it may indeed take 10 yearsor morefor a common method of keeping track of patient care instructions and history to emerge and be adopted.
So why would any health-care institution want to go through the pain of converting to electronic records? If they want to see why it's worth it, administrators and physicians need only look at Cincinnati Children's Hospital.
Despite the difficulties, Cincinnati Children's, through hard work and force of will, built a system that, in the two years it's been installed, has cut medication order and dispensing errors to fewer than 90 a month from almost 120 a month in 2003; virtually eliminated mislabeled lab reports, such as putting the wrong patient's name on a blood test, to 0.02% from about 0.08% in 2002; and cut the time it takes to deliver drugs from the pharmacy to the bedside from almost two hours in 2002 to one hour.
The result: the 423-bed, not-for-profit medical center, which specializes in pediatric medicine, research and teaching, last year was the first children's hospital to win the Nicholas E. Davies Award of Excellence, given by the Health Information Management Systems Society for progress in computerizing patient records.
"Their drive to become better, and their willingness to pay the price, is unique," says Jerome Dykstra, a systems consultant in Chicago who has worked with Cincinnati Children's since 1997.
Parents from around the world bring their children babies in strollers, toddlers walking the halls with stuffed animals in handto Cincinnati Children's. And for good reason: The pediatric medical center is consistently placed among the top 10 children's hospitals in an annual U.S. News & World Report ranking.
Among similarly sized U.S. pediatric hospitals, the National Association of Children's Hospitals has ranked Cincinnati Children's second in the number of surgical procedures performed (24,000 inpatient and outpatient procedures in fiscal 2003) and fourth in the number of emergency visits (84,486 in fiscal 2003). In all, the hospital last year saw 700,000 kids for traumas, liver ailments, and heart and bone marrow transplants.
Dr. Johnson, a slim, 51-year-old radiologist who was born in Australia, glides quickly across the facility's finely polished floors, offering a friendly "G'day" to the doctors and nurses he recognizes. A typical day for Johnson, who coordinates the hospital's medical services with its information-systems initiatives, might be a morning meeting in his office to explain a plan to install a new medical-imaging management system, and an afternoon over an operating table where he'll take a biopsy of a 16-year-old boy with a strange growth in his hip.
After a doctor recruited him to the States, Johnson found himself in Cincinnati in the late 1990s just as radiology digital-imaging systems, known as Picture Archiving and Communication Systems (PACS), were coming onto the market. Soon, Johnson was helping get one of the systems installed in Cincinnati Children's radiology department.
Between 85% and 90% of patients at Cincinnati Children's have an X-ray, CT scan or other medical image taken. But, Johnson says, when he arrived, the department was awash in pictures and paper files: "It was obvious what had to happen."
The imaging archive Johnson put in place was the hospital's first big deployment of an information system for a clinical service. Today, Cincinnati Children's uses no film. The system captures X-ray, Magnetic Resonance Imaging and other medical images in digits and then zaps them around the hospital. Images are put up as dots on screens, not sheets of film in folders, speeding analysis and reporting.
Now it takes just 7 hours for a doctor to examine X-rays and CT scans and prepare a report on a patient's condition. In 2000, it took more than 28.
In the use of computers, Johnson says, "Radiology was way ahead of the hospital."
But some doctors, such as orthopedic surgeons, resisted. They wanted to hold a picture in their hand, or didn't want to take the time to log in to a computer to see medical images, or both. User complaints are something Johnson has gotten accustomed to over the years, and they are commemorated by decals of bullet holes on his office door. "We got shot at a lot," he says. But the archiving team slowly brought dissenters along.
Johnson personally spent time with the doctors, showing them the ropes, and even took some of them on field trips to other hospitals that had adopted the system to show skeptics how the system helped save hours in figuring out the problems a patient was experiencing.
"It was a standoff for a while," he says. "But I knew it was the right thing to do."
About the time Johnson was completing the PACS system, the Institute of Medicine issued a sobering report asserting that errors in medical treatment killed as many as 98,000 people per year. The report shocked the public, while the medical community debated fiercely whether the institute's death rates were accurate. There was, however, no debate on the central thesis: Everyday errors in prescribing and executing care for patients were a big problem. And just recently, on July 27, a Colorado health-care consulting firm, HealthGrades, released a study that doubled the estimate of deaths each year due to medical errors, to 195,000.
The 1999 Institute of Medicine study and an internal report that found its own staff making medication errors forced Cincinnati Children's to concentrate on how to protect its patients from human mistakes. By 2000, a committee of doctors, nurses and staff were looking into the benefits of computerized medication order entry. The group found several studies indicating that computer systems for ordering drugs did in fact reduce errors from bad handwriting, could warn physicians about potential overdoses, and tracked procedures and medications better than paper-based systems.
A 1999 study by a group of physicians, including Dr. David Bates of Brigham and Women's Hospital and Harvard Medical School, and Dr. Jonathan Teich of the Harvard School of Public Health, found that medication errors fell more than 80% when a hospital installed an electronic order system, although the paper also warned of the potential for "causing new errors."
The committee recommended that the hospital move to computerized order entry. Hospital managers were also realizing that what the hospital really needed was to automate and integrate all of its patient care processes. The paper-based process that had long been in place, says chief executive officer James Anderson, was "inefficient, shabby."
At that point, however, the hospital managers had little inkling of the challenges ahead.