Doctors criticise Cerner system six months after it went live

             Should hospitals study mortality rates before and after a major IT installation?
 
The Daily Examiner, which is one of the oldest newspapers in Australia, reports on the controversial installation of a Cerner-based hospital system in New South Wales.

It’s not clear whether the controversy is because the IT is making the lives of doctors more difficult –  and therefore potentially dangerous for patients – or whether clinicians are critical of a system that, given time, could make their working lives more productive and improve outcomes for patients.

Or both?

Cerner is one of two software products that are at the heart of the NPfIT, the other being iSoft’s Lorenzo.

In New South Wales the 151 year-old Daily Examiner reports that an electronic medical records system is frustrating doctors more than six months after its installation.

The article also quotes a US  study which said there had been increased paediatric mortality in one emergency department after installation of a Computerised Physicians Order Entry [CPOE] system.


The study, “Unexpected Increased Mortality After Implementation of aCommercially Sold Computerised Physicians Order Entry system”, wascarried out by eight doctors who investigated the go-live in 2002 of aCPOE system at the Children’s Hospital Pittsburgh in 2002. The CPOE installation was based on Cerner software.

Helping to carry outthe study was the Universityof Pittsburgh which has become a particularly enthusiastic user ofCerner .
 
In last week’s article in the Daily Examiner, thechairman of a local hospital’s medical staff, Dr Allan Tyson, suggestedthat it took four times longer to properly record patient records in theCerner system than writing it down using paper.

There are othercriticisms of the system by an unnamed doctor.

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Commentson the article are mixed.

The first comment is highly criticalof the US study that found increased mortality after the implementationof the CPOE system at the Children’s Hospital, Pittsburgh.

Anothercommentator is critical of the New South Wales Government’s North CoastArea Health Service [NCAHS].

Another praises the local recordssystem, saying that, after he’d had a bad fracture,  electronic noteswere available of his past treatments at different  locations. Thecommentator suggested that doctors who resented the new system might nothave come to training or didn’t like being accountable for the workthey had or hadn’t done.

 “Surely this system cannot be that badif it s being used elsewhere in the state and/or the world?”

 Anothercommentator, who was a doctor working in the local fracture clinic,said that there had been “weeks when I have not had access to any notesor X-ray reports” which has “considerably added to the length of timethat patients have had to wait to be seen”.

 **

Thearticle in the Daily Examiner is useful in drawing attention to the USstudy on the unexpected increased mortality after implementation of aPhysician Order Entry System. 

In England, some suppliers arehoping CPOE will take centre-stage as part of the NPfIT, should thenational programme survive the coalition government.

I hadn’tnoticed the US study when it was published in 2005 but it triggered somefascinating discussion on the complexities of installing major newsystems in hospitals.

The upshot of the discussion is thatinstalling new hospital systems is likely to be much more complicated,take longer and be more risky for patients than suppliers say.

Indeedthe discussions and papers suggest that it may take a year or more for amajor new hospital system to settle down, rather than the few daysallowed for in some supplier-led implementations.

While thesystem is settling down, patients may be in danger.

That said, it’s easy to see how CPOE would reduce potentially serious and even fatal medical errors when it’s properly installed, tested and used, and when it’s fully supported by clinicians.

Some doctors criticise the USstudy but there seems to be, in general,  support for the idea ofstudying mortality before and after a hospital-wide IT installation.  

Toblame the supplier’s system, though, may be over-simplifying things: ifyou bought a new hammer that caused injury would you blame the hammer,unless it were faulty?

I’ll cover in a separate blog post thepoints that struck me as some of the most pertinent from the papers anddiscussions.

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The conclusion of US study UnexpectedIncreased Mortality After Implementation of a Commercially SoldComputerised Physicians Order Entry system:

“We have observed anunexpected increase in mortality coincident with CPOE implementation.

“AlthoughCPOE technology holds great promise as a tool to reduce human errorduring health care delivery, our unanticipated finding suggests thatwhen implementing CPOE systems, institutions should continue to evaluatemortality effects, in addition to medication error rates, for childrenwho are dependent on time-sensitive therapies.”

Links:

Doctorsblast data system – Daily Examiner, Australia

DoesCerner kill children? I don’t think so – HIStalk.

“UnexpectedIncreased Mortality After Implementation of a Commercially SoldComputerised Physicians Order Entry system” – Journal of AmericanAcademy of Pediatrics 

LessonsFrom Unexpected Increased Mortality After Implementation of aCommercially Sold Computerized Physician Order Entry System -Journal of American Academy of Pediatrics  

CPOE- what is it? – Wikipedia

Apaper on CPOE –  Cerner website

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For each negative paper on CPOE there will be a positive one, this one for example published a week ago which indicates a 20% fall in paediatric mortality after introduction of CPOE http://pediatrics.aappublications.org/cgi/content/abstract/peds.2009-3271v1

It would be useful to examine the circumstances in which CPOE implementations work, and I would bet it's got little to do with the choice of system.

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Thanks for drawing attention to a positive CPOE study. The studies so far, it seems to me, show that the system is only one cog on which success depends.

If the position of the system within the working processes of doctors, nurses and administrators is not fully understood - or the potential problems of system and data demands are not faced and resolved before go-live - the risks of failure are greatly increased.

This is from a paper on the lessons learned from the CPOE go-live at the Children's Hospital, Pittsburgh:

"... The question that must be asked is how can intelligent and well-intentioned leaders at all levels of an institution make the kind of implementation decisions that ultimately place excellent patient care in jeopardy?

"Clearly, that was not their intent, so how could it happen? What is it about CIS and CPOE that makes implementation so risky?

"Why are these implementations prone to causing emotional distress,rework,delay,user protest, temporary system withdrawal, and later repeat implementation,often at a cost of millions of dollars to the hospital or health system involved?

"How can institutions avoid these risks and additional costs? These are the questions that demand answers.

"We posit that the primary reason CISs and CPOE are prone to failure is that they have the ability to profoundly alter patient care workflow processes.

"Although the intent of computerization is to improve patient care by making it safer and more efficient, the adverse effects and unintended consequences of workflow disruption may make the situation far worse.

"It is important to remember that the manual processes of patient care and documentation in place within an institution have been finely tuned over long periods of time, usually years to decades.

"Although paper charting forms, medication ordering, delivery and administration, and processes for patient admission and transfer are appropriate subjects for computerization, the transition from manual to computerized methods is notoriously complex. This is a severely underappreciated fact of CIS and CPOE implementation..."

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Tony,

Please provide the reference on the "lessons learned" commentary.

As for the "positive" CPOE paper, the methodology was flawed. In an earlier study, the same authors reported an 18 per cent reduction in mortality from deployment of the rapid response teams. The current study confounded its results by using the mortality benefit from the introduction of the rapid response teams as if it were from CPOE deployment.

The conclusion is not supported by the data. CPOE does not appear to add any mortality reduction to that which was achieved by the rapid response teams.

How this slipped by the editors of Pediatrics is astounding.

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Hi Tony - any readers who would like to know more about this very large project might want to visit the project website and read some of the regularly published newsletters.

(link:http://www.emr.health.nsw.gov.au/index/newsletters).

I think two lessons for the UK are (1) not everyone is going to like the system no matter what you do; and (2)once you raise your head above the parapet by succeeding, academics will throw books at you.

Neither of those of course are a reason to stop.

Also I agree with your first commentator - I found the 2005 study highly suspect, totally unbalanced sizes of the before and after populations. But I admit my bias, I think this is a good system.

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atenolol

You asked for the reference on the "lessons learned" commentary from the mortality statistics before and after a CPOE implementation at the Children's Hospital Pittsburgh. It's

http://pediatrics.aappublications.org/cgi/content/full/118/2/797

I've four thoughts:

a) It's a good thing death rates are beginning to be studied before and after major hospital IT implementations. It concentrates the mind on patients, however big or small the effect of the new system on the statistics.

b) CPOE has the potential to stop avoidable deaths, say through warning a nurse or doctor of a drug dose that is dangerously high, but a go-live that treats patients as guinea pigs, in other words a go-live that hasn't properly considered the implications of the IT on the end-users, has the potential to cause more harm than good.

c) Before a new safety-critical system goes live in a passenger aircraft it has to be certified as safe.

What role - if any - do regulators have in certifying new NPfIT systems at their implementation sites?

As far as I know, no safety certification takes place.

d)CPOE has a role at Morecambe Bay where staff, officials and suppliers are trying to get a Cerner system to go live by the end of this month.

Has this implementation had an independent safety assessment and if so are the results published? I doubt it.

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So doom and gloom abounds on CPOE, and yet I know personally of many sites processing million of orders a year and with succesful multi-year 100% doctor adoption and use of CPOE systems. None of them have gone broke, had a major clinical disaster or been sued out of existence by the (let's face it) not normally shy litigation attorney's in the US.

A critical part of system adoption is the pre-existing culture of the medical organisation being asked to change and the willingness to change. Where there is unanimity and strong medical leadership on policy and patient safety, CPOE goes in quickly and adoption spreads relatively quickly. Where that is missing, CPOE goes in slowly and spasmodicly.

As to the CPOE benefits argument, there are any number of papers to support the polar opposits of the argument. As an optimist and believer, I point to just one organisation that embraced the use of this particular solution type, developed out the system they installed to use all its clinical decision support capability of the system and achieved some quite significant outcome improvements in the management of stroke patients. This was done with patient admitted during a period using a control group and a group managed under specific evidence based order set embedded in their CPOE solution.

Now this is no fancy major city academic with an army of intern doctors entering oreders, but a regular hospital network in Northern Ohio. http://www.qualitydigest.com/inside/health-care-article/computerized-physician-order-entry-helps-hospitals-improve-care.html.

Could you have rolled out this change using paper order sets, possibly, but I will be that the doctors would have complained like crazy about the additional data entry that was being asked of them and admin would have complaind about the cost of the extra printing. In addition the effort to measure the impact of the two approaches would have been cost prohibitive to collect the data and analyse the data on this study over a longer period whereas with CPOE analysis was a byproduct of just using the system. Multiply that effort by 10-12 major clinical initiatives a year and you quickly get the picture of the resources and time that could consume in your average 800 beds NHS acute trust.

So where the will is there and the appropriate technology is flexible enough to assure doctor adoption of the systems without bruised ego's and major impingement of time and effort, the benefits can come.

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For a more Cerner centric point of view, this interview with the CMIO of Memorial Hermann health system in Texas could not have been more timely in its publication. Bob Murphy's point of view in here is spot on about the challenges and the learning that UK NHS trusts still have to get through. There is goodness in CPOE for its own sake, but it is when the power of Clinical Decision Support in a mature system like Cenre/Eclipsys is emplyed that you really get the value. See here: http://histalk2.com/2010/05/24/histalk-interviews-bob-murphy/

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Your four thoughts get to the point. The CPOE products have not been proven to be safe and efficacious, having avoided all regulation except in Sweden. The one featured down under does not warn of absurdity. Au contraire, it enables absurdity. I recently learned that the FDA of the US is accepting complaints about CPOE and EMR contrivances, though somehow, these devices have escaped appropriate methodological scrutiny for safety and efficacy.

This link brings the reader to more than 15 pages of complaints about CPOE and more. Do any strike a chord with your readers?

http://google2.fda.gov/search?q=maude+cerner+millennium&x=20&y=15&client=FDAgov&site=FDAgov&lr=&proxystylesheet=FDAgov&output=xml_no_dtd&getfields=*&ie=UTF-8&ip=141.151.182.218&access=p&sort=date%3AD%3AL%3Ad1&entqr=3&oe=UTF-8&ud=1&filter=0&start=140

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As someone who has been intimately involved with the NSW project for more than four years, I have now seen several instances of “shroud-waving” from clinicians either upset that their favourite system was not chosen and Cerner was, or more often just frustrated by the extra workload that an EMR undoubtedly does generate for already busy clinicians...

However I have yet to hear of a single case where any patient has actually come to any harm, and indeed it would be astounding if a patient were to experience a computer-related misadventure in a hospital as small as Grafton.

UK readers should beware reading too much into this “controversy”, which unfortunately seems to be being fanned by certain IT academics here who are happy to criticise Cerner, but who, spookily enough, sometimes turn out to have their own alternative “solution” under development (but not of course actually rolled out anywhere).

Readers should also note that the phase one Cerner EMR is now in use by more than 70,000 staff across NSW Health, so a percentage of dissatisfied customers should be no surprise. Finally they should note that NSW phase one includes Orders and Results for Labs and Radiology, but no medications ordering or dispensing functionality has been rolled out yet. Neither are there are ICU installations of Cerner in NSW at this point.

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atenolol - Your link actually comes to a search for results related specifically to Cerner Millenium and not all of the results relate to behavior related to CPOE. I leave the Kansas City marketing masters to defend themselves as to why they have so many instances of reports of MAUDE incidents. However, that is just one company involved in the CPOE industry in the US. Try entering in the search Siemens, Epic, Meditech, Eclipsys all of whom have significant CPOE usage in the US healthcare market etc and see what hit rate you get.

The FDA and Senator Graseley are complaining quite rightly, and perhaps as a byproduct of the certification debate there will be a move to focus certification in this area. I say that's a good thing, but dont tar all CPOE systems with the same brush.

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