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PubMed1999

The Regenstrief Medical Record System: a quarter century experience.

Entrusted with the records for more than 1.5 million patients, the Regenstrief Medical Record System (RMRS) has evolved into a fast and comprehensive data repository used extensively at three hospitals on the Indiana University Medical Center campus and more than 30 Indianapolis clinics. The RMRS routinely captures laboratory results, narrative reports, orders, medications, radiology reports, registration information, nursing assessments, vital signs, EKGs and other clinical data. In this paper, we describe the RMRS data model, file structures and architecture, as well as recent necessary changes to these as we coordinate a collaborative effort among all major Indianapolis hospital systems, improving patient care by capturing city-wide laboratory and encounter data. We believe that our success represents persistent efforts to build interfaces directly to multiple independent instruments and other data collection systems, using medical standards such as HL7, LOINC, and DICOM. Inpatient and outpatient order entry systems, instruments for visit notes and on-line questionnaires that replace hardcopy forms, and intelligent use of coded data entry supplement the RMRS. Physicians happily enter orders, problems, allergies, visit notes, and discharge summaries into our locally developed Gopher order entry system, as we provide them with convenient output forms, choice lists, defaults, templates, reminders, drug interaction information, charge information, and on-line articles and textbooks. To prepare for the future, we have begun wrapping our system in Web browser technology, testing voice dictation and understanding, and employing wireless technology.

Computer Terminals↗
PubMed2004

Preventing provider errors: online total parenteral nutrition calculator.

OBJECTIVE: To describe the development of a pragmatic low-cost medical information system that reduces errors in the ordering of total parenteral nutrition (TPN) in the newborn intensive care unit at the Johns Hopkins Hospital. METHODS: We designed an online total parenteral nutrition order entry system (TPNCalculator) using Internet technologies. Utilization, impact on medical errors, and user satisfaction were evaluated prior to and immediately after introduction of TPNCalculator (intervention 1) and after 2 years (intervention 2). RESULTS: Total software development time was 3 weeks. The number of orders was similar during the 3 periods: 0.39 orders per patient per day (N = 557) were received compared with 0.35 and 0.43 orders per patient per day (N = 471 and N = 656) in 2 intervention periods. During the control period, an average of 10.8 errors were detected per 100 TPN orders compared with 4.2 per 100 orders in the first intervention period (61% reduction of error rate) and 1.2 per 100 orders after 2 years and some redesign of TPNCalculator (89% reduction of error rate). We found a reduction in the following types of problems (intervention 1; intervention 2): calculation errors (100%; 100%), osmolality outside the allowed range (88%; 91%), and other knowledge problems (84%; 100%). There was a 35% increase in the number of incomplete forms in the first intervention period and a 100% reduction in the second. Rapid cycle development was used in the development of this application. Users of the system were enthusiastic and supportive and compared it favorably to the previous paper-based system. CONCLUSION: Low-cost, pragmatic approaches using Internet technology in the design of medical information systems can reduce medical errors and might pose a viable option for the prevention of adverse drug events.

Baltimore↗
PubMed2002

Provider error prevention: online total parenteral nutrition calculator.

OBJECTIVE: 1. To reduce errors in the ordering of total parenteral nutrition (TPN) in the Newborn Intensive Care Unit (NICU) at the Johns Hopkins Hospital (JHH). 2. To develop a pragmatic low-cost medical information system to achieve this goal. METHODS: We designed an online total parenteral nutrition order entry system (TPNCalculator) using Internet technologies. Total development time was three weeks. Utilization, impact on medical errors and user satisfaction were evaluated. RESULTS: During the control period, 0.39 orders per patient per day (N=557) were received compared to 0.35 orders per patient per day (N=471) in the intervention period (NS). There was no significant difference in the percentage of late (incomplete by order deadline) TPN orders. During the control period, an average of 10.8 errors were detected per 100 TPN orders compared to 4.2 per 100 orders in the intervention period (61% reduction of error rate; p < 0.01). We found a reduction in the following types of problems: Calculation errors (100%), osmolality issues (87%) and other knowledge problems (84%). There was a 35% increase in the number of incomplete forms. Users of the system were enthusiastic and supportive and compared it favorably to the prior paper based system. CONCLUSION: Low-cost, pragmatic approaches utilizing Internet technology in the design of medical information systems can reduce medical errors and might pose a viable option for the prevention of adverse drug events.

Computer Systems↗
PubMedDate not supplied

Evaluation of a command-line parser-based order entry pathway for the Department of Veterans Affairs electronic patient record.

OBJECTIVE: To improve and simplify electronic order entry in an existing electronic patient record, the authors developed an alternative system for entering orders, which is based on a command- interface using robust and simple natural-language techniques. DESIGN: The authors conducted a randomized evaluation of the new entry pathway, measuring time to complete a standard set of orders, and users' satisfaction measured by questionnaire. A group of 16 physician volunteers from the staff of the Department of Veterans Affairs Puget Sound Health Care System-Seattle Division participated in the evaluation. RESULTS: Thirteen of the 16 physicians (81%) were able to enter medical orders more quickly using the natural-language-based entry system than the standard graphical user interface that uses menus and dialogs (mean time spared, 16.06 +/- 4.52 minutes; P=0.029). Compared with the graphical user interface, the command--based pathway was perceived as easier to learn (P<0.01), was considered easier to use and faster (P<0.01), and was rated better overall (P<0.05). CONCLUSION: Physicians found the command- interface easier to learn and faster to use than the usual menu-driven system. The major advantage of the system is that it combines an intuitive graphical user interface with the power and speed of a natural-language analyzer.

Consumer Behavior↗
PubMed2001

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing--2001.

Results of the 2001 ASHP national survey of pharmacy practice in hospital settings that pertain to prescribing and transcribing are presented. A stratified random sample of pharmacy directors at 1091 general and children's medical-surgical hospitals in the United States was surveyed by mail. SMG Marketing Group, Inc., supplied data on hospital characteristics; the survey sample was drawn from SMG's hospital database. The response rate was 49.0%. During 2001, nearly all hospitals are estimated to have pharmacy and therapeutics (P&T) committees that meet an average of seven times per year. It is estimated that more than 90% of P&T committees are responsible for formulary development and management, drug policy development, adverse-drug-reaction review, and medication-use evaluation. More than 90% of hospitals use clinical and therapeutic, cost, and pharmacoeconomic information in the formulary management process, while nearly two thirds consider quality-of-life issues. Nearly 70% use clinical practice guidelines in the formulary management process, and 78% have a medication-use evaluation program designed to improve prescribing. Pharmacists in more than 75% of hospitals provide consultations on drug information, dosage adjustments for patients with renal impairment, antimicrobials, and pharmacokinetics. Further, a majority of hospitals ensure accurate transcription of medication orders by clarifying illegible orders before transcription or entry into medication administration records (MARs), using standardized prescriber order forms, requiring prescribers to countersign all oral orders, and reconciling MARs and pharmacy patient profiles at least daily. In 2001, large hospitals are most likely to use prescriber order-entry systems to improve patient safety and are least likely to require the reentry of medication orders into the pharmacy computer system. The 2001 ASHP survey results suggest that pharmacists in hospital settings have positioned themselves well to improve the prescribing and transcribing components of the medication-use process.

Data Collection↗
PubMed1988

A model for capacity planning of a comprehensive integrated information system for hospitals and clinics.

Appropriate system sizing is essential to ensuring a reasonable computer response time for end users. A model is discussed that describes the type and number of interactions between user terminals and printers and the central processor for a comprehensive, integrated medical information system. The system modeled includes support to inpatient and outpatient order entry and results reporting for clinical services; registration; admission, disposition, and transfer; patient appointing; pharmacy, clinical laboratory, and radiology; medical record management; and electronic messages. Originally developed for use in benchmark testing of comprehensive systems designed for military hospitals and clinics, the model has been generalized to be applicable to other systems and settings. Results are presented for a routine busy day in a 200-bed teaching hospital providing extensive outpatient services, and a large free-standing clinic. The model results can be applied to several facets of system planning, including sizing of the central processor and communications network, determining the optimal number of storage devices and user devices, and fine tuning the user interface.

Ambulatory Care Information Systems↗
PubMedDate not supplied

Online support functions of prescription order system and prescription audit in an integrated hospital information system.

The role of the online prescription support functions of a prescription order entry system was analysed and the results of the prescription audit by pharmacists were examined. In the Kochi Medical School Hospital, an online prescription order system has been developed as part of an integrated hospital information system named IMIS (the Integrated Medical Information System), in which all the physicians enter their prescription orders into online display terminals. The prescription order entry system is provided with prescription support functions, which check the entered prescription data, issue warnings, and offer information about drugs or patients. The prescription order system reduces the incidence of simple prescription mistakes and greatly decreases the cases of inquiries by pharmacists. However, results of the analysis show that such functions as warnings of double order and repeated prescription of a drug do not work as well as expected. The system would thus require some kind of intelligence like that of the auditing pharmacists or that of the physicians with accurate knowledge of clinical pharmacology.

Drug Prescriptions↗
PubMed2002

Low-technology, cost-efficient strategies for reducing medication errors.

Medication-related errors are a common cause of patient morbidity and mortality. However, a number of strategies use the latest technology, such as computers and associated hardware and software, to reduce medication-related errors. In this era of reduced operating margins for most hospitals, strategies that employ physician order entry and bar code-labeled medication systems may be prohibitively expensive. Cost-efficient methods are available that can make simple changes in the way medications are mixed, stored, prescribed, and delivered, and they have the potential to have a major effect on medication safety. These methods do not rely on purchasing new hardware or expensive software. They include changing the culture within the hospital to one that focuses on patient safety, developing standardized protocols, developing an education program that provides direct feedback, and using protocols for high-risk medications. Coordinating hospital efforts with regional organizations may also be beneficial in reducing the occurrence of medication-related errors.

Clinical Protocols↗
PubMedDate not supplied

Using the nursing process to implement a Y2K computer application.

Because of the coming year 2000, the need was assessed to upgrade the order entry system at many hospitals. At Somerset Medical Center, a training team divided the transition into phases and used a modified version of the nursing process to implement the new program. The entire process required fewer than 6 months and was relatively problem-free. This successful transition was aided by the nursing process, training team, and innovative educational techniques.

Computer User Training↗
PubMed2003

Enhancing Computerized Provider Order Entry (CPOE) for neonatal intensive care.

The authors describe design, implementation, and use of a new order entry system module for neonatal intensive care. WizOrder is a Computerized Provider Order Entry (CPOE) system developed at Vanderbilt University Medical Center. Since WizOrder's introduction in 1995, it has been continually refined and enhanced; especially when new hospital units and specialties are implemented. Recently, in March 2003, WizOrder was updated and implemented in the Neonatal Intensive Care Unit (NICU).

Academic Medical Centers↗
PubMed2001

Improving medication safety across a multihospital system.

BACKGROUND: The Massachusetts Coalition for the Prevention of Medical Errors and the Institute for Healthcare Improvement have identified 16 best practices to reduce adverse drug events. CareGroup, a network of six hospitals in eastern Massachusetts, multiplied its routine use of these best practices tenfold in the first 18 months of its medication reliability project. DEVELOPING THE COLLABORATIVE STRATEGY: Although CareGroup's long-term plans included technological advances such as clinical order entry, computer systems in the pharmacy, dispensing stations on patient floors, and bedside bar-coding, efforts first focused on manual improvements feasible within a year's time. A 4-year strategy involves helping the medication reliability team leaders at each hospital to create impressive local results, publicize the results to their colleagues, invite their clinical colleagues to learn to use plan-do-study-act (PDSA) cycles, and have colleagues lead PDSA cycles themselves. At monthly or bimonthly task force meetings, team results are presented and team leaders are given specific assignments for their teams. CASE STUDIES: One project reduced the time to blood anticoagulation for heparinized patients. The second dramatically reduced lookalike/soundalike errors. The third improved the safety of patient-controlled analgesia. The fourth reduced coumadin incidents. The fifth improved the education of patients about their medications. The sixth greatly reduced the morning dispensing backlog in the pharmacy. SUCCESS FACTORS: Key success factors, in addition to leadership, are the use of data, forcing functions, appropriate pacing, inexpensive practices, and a consultant. The pace needed to implement the best practices overall made it imperative to make many changes rapidly. Often, the team initiated several changes at one time, rather than sequencing changes in successive PDSA cycles. LIMITATIONS, BARRIERS, AND NEXT DIRECTIONS: CareGroup faces key challenges in measurement and in spreading and deepening the involvement of clinicians, particularly physicians. It lacks an overall, objective measure of medication safety. Spread of the changes made has been incomplete although the adoption of the best practices increased tenfold (from 6 to 60) in 21 months. Two of the case study interventions--in coumadin order sequencing and dedicating a pharmacy technician to order entry--have been implemented at only one site to date, even though the adoption of the change ideas across hospitals is encouraged. The eventual impact of the changes planned for the future, through automated systems such as computerized order entry, is much larger. Considerable progress is anticipated in adoption of best practices; improvement in top-priority areas of each hospital; improved automation and technology in ordering, dispensing, and administering medication; and better reporting.

Anticoagulants↗
PubMedDate not supplied

Reducing excessive medication administration in hospitalized adults with renal dysfunction.

Medication errors are common and harm hospitalized patients. The authors designed and implemented an automated system to complement an existing computerized order entry system by detecting the administration of excessive doses of medication to adult in-patients with renal insufficiency. Its impact, in combination with feedback to prescribers, was evaluated in 3 participating nursing units and compared with the remainder of a tertiary care academic medical center. The baseline rate of excessive dosing was 23.2% of administered medications requiring adjustment for renal insufficiency given to patients with renal impairment on the participating units and 23.6% in the rest of the hospital. The rate fell to 17.3% with nurse feedback and 16.8% with pharmacist feedback in the participating units (P<.05 for each, relative to baseline). The rates of excessive dosing for the same time periods were 26.1% and 24.8% in the rest of the hospital. Automated detection and routine feedback can reduce the rate of excessive administration of medication in hospitalized adults with renal insufficiency.

Academic Medical Centers↗
PubMedDate not supplied

An efficient fault-tolerant out-patient order entry system based on special distributed client/server architecture.

An automatic order entry system is very important for processing out-patient information. This system not only helps physicians to enter their orders directly, but can also reduce order communication error and thus improve medical quality. Therefore, many hospitals have high aspirations to generate and implement direct order entry systems, but they are also concerned about the setbacks of system failure. In this paper, we present an effective and efficient fault-tolerant order entry system based on special distribution client/server architecture that satisfies the requirements of out-patient order entry very well. From the experimental results carried out on a prototype, we found that this system can improve the system response time of order entry and can also generate an operational method having a user friendly interface. The physicians can enter their orders easily, accurately, directly, flexibly and at a faster rate by making choices from standardized and personalized menus in this system.

Ambulatory Care Information Systems↗
PubMed2002

Impact of a computerized alert during physician order entry on medication dosing in patients with renal impairment.

Computerized assistance to clinicians during physician order entry can provide protection against medical errors. However, computer systems that provide too much assistance may adversely affect training of medical students and residents. Trainees may rely on the computer to automatically perform complex calculations and create appropriate orders and are thereby deprived of an important educational exercise. An alternative strategy is to provide a critique at the completion of an order, requiring the trainee to enter the entire order but displaying an alert if an error is made. While this approach preserves the educational components of order-writing, the potential for errors exists if the computerized critique does not induce clinicians to correct the order. The goal of this study was to determine (a) the frequency with which errors are made by trainees in an environment in which renal dosing adjustment calculation for antimicrobials are done by the system after the user has entered an order, and (b) the frequency with which prompts to clinicians regarding these errors leads to correction of those orders.

Anti-Bacterial Agents↗
PubMed2005

Medication errors in an internal medicine department. Evaluation of a computerized prescription system.

OBJECTIVE: Evaluation of a computerized physician order entry in an Internal Medicine Department, with a unit-dose distribution system. SETTING: Pharmacy Department, Internal Medicine Department. S. Francisco Xavier Hospital, Lisbon, Portugal. METHOD: This study was carried out in December 2001 and January 2002. After two years experience of the CPOE system, medication errors were evaluated prospectively, in an internal medical department of a 360-bed academic hospital. Data were collected once a week. Pharmacists reviewed all medical prescriptions as part of their routine work. Medication errors detected were recorded on a data collection form with a design based on the types of errors as defined by the American Society of Hospital Pharmacists (ASHP). Completed forms were reviewed and medication errors were classed according to ASHP guidelines. RESULTS: A total of 2268 orders were monitored (162 patients). In these orders, 73 medication errors (22.4% of the patients) were detected and documented (59 prescribing errors and 14 monitoring errors). The most common prescribing errors were deficiencies related to the right class but wrong drug (28.3%): omeprazole vs. ranitidine/sucralfate in stress ulcer prophylaxis; incorrect dose (30%) and unclear orders (13.3%). Errors related to incorrect frequency of administration (5%); maintenance of IV route (5%); duplicated drug therapy (11.7%); drug interactions (1.7%) and length of therapy (3.3%) were also detected. The 14 monitoring errors detected were failures to review a prescribed regimen for appropriateness and detection of problems. CONCLUSIONS: Computerized prescription order entry has demonstrated effectiveness in eliminating medication errors related to transcribing and patient identification. Nevertheless, medication errors related to prescription and monitoring still occur. The use of clinical decision support systems and pharmacist involvement is vital to achieve maximum medication safety and reduce medication error rates.

Drug Prescriptions↗
PubMed2004

Evaluation of drug interaction software to identify alerts for transplant medications.

BACKGROUND: The ability of computerized physician order entry (CPOE) systems to identify clinically significant drug interactions is dependent upon the integrity of the drug information populating the software. A CPOE system with incomplete or inaccurate drug information will fail to identify clinically important drug interactions and, therefore, fail to reduce preventable adverse drug events (pADEs). OBJECTIVE: To evaluate, from the prescribers' perspective, the ability of a common drug interaction database to identify clinically important drug interactions involving drugs used in transplantation. METHODS: The clinical significance of drug interactions involving 5 transplant drugs was evaluated by an expert panel to determine whether alerts should be generated for physicians not involved in the transplant at the time of order entry. Drug interactions included in the analysis were generated from the expert panel, a common drug interaction database, and 2 standard drug interaction references. Responses on the clinical significance were used to calculate the sensitivity, specificity, and positive and negative predictive values for each severity setting of a common electronic drug interaction database. RESULTS: Overall, the database failed to identify approximately 70% of interactions considered significant by the expert panel. Of the alerts that were generated, >85% were considered clinically significant. The database was most deficient in identifying interactions resulting from additive toxicity. CONCLUSIONS: To expect a decrease in pADEs caused by drug interactions, the information used to populate CPOE systems must be validated. Establishing consistency and integrity of this information may be a future role for pharmacists.

Databases as Topic↗
PubMed1999

Tracking vaccine compliance in a primary care setting: online history, reminders, order entry, and charting.

In a new primary care setting with three medical disciplines participating, a vaccine history and order entry system was implemented along with other online documentation systems as the primary documentation tools for the clinic. Reminders were generated based upon a set of algorithms consistent with 1998 nationally accepted vaccine guidelines. Vaccine compliance data were analyzed for the entire population cared for in this setting for a 6 month period. Rates of compliance with national recommendations for eight key vaccine groups were calculated based on the online data. Trends in the rates of compliance, interpreted within limitations, showed statistically and clinically significant improvements. The immunization application accomplished several goals: accurate history and patient-specific recommendations, online ordering of vaccines or serum products, online charting of administration that, in turn, automatically maintained the vaccine history.

Adolescent↗