Errors in using the medicines are major health care problem and can often results into injuries and even death. According to a 1999 report of Institute of Medicine (USA), approximately 44,000 - 98, 000 Americans die each year due to medication errors. More than 7,000 of those errors are related to prescription drugs. The fact that half of the medication errors occur at the stage of prescribing is confirmed by another study published in JAMA.
The prescribing process is complex and opportunities for error abound. One of the weak areas is the writing of the prescription. There are instances where poor handwriting has resulted into serious consequences. For example in a prescription of Isordil (Isosorbide dinitrate) was read, incorrectly, as Plendil (Felodipine) resulting into the death of the patient and quarter million dollar malpractice verdict. In another prescription, 10U (ten units) was interpreted as 100 units because of inappropriate use of abbreviation. Patients may be given drugs they are allergic to, or which are contraindicated or have already been prescribed under another name. There is also a possibility that the doses, or duration, or formulation, or route may be inappropriate: in short, anything that goes wrong in prescribing will lead to undesired results.
In this context, great hopes have been pinned on the Computerized Physician Order Entry (CPOE) system.
CPOE is a system permitting the physicians to enter orders directly into a computer rather than handwriting them. CPOE has been sanctified as a proven and highest priority change for reducing medication errors. This computer-based system shares the common features of automating the medication ordering process and ensures standardized, legible and complete order.
The features of CPOE that promote the safe use of medications include structured orders, patient-specific dosing suggestions, reminders to monitoring drug levels, reminders to choose an appropriate drug, checking for drug-allergy and drug-drug interactions, automated communication to ancillary departments, and easy access to patient data and reference information while prescribing. A CPOE application with an integrated antibiotic adviser has been shown to reduce the rates of excessive drug doses and antibiotic-susceptibility mismatches.
The CPOE system has had the largest impact of any automated intervention in reducing medication errors and associated costs and injuries. The rate of serious error fell by 55 per cent in one study and the rate of all errors were reduced by 83 per cent in another. Some studies also show that implementation of CPOE reduces the overall hospital cost and length of stay in patients
CPOE provides health care organization opportunities to standardize practice; improve interdepartmental communication; facilitate patient transfers and capture data for management, research, and quality monitoring. It provides physicians and other clinicians with an environment that is more appropriate than a paper based setting to the complexicities of today's medicine. Patients can also have the comfort of knowing that sophisticated technologies are being applied to help ensure their safety.
The five advantages offered by a CPOE system are a) demonstrated reduction in medication errors, b) absence of hand writing related problems, c) structured, complete and legible orders, d) absence of drug related problems, and e) betterment of patient care.
As every coin has two sides, CPOE does have some limitations. The diffusion of CPOE in health care system is surprisingly slow. A survey, published in 2002, has shown that only 3.3 per cent of US hospitals were using CPOE. The major reason is the high cost of CPOE. Implementation CPOE is an expensive (million of dollars) and complex project. CPOE also requires the hospitals to have a robust information infrastructure.
The use of CPOE requires major behavioral changes, not only by physicians but also by the entire health care organization. Health care professionals are often reluctant to disturb their routine work flow and embrace new technology. The management of Cedarsinai health system, in Los Angeles, was compelled to remove its CPOE system after almost unanimous protest from the medical staff.
To prescribe a drug with an electronic tool takes more time than to write orders on paper and a study revealed that it took medical interns 9 per cent of their time ordering with CPOE system compared with 2 per cent with paper order systems. Although the computerized approach saved them an additional 2 per cent of time with regard to the time spent for other duties, the net difference between the two systems was a 5 per cent increase of their total time. Findings from another study showed that CPOE doubled the time required to write medication orders.
To make this overtime acceptable by physicians, the advantages of using CPOE need to be considered. A human life cannot be equated with any amount of money and therefore even if the health care organizations have to pay the additional overtime wages to the employees, CPOE does contribute to reduction of medication errors.
The data on occurrence of medication errors in India is lacking. However unpublished results of a recently concluded study indicate a very high incidence of medication prescribing errors. In view of this CPOE systems certainly have an application in the Indian clinical practice as well. India being leaders in information technology, the corporate hospitals probably may take initiative and start using CPOE systems. The authors are not aware of any CPOE system being used in the country.
CPOE, therefore, holds the potential to improve the prescribing process and provides guidance to physicians as they care for patients. When an organization decides to implement CPOE, it should be planned well and should provide sufficient training to the medical staff. The objective of implementation of CPOE must be a significant increase in the quality of patient care.
- (The authors are with Department of Pharmacy Practice, NIPER)