Computerized physician order entry system linked with increased patient mortality

Mortality unexpectedly increased after implementation of a commercially sold computerized physician order entry (CPOE) system, according to a report in the December issue of Pediatrics. "CPOE is an important technology that holds great promise; but it is also a complex system with considerable 'ripple effects' beyond its intended purpose of reducing medication errors," Dr. Yong Y. Han from University of Michigan Medical School, Ann Arbor, told Reuters Health. "Systems integration and human-machine interface issues should be thoroughly addressed as this technology is being implemented." Dr. Han and colleagues examined mortality rates among children who were admitted after they were transported from another facility before and after CPOE implementation. The hypothesis was that patient outcome would improve after this intervention, in this case PowerOrders (Cerner, Kansas City, Missouri). The unadjusted mortality rate during the study period was 3.86%, the authors report, but this increased from 2.80% before CPOE implementation to 6.57% after CPOE implementation. Observed mortality was consistently better than predicted mortality before CPOE implementation, the results indicate, but not afterwards. According to regression analyses performed to determine which factors might be associated with the increased mortality, shock was associated with a 6.24-fold increased odds of mortality, followed by CPOE (3.71-fold increase) and severe coma (3.43-fold). "After CPOE implementation, order entry was not allowed until after the patient had physically arrived to the hospital and been fully registered into the system, leading to potential delays in new therapies and diagnostic testing (this policy later was rectified)," the investigators explain. "Our unanticipated finding suggests that when implementing CPOE systems, institutions should continue to evaluate mortality effects, in addition to medication error rates, for children who are dependent on time-sensitive therapies," the authors conclude. "CPOE technology is still evolving and requires ongoing assessment of 'systems integration' and 'human-machine interface' effects, both predictable and unpredictable, on patient care and clinical outcomes," they add. "Any limitations or programming flaws that a specific CPOE system might have will most likely surface in the setting where multiple, rapid-fire interventions are commonly made," Dr. Han said. "Our study raises the question whether CPOE should be viewed similarly to drugs and medical equipment," Dr. Han added. "Before a CPOE system is allowed to enter the market, should that system be evaluated for unforeseen adverse effects in addition to its anticipated benefits? In other words, should a CPOE vendor be held to similar product evaluation process and standards that pharmaceutical and medical device companies must currently meet?" Pediatrics 2005;116:1506-1512.
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