Computerized Order Entry Results in More Timely and Efficient Care
To reduce medical errors and improve patient safety, many hospitals have begun to implement computer-based systems in which medical orders are entered and documented electronically. Little information has been available, however, to help determine the impact of these systems -- not only on patient safety but also on the timeliness and efficiency of care delivery.
But a study presented January 31 shows that a computerized order entry (COE) system implemented at Cincinnati Children's Hospital Medical Center significantly reduces the time it takes to obtain radiology films on patients in the pediatric intensive care unit and to receive verbal results from the radiologist. The study will be presented at the annual meeting of the Society for Critical Care Medicine in San Antonio.
"The COE system reduced the time of arrival to take the X-ray from 18 to eight minutes (56 percent) and the time the X-ray was available for viewing from 33 to 24 minutes (27 percent)," says Brian Jacobs, MD, a critical care physician at Cincinnati Children's and lead author of the study. "The system also resulted in fewer phone calls between clinicians and radiologists to either clarify augment information. User satisfaction surveys indicated that physicians, radiologists and radiology technicians were very happy with the new system."
Cincinnati Children's computer-based system has two main parts, COE and clinical documentation. The system is believed to be the most comprehensive in any pediatric hospital in the United States and is expected to reduce medical errors significantly – an estimated 30 percent.
"The primary focus of this clinical informatics system is patient safety, particularly the reduction of medical errors," says Dr. Jacobs, who directed the COE part of the system implementation. "This system provides complete, unambiguous, safe and legible orders. And, it brings to clinicians' fingertips information that allows them to make informed decisions during the ordering process."
"In addition to increasing patient safety, the COE system results in overall process efficiency, clinician satisfaction, and more time for clinicians to spend with their patients," he adds. "Most important for the patient is that the overall process of care delivery is improved."
The system uses fixed workstations and portable computers with a wireless infrastructure so that orders can be entered at any time and place throughout the hospital. Orders can be generated during patient rounds, allowing direct patient care to begin much earlier in the day, sometimes as much as two hours earlier, according to Dr. Jacobs.
The COE system includes all patient orders, including medications, special diets, laboratory studies, radiology studies, tests and consultations. Clinicians, including physicians, nurse practitioners and other nurses, simply log onto the COE system, select a patient, and begin the ordering process. Built-in decision support tools include policies and procedures, Internet search capability, help screens, medication formularies and clinical pathways. The system also has built-in safety checks to eliminate the possibility of errors due to improper dosage, drug allergies, drug interactions, duplicated orders and a patient's age or weight. Orders are instantly routed to pagers, printers or electronic interfaces throughout the hospital so that care can be initiated immediately.
Stat radiology orders, for example, are electronically routed to a pager carried by a radiology technician. In his study, Dr. Jacobs found that time from technician arrival at the bedside to take an X-ray through verbal report from a radiologist on the result of the X-ray decreased dramatically. The study is the first to measure the effectiveness of Cincinnati Children's system.
"The COE system makes illegible physician handwriting a thing of the past," says Dr. Jacobs. "It also is seamlessly integrated with a clinical documentation system. This system documents things nurses used to document on multiple paper forms, such as vital signs, allergies, heights and weights. And, it includes an electronic medication administration record, formerly transcribed onto a piece of paper by a health unit coordinator and/or a nurse but now seamlessly integrated into the informatics system."
Clinical documentation is essentially electronic charting and supports the COE system by providing patient data such as vital signs, weights and patient assessment information for use in the ordering process. It eliminates safety issues, such as misinterpretation of orders and transcription errors, and it gets rid of redundant charting, which is an inefficient use of a nurse's time.
"Supporting patient safety and increasing efficiency in care delivery is the goal of clinical documentation," says Terri Price, RN, a director in the department of Patient Services who has led the implementation of the clinical documentation part of the system with the nursing staff. "Studies have demonstrated that as much as 40 minutes per shift can be gained by using electronic charting systems. That's 40 minutes more per shift that a nurse can spend with a patient and family. Overall, clinical documentation facilitates a family centered approach to care by improving efficiency in care delivery, improving outcomes and reducing length of stay."
A Harvard Medical Practice study estimated that nearly 4 percent of hospitalized adult patients experienced adverse events related to medical errors and that two-thirds were preventable. Other studies estimate that between 44,000 and 98,000 people die each year in the United States due, in part, to medical errors.
Treating children is even more complicated than treating adults. Data suggest that adverse drug event rates are three times higher in children than adults and that more than two-thirds of these errors occur during the ordering process.
Cincinnati Children's expects to expand the clinical informatics system to outpatient clinics and satellite facilities in the coming years.
Contact Information
Jim Feuer, 513-636-4656, jim.feuer@cchmc.org
