Study: CPOE can cause errors, needs to be monitored

Over the past decade, computerized provider order entry has become a standard tool in most electronic medical record systems. Yet even as the use of those systems has grown, many acknowledge the potential risk of introducing errors via health IT. In a new study published in BMJ Quality & Safety, researchers reviewed more than 63,000 errors related to CPOE, concluding that enhanced review, monitoring and testing of systems is needed to reduce the risk of error.

Gordon Schiff, M.D., a practicing internist and director of the Center for Patient Safety Research and Practice at Brigham and Women's Hospital in Boston, was principal investigator of the study, which was funded in part by a National Patient Safety Foundation research grant. Schiff and his co-investigators used data from the United States Pharmacopeia MedMARx medication error reporting system (now owned and administered by Quantros), which has collected more than 2 million medication errors from more than 800 hospitals and health systems. Beginning in 2003, MedMARx added "Computerized Prescriber Order Entry as a Cause of the Error" as one of the variables in their error reporting tool.

"One thing that surprised us was all of the effort that people had put into making reports across a 10-year period, but how little had been done to review the reports," Schiff said. "There was a lot of very rich data with paucity of effort to learn from it."

Once they identified errors related to CPOE, the researchers studied a subset to develop a taxonomy of what went wrong and why. They created 101 codes for what specifically went wrong (for example, "missing quantity or wrong number ordered"); 67 codes for why the error occurred (such as "typing error"); and 73 codes for potential strategies to prevent these errors in future (such as "dose range checking").

To test the vulnerability of current systems to the types of errors reported, the researchers then enlisted typical users to test 13 different CPOE systems at 16 sites. They developed a set of 20 erroneous test orders based on errors reported to MedMARx and attempted to replicate the errors by entering the erroneous orders. Overall, 79.5% of the errors were able to be entered, with 28 percent of these easily going through and 28 percent going through with only minor workarounds.

"CPOE systems have gotten better — we've all seen that," Schiff said, "but we were surprised at the level of vulnerability that still exists."

He said that a decade ago, clinicians saw CPOE as a big advance in patient safety. "We're not saying it's not very useful," he said. "CPOE is necessary, but not sufficient on its own, to improve safety. We need to do more to monitor and improve these systems."


Short hospital stays after angioplasty often sufficient

Patients 65 or older discharged from the hospital as early as 48 hours after angioplasty following a major heart attack have similar outcomes as those who stay four to five days, provided there are no in-hospital complications. This finding was published in the Journal of the American College of Cardiology.

Using data from the American College of Cardiology's CathPCI Registry linked with Centers for Medicare and Medicaid Services claims data, researchers reviewed records for 33,920 patients between Jan. 6, 2004, and Dec. 21, 2009. The study found regional differences in length of stay. Patients in hospitals in the West and Midwest tended to have shorter hospital stays than those in the North and Southeast.

Researchers also noted a trend in shorter hospital stays over the course of the study. In 2005, 24 percent of the patients in the study were discharged in fewer than three days, but by 2009, that number had increased to 30 percent. Similarly, 47 percent of patients had stays of four to five days, and 29 percent had remained hospitalized more than five days; by 2009, the stays of four to five days had decreased to 45 percent and long stays of more than five days had decreased to 25 percent, respectively. There was no significant difference in 30-day mortality or major adverse cardiac events between the two groups.

Patients with the longest stays, those over five days, tended to be older, had more comorbidities, and had more extensive coronary vessel disease than patients with medium or short hospital stays.

On the other hand, little was known about the small number of patients who were discharged early, the same day or after an overnight stay. This group had poorer 30-day clinical outcomes, perhaps indicating the need for appropriate inpatient monitoring after the procedure.

"Our study suggests that early discharge after an acute heart attack — but not less than 48 hours after stenting and balloon angioplasty — may be safe among selected older patients who do not develop post-procedural complications," said Rajesh V. Swaminathan, M.D., director of interventional cardiology research and assistant professor of medicine at Weill Cornell Medical College/New York-Presbyterian Hospital and the study's lead author. "The results of this study should prompt physicians to take a closer look at discharge practices in their own institutions for heart attack patients. Many centers, particularly in the North and Southeast, may have the opportunity to shave off at least one hospital day post-angioplasty for their low-risk heart attack patients."

Physicians need support to succeed with new payment models

Physician practices are engaging in new health care payment models intended to improve quality and reduce costs, but are finding that they need help with successfully managing increasing amounts of data and figuring out how to respond to the diversity of programs and quality metrics from different payers, according to a joint study by the RAND Corporation and the American Medical Association.

Both the federal government and private payers are changing the way they pay physicians and other health professionals, moving to innovative models intended to improve quality and reduce costs.

Many physician practices are responding by partnering or merging with other medical practices or hospitals to better support the investments necessary to succeed in new payment models, such as care managers and information technology. Practices say that realigning their operations to the goals of the new payment strategies can be challenging when necessary data are not available or different payment models conflict with each other.

"We found that changing the payment system probably isn't enough to ensure that patient care will improve," said Mark W. Friedberg, M.D., the study's lead author and a senior natural scientist at RAND. "For alternative payment methods to work best, medical practices also need support and guidance. It's the support that accompanies a new payment model, plus how well the model aligns with all of a practice's other incentives, that could determine whether it succeeds."

Researchers performed case studies of 34 physician practices in six diverse geographic markets to determine the effects that alternative health care payment models are having on physicians and medical practices in the United States.

The payment models include episode-based and bundled payments, shared savings, pay-for-performance, capitation and retainer-based practices. Accountable care organizations and medical homes, two new organizational models, also were examined.

The findings are intended to help guide systemwide efforts by the AMA, the study's sponsor and co-author, and other health care stakeholders to improve alternative payment models and help physician practices successfully adapt to the changes.

The report found the effect that alternative payment models have on practice stability, including the overall financial impact, ranged from neutral to positive. Among the practices surveyed, none had experienced financial hardship as a result of involvement in new payment models.

There was general agreement among physicians that the transition to alternative payment models has encouraged the development of collaborative team-based care to prevent the progression of disease. Additional benefits for patients include increased access to care and physicians through tele-health or community-based care.

Most physician leaders were optimistic about alternative payment models, while physicians not in leadership roles expressed some apprehension, particularly with regards to certain new documentation requirements. For example, physicians were supportive of new patient registries that list patients with certain health conditions as a way to improve care. But they had concerns about documentation requirements where the link to better care was less clear.

The report, "Effects of Health Care Payment Models on Physician Practice in the United States," is available at