At the same time, CPOE is a mixture of complex technologies that interface in complicated ways with the culture of clinical medicine. The view that medical informatics is a technical problem that has been solved long ago is simplistic and naïve. The article by Koppel, et al, has two important implications: 1) It is critical to look at clinical information systems in the social milieu in which it functions, and 2) there are often unintended consequences that may not beneficial.
This article examines a widely used, commercial CPOE system in use at the University of Pennsylvania (Philadelphia) using both quantitative and qualitative methods. The researchers conducted focus groups and expert interviews in addition to field observations of physicians (house officers and attendings), nurses, and pharmacists in order to identify themes relating to work with the order entry system. This work helped to guide the creation of a survey instrument subsequently used to survey house staff about working conditions and sources of error and stress. There was an 85%-90% response rate that primarily included house staff who ordered more than nine medication orders per month.
Researchers found two broad categories of errors that were fostered in this environment. The first category, which they termed “information errors” were generated by fragmentation of data and the failure to integrate the hospitals various systems both electronic and paper. Examples of this type of error include antibiotic renewal failures. A common way this failure would occur is that renewal reminder stickers would be placed in the patients’ charts, but the house staff would overlook these because medication orders occurred electronically. Another example is assumed dose errors, where house staff would assume that the default dose displayed was the recommended starting dose, when in fact this was the smallest dose unit available. Physicians were assuming decision support was available when it was not.
The second type of error, human-machine interface flaws, occurred when machine rules did not correspond to work behaviors. An example of this is when patients were listed alphabetically rather than by service, making it easy to select the wrong patient. In another instance, many screens (up to 20) were required to view all of a patient’s medications, making it difficult to choose a correct medication for editing.
This study has been criticized by industry advocates for focusing on an older set of technologies or because a number of these issues related to training or “user factors.” At the other extreme, this study has been cited as a cautionary tale about the risks of CPOE. Both types of criticism miss the point. This study demonstrates that CPOE and the social environment in which it sits is a complex entity and that careful design, proper support, and maintenance are critical ingredients to the success of an incredibly complex but vital new component of hospital medicine.
Point-of-Care HIV Testing in Inpatients
Lubelchek R, Kroc K, Hota B, et al. The role of rapid vs conventional human immunodeficiency virus testing for inpatients: effects on quality of care. Arch Intern Med. 2005;165:1956-1960.
Despite advances in treatment, infection with HIV and AIDS remains a public health problem in the United States. According to the CDC the rate of new diagnosis of HIV infection has remained steady from 2000 to 2003 at about 20 per 100,000 people. (Centers for Disease Control and Prevention. Diagnosis of HIV/AIDS–32 states, 2009-2003. MMWR Morb Mortal Wkly Rep. 2004;53:1106-1110). Currently, about 850,000 to 950,000 people are believed to be living with HIV infection, and it is estimated that 180,000 to 280,000 are unaware of their diagnosis. (Fleming P, Byers RH, Sweeney PA, et al., HIV prevalence in the United States, 2000 [Abstract 11]. Presented at the Ninth Conference on Retroviruses and Opportunistic Infections, Seattle; February 24–28, 2002). These patients are not only at risk for disease progression, but can undermine efforts at disease prevention if they continue to engage in unsafe activities. Thus, increasing awareness of HIV status is an important aspect of disease prevention.