ReviewThe impact of computerized physician medication order entry in hospitalized patients—A systematic review
Introduction
Medication prescription plays a central role in health care. It concerns 65% of the US population and it annually accounts for 13% of health care expenditures [1]. Various studies show that adverse drug events (ADEs), many of which are preventable, form a major problem in the US [2], [3], [4], [5]. In the early 1990s, it was estimated that there are 3.7 adverse events per 100 admissions in the US [6]. Of these, 28% are medication related, half of which preventable. From an economic point of view, hospital costs of adverse drug events were estimated at $2 billion per year. Similar reports in other countries show that medication errors indeed have important impact on mortality, morbidity and cost of care [7].
Medication errors are usually the result of failures during the medication process. Errors can occur in any step of this process: taking history, ordering, pharmacy management, administration management or surveillance [8]. A medication error may or may not result in patient harm, but almost all medication errors are considered to be preventable. adverse drug events (ADEs) are usually considered to include both medication errors that result in harm (preventable ADEs), and adverse drug reactions (ADRs), which are considered unpreventable [9]. Although high workload [10] and failures in monitoring patients [11] have been reported as a possible causes of medication errors, most medication errors and preventable ADEs are related to the medication process and mainly occur during the ordering step [3], [12]. In addition to the inability of the average physician to memorize the ever increasing number of drugs, treatment regiments and side effects, prescribing the old fashioned way with pen and pad is prone to slips which are sometimes errors of inattention [13].
The institute of medicine and other important stakeholders have identified computerized physician order entry (CPOE) or electronic prescription (EP) as the main opportunity to reduce medication errors and thereby improve safety [2], [14] especially when decision support is provided. CPOE systems promise to have also effects on outcomes other than safety, such as medication and process costs. A CPOE system refers to a variety of computer-based systems that share the common features of automating the medication ordering process and that ensure standardized, legible, and complete orders [15]. Electronic medical record systems which merely document medication orders and medication administration, after the time of ordering, are beyond the scope of this paper and are therefore excluded. In addition, we defined a decision support system (DSS) in this context as any system designed to aid a health professional in decision-making at the moment of ordering medication. A DSS can be an inherent part of CPOE or a separate system communicating with the CPOE system. The main objective of this review is to identify, uniformly characterize, and assess the reported CPOE impact in all published studies evaluating any aspect, safety and otherwise, associated with the use of a CPOE system in the inpatient setting. We excluded all studies in the outpatient setting since this is a completely different context with different challenges and a review on CPOE in the outpatient setting is published elsewhere [16]. The measured effects are summarized and associated with an evidence level. One should, however, realize that the assessment of effects of information technology in health care is inherently hard because the technology is only part of a much larger and complex social system [17]. Nevertheless, by presenting and assessing the state-of-the-art in CPOE evaluation studies, this review contributes to a better understanding of the merits of CPOE systems in the inpatient setting, and identifies lacunas in current research on CPOE evaluation.
Section snippets
Methods
We searched for relevant english language articles, based on keywords in title, abstract and MeSH terms, using Ovid MEDLINE® & MEDLINE® in-process (1966 to August 2006), Embase® (1980 to August 2006), and Cochrane library. Fig. 1 shows the two applied search strategies and the corresponding search flowchart. In strategy 1, keywords and MeSH terms that are currently in use for referring to a CPOE system (part A) are combined with terms related to inpatient care (part B). In strategy 2, computer
Results
Searching the online databases resulted in 1,004 articles from Ovid MEDLINE®, Ovid MEDLINE® In-process, Ovid EMBASE®, and the Cochrane library. After initial screening of titles and abstracts, 74 articles were considered for full text review. Six additional articles were identified by reviewing bibliographies, yielding a total of 80 articles. Based on the full text review, six articles were excluded because they turned out not to address a CPOE system according to our definition, and seven
Discussion
We identified and described the results of 67 papers on evaluation of CPOE systems in hospitalized patients. The number of such evaluation studies shows a strong increase in recent years.
Our findings suggest that the impact of CPOE systems has been shown to be positive especially in Adherence to guidelines, but also in Alerts and Appropriateness of alerts; costs and organizational efficiency, and satisfaction and usability. A major goal for the implementation of CPOE is safety improvement.
Conclusion
In conclusion, CPOE evaluation studies vary in scope, aims and results, and one should not expect unequivocal judgment about their effects. One could perhaps argue for more RCT studies in the evaluation of CPOEs but they do have prohibitive costs. One fruitful way to proceed with is the use of controlled trials focusing on CPOE systems with more decision support for specific patient groups, high risk drugs, typical ADEs, using more powerful designs like interrupted time-series. Another fruitful
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