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It's a Wired World:

Information Technology Enhancing Patient Care

By Barbara A. Gabriel

Physicians at Brigham and Women's Hospital are required to enter all orders into a computerized physician order entry system that provides an adjunct to clinical decision-making.

"Medical ignorance is widely assumed to be the cause of errors in medical practice," wrote Clement J. McDonald, M.D., in a 1976 article appearing in The New England Journal of Medicine. In an era of heightened awareness of the pervasiveness of medical errors in this country's health care system, for many that statement still rings true today. But a quarter century ago Dr. McDonald set out to prove his hypothesis that "many medical errors are due to the physician's intrinsic limits rather than to remedial flaws in his fund of knowledge."

"The amount of data presented to the physician per unit time is more than he can process without error," wrote Dr. McDonald, now the director of the Regenstrief Institute and a distinguished professor of medicine at Indiana University School of Medicine. "The computer augments the physician's capabilities and thereby reduces his error rate." Through the use of the Regenstrief Institute's rudimentary but rapidly evolving electronic medical records system, Dr. McDonald analyzed in 1976 the responses of nine physicians to computer-generated suggestions based on a set of institution-wide protocols when the physicians ordered tests or medications. Physicians warned by the computer of potentially adverse events were more likely to change their orders, leading Dr. McDonald to conclude: "It appears that the prospective reminders do reduce errors, and that many of these errors are probably due to man's limitations as a data processor rather than to correctable human deficiencies."

Flash forward 25 years. The age of information technology has saturated the study of medicine, breathing life into complex fields such as genetics and creating new areas of study and discovery such as biotechnology and medical informatics. The use of computers is ubiquitous in the delivery of patient care, but in many ways health care still lags behind other fields in the application of modern technology. In the well-publicized 1999 Institute of Medicine report, "To Err Is Human: Building a Safer Health System," it was estimated that medical errors had caused the death of as many as 98,000 hospitalized patients a year, costing the nation over $37 billion annually. The report emphasized that most medical errors were "systems related" and not the result of physician negligence.

The Agency for Healthcare Research and Quality (AHRQ) contends, "the key to reducing medical errors is to focus on improving the systems of delivering care and not to blame individuals." AHRQ estimates that between 28 percent and 95 percent of adverse drug events can be prevented by reducing medication errors through computerized monitoring systems and that computerized medication order entry has the potential to prevent approximately 84 percent of dose, frequency, and route errors.

The Regenstrief Story

According to Dr. McDonald, what is today known as the Regenstrief Medical Record System (RMRS) had its start in 1972 when the Regenstrief Institute created electronic medical records for 32 diabetic patients. Today, more than two million patients have their medical data stored in the RMRS. Physicians at Regenstrief and Wishard Health Services, the hospital in which Regenstrief resides, must order all patient tests, lab work, and medications through a computerized physician order entry (CPOE) system, which links to patients' individual medical records. "It includes just about everything about patients, including dictation about their status; typed-in information by physicians; vital signs; laboratory, radiology, and pathology reports; EKG tracings; and actual x-ray and imaging scans," says Dr. McDonald of today's RMRS.

"When a physician orders a test or a drug, the logic system kicks in," Dr. McDonald adds. "According to a patient's individual data, the system may suggest not ordering it, ordering something else, changing the dosage, or another option."

But the implementation of such a sophisticated system is by no means seamless. Dr. McDonald says that getting physicians to agree on the protocols that drive Regenstrief's CPOE was difficult. "Under the manual system, there were orders that varied from ward to ward for even simple tasks like cleansing before an x-ray procedure or conducting a physical examination. Getting agreement on an institution-wide standardized approach was a significant effort."

Nevertheless, Regenstrief has been successful in integrating systems not only across departments but across different hospitals as well. In a project supported by the National Library of Medicine, five major hospitals in Indianapolis share a central computer system where individual patient data can be accessed for emergency room care, allowing physicians to obtain vital information about patients' medication allergies and medical histories when patients are unable to provide that information themselves.

Brigham and Women's Hospital

Jeffrey Otten, president of Brigham and Women's Hospital, says that his institution's comprehensive set of information technologies that support patient care "range from management of individual departments and ancillary services to enterprise-wide reporting and cost-accounting and decision-support tools." Approximately 5,600 workstations throughout the hospital support this fully integrated system.

Like Regenstrief, Brigham and Women's requires all physicians to type in orders through a computerized physician order entry system it calls the Brigham Integrated Computing (BIC) System. "Smart" technologies within the system provide an adjunct to clinical decision-making. "For example," says Otten, "if a patient has a known allergy to a particular medication and that medication is ordered, the system will tell you that you can't order it without an override. Or if you're ordering a medication for a patient who is on another medication that would contraindicate that particular order, the computer will not allow you to order that either."

A patient management system works with the BIC system to create Brigham and Women's paperless emergency department. By looking at a computer screen, doctors in the ER can tell how many patients are in the waiting room, ascertain how long they have been waiting, and determine the classification of their illnesses or injuries via a triage system. All this information helps physicians easily prioritize who needs to be seen first. If a patient is admitted, physicians assigned to their care can call up their presenting diagnosis, the name and phone number of their primary care physician, diagnostic tests ordered, and how long they have been there.

Otten considers the cost of being a "wired" hospital minimal in light of the return on investment Brigham and Women's has experienced. "We spend about 2.2 percent of our operating budget on information technology, which in the fiscal year 2002 budget works out to approximately $24 million," says Otten. "In addition, we spend about $10 million in capital."

The return on investment, in terms of both enhancing patient safety and improving the hospital's bottom line, is staggering. Otten says that the BIC system has reduced medical errors at Brigham and Women's by 55 percent, saving the hospital between $5 million and $10 million a year. According to Otten, patient allergy warnings result in 60 percent to 70 percent of orders being cancelled. Drug interaction warnings result in a 100 percent change in orders. Fifty percent of orders are changed when the system indicates that an order or test has already been administered.

Like Dr. McDonald, Otten lists systems integration as one of the biggest obstacles to implementing a computer-based patient care system. "When we developed these smart devices, the algorithms used to determine warnings and the warnings themselves had to be agreed upon by our physicians," says Otten. "That was a tedious process, but it did invest a lot of support in the system." But one problem Otten has never experienced at Brigham and Women's is physician resistance to new technologies. "If you can develop a culture where the clinician feels like the information technology is helping him or her do the job he or she wants to do, which is mostly taking care of patients, they tend to really embrace it."

Starting From Scratch

Nancy Chapman, a health care IT consultant, says computerized safeguards in the delivery of patient care can save hospitals millions each year.

Nancy Chapman, senior vice president at Superior Consultant Company, Inc., a health care consulting firm specializing in IT strategy and implementation, says that hospitals and health systems that want to adopt patient care technologies like the ones described above need to take a pragmatic approach that will eventually lead to full-scale computerized physician order entry. "CPOE is an 18- to 24-month initiative regardless of which system an organization selects, and it costs millions of dollars," explains Chapman.

Chapman recommends to organizations that want to put together a patient safety strategy that they first determine where errors are occurring. She says evidence-based medical error reporting applications allow hospitals to go through the data in existing systems to detect where in their organizations adverse events are happening with the most frequency.

Another system Chapman says can be easily implemented and can contribute to a CPOE initiative is clinical alerting software. "This software will detect lab results in the abnormal range and send alerts out in a variety of media, such as cell phones and pagers, to providers so they can take immediate action and prevent a patient from receiving a particular medication or having a certain procedure that is not in the patient's best interest," she explains. Similarly, medication administration applications, the most significant component of any CPOE, are easily implemented within six months. "They put alerts at the fingertips of the nurses and clinicians about to administer drugs to ensure they are covering the five 'rights': the right patient, the right dose, the right drug, the right route of administration, and the right time of administration," says Chapman.

Medication administration applications can run hospitals about $1 million, but Chapman says the return on investment is easily realized within a year. "Most hospitals don't realize the total costs of adverse events," she emphasizes. "An average hospital will spend between $2.5 million and $4 million a year on adverse events for every 100 beds. And that doesn't include lawsuits. Once these costs are offset by IT safeguards, hospitals can recoup revenue that can be invested in a comprehensive CPOE system."

Like Otten, Chapman says clinicians who experience first hand the benefits of IT in patient care are more open to transitioning from paper to computer. "Clinicians are looking for applications that are relevant to them," says Chapman. "If they see first hand how these technologies can help them improve patient care, they will use them."

Chapman's work has led her to the conclusion that patient safety and technology are inextricably linked. "Lapses in patient safety are not the result of physician negligence; they're the result of physicians not having access to patient data when they need it," she affirms. "These technologies hold the promise of freeing them from what I call 'administrivia' so they can focus on the safe delivery of patient care."

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