Implementations of computerized physician order entry (CPOE) systems have previously been associated with either an increase or no change in hospital-wide mortality rates of inpatients. Despite widespread enthusiasm for CPOE as a tool to help transform quality and patient safety, no published studies to date have associated CPOE implementation with significant reductions in hospital-wide mortality rates.
The objective of this study was to determine the effect on the hospital-wide mortality rate after implementation of CPOE at an academic children's hospital.
We performed a cohort study with historical controls at a 303-bed, freestanding, quaternary care academic children's hospital. All nonobstetric inpatients admitted between January 1, 2001, and April 30, 2009, were included. A total of 80 063 patient discharges were evaluated before the intervention (before November 1, 2007), and 17 432 patient discharges were evaluated after the intervention (on or after November 1, 2007). On November 4, 2007, the hospital implemented locally modified functionality within a commercially sold electronic medical record to support CPOE and electronic nursing documentation.
After CPOE implementation, the mean monthly adjusted mortality rate decreased by 20% (1.008–0.716 deaths per 100 discharges per month unadjusted [95% confidence interval: 0.8%–40%]; P = .03). With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame.
Implementation of a locally modified, commercially sold CPOE system was associated with a statistically significant reduction in the hospital-wide mortality rate at a quaternary care academic children's hospital.
The recent Pediatrics report, “Decrease in Hospital-wide Mortality Rate After Implementation of a Commercially Sold Computerized Physician Order Entry System,”(1) provides a case study of an health information technology (HIT) implementation at a tertiary children’s hospital. The ambitious implementation described at Lucille Packard between November 2007 and September 2008 included online clinician order entry, advanced clinical decision support such as weight-based medication safety checks, integration with the hospital pharmacy system, and comprehensive bedside documentation.
The authors contrast the outcomes of this implementation to the October 2002 go-live at the Children’s Hospital of Pittsburgh.(2-4) Casual readers, however, may not appreciate that the previous mortality report from Pittsburgh(2) looked at a short time period after initial CPOE implementation (5 months versus 18 months in the current study) and at a small fraction of hospitalized patients (approximately 10% versus 100%). When analyzed in a comparable manner, Pittsburgh Children’s saw no change in mortality in the 18 months after initial CPOE implementation (from 0.89 to 0.90 deaths per 100 discharges). Furthermore, using the identical APR- DRG standardized mortality ratio (SMR) approach as described1 there was a 17% decrease in the SMR in the 18 months after Pittsburgh’s initial CPOE implementation (from 1.0 to 0.8).
In 2002, the primary immediate benefit of CPOE was to replace handwritten orders with standardized, complete, legible orders(5) as well as providing a foundation for future technology and workflow improvements. Since that time, Pittsburgh Children’s has implemented multiple enhancements to the medication process, creating a house-wide fully closed -loop medication system with advanced decision support, bedside documentation, pharmacy integration and bedside bar-code scanning.(6) These features have been shown to have independent positive impact on reducing medication-related accidents.(7) The Pittsburgh SMR has continued to decline, reaching 0.6 during the 18 month period corresponding to the current study’s postintervention period. In total, during the 79 months from the CPOE implementation in October 2002 through April 2009 there has been a 60% reduction in medication errors reaching the patient and 321 fewer deaths than expected if there had been no improvement in Pittsburgh’s SMR. It is not possible to determine the impact of HIT independently from other changes in care delivery, and comparing or generalizing from the experience of individual hospitals must be done with caution.(8,9)
The Lucile Packard team is also to be congratulated on the decreased medication turnaround times that they report after their intervention. The authors imply that this is contrast to the Han study of the Pittsburgh implementation, but that study reported no measurement regarding possible delays in the medication process. In fact, some of the statements that fueled this speculation were later corrected in a published errata.(10)
In part because of the economic incentives to adopt HIT created by the recent American Recovery and Reinvestment Act(11) many hospitals are currently wrestling with planning their own implementations: What HIT features should be implemented? How broadly throughout the hospital? How quickly? These decisions are based on each organization’s goals, technical and cultural capacity to absorb change, implementation costs, and the maturity of the products available from the HIT venders. In addition, hospitals must make a commitment to redesign the clinical work to take advantage of the technology and then to optimize their systems of care after implementation using an incremental performance improvement cycle.(12)
Longhurst et al. are to be commended in their desire to follow an evidence-based HIT implementation strategy. As other hospitals consider their HIT strategy the current study is an important contribution to that evidence base.
1. Longhurst CA, Parast L, Sandborg CI, et al. Decrease in Hospital- wide Mortality Rate After Implementation of a Commercially Sold Computerized Physician Order Entry System. Pediatrics. 2010. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20439590
2. Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116(6):1506-1512.
3. Upperman JS, Staley P, Friend K, et al. The introduction of computerized physician order entry and change management in a tertiary pediatric hospital. Pediatrics. 2005;116(5):e634-642.
4. Upperman JS, Staley P, Friend K, et al. The impact of hospitalwide computerized physician order entry on medical errors in a pediatric hospital. J. Pediatr. Surg. 2005;40(1):57-59.
5. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc. 1999;6(4):313-321.
6. Hagland M. First Place. Children's Hospital of Pittsburgh. Improving patient care through data availability in the ICU. Healthc Inform. 2010;27(3):20-21, 23, 26 passim.
7. Poon EG, Keohane CA, Yoon CS, et al. Effect of bar-code technology on the safety of medication administration. N. Engl. J. Med. 2010;362(18):1698-1707.
8. Welke KF, Karamlou T, Ungerleider RM, Diggs BS. Mortality rate is not a valid indicator of quality differences between pediatric cardiac surgical programs. Ann. Thorac. Surg. 2010;89(1):139-144; discussion 145- 146.
9. Iezzoni LI. The risks of risk adjustment. JAMA. 1997;278(19):1600- 1607.
10. ERRATUM. Pediatrics. 2006;117(2):593-594. Available at: http://www.pediatrics.org/cgi/content/full/117/2/593
11. Health IT Gold Rush Under Way. Health Aff. 2010.
12. Berwick DM. A primer on leading the improvement of systems. BMJ. 1996;312(7031):619-622.
Conflict of Interest:
None declared