I've been reading up on literature regarding Computerized Provider Order Entry (CPOE) implementation strategies and ran into this article. It's quite old but significant and controversial. When the article was published, it was during a time when CPOE was still very young with relatively little solid data to back it up. This paper from Children's Hospital of Pittsburgh serves as a good case study of how bad things may happen to good technology.

In essence, the hospital retrospectively showed that the unadjusted mortality rate rose from 3.86% pre-CPOE to 6.57% post-CPOE in an intensive care setting. The reasons stated why CPOE didn't work did not seemed like they were issues with CPOE itself, but rather the hospital's infrastructure and work processes.

The article states "[a]fter CPOE implementation, order entry was not allowed until after the patient had physically arrived to the hospital and been fully registered into the system, leading to potential delays in new therapies and diagnostic testing." It's hard to believe the software would do this; was this a tech issue or a policy problem?

Furthermore, they complained that the "...physical process of entering stabilization orders often required an average of ten “clicks” on the computer mouse per order, which translated to 1 to 2 minutes per single order as compared with a few seconds previously needed to place the same order by written form." UI design is very important, but they didn't state the technological "savy-ness" of the user. 10 clicks = 1 to 2 minutes?! I've seen some Twittered-frenzied residents microblog 140 characters faster than I could hand write my own name.

http://www.ajhp.org/cgi/content/full/66/15/1394

An interesting piece in this month’s AJHP.  The order processing time was reduced from 115 minutes pre CPOE to 3 minutes post CPOE.  This is a very striking delta, and as discussed in the article it reinforces the justification for 100% pharmacist order review with no “override meds” in automated dispensing cabinets. 

It was not completely clear whether or not completion of order verification by the pharmacist was included, but this has taken the greatest amount of pharmacist attention in past experiences.  Physicians are not typically interested in the solution or volume in which medication is administered, so pharmacists end up making lots of “compatibility” changes in verification.  CPOE is implemented in many different ways, some are more geared towards “every product the pharmacy carries”, while others try to mimic what physicians write on paper orders.  This pharmacist happens feels the latter leads to a more effective and successful implementation.  Trying to compromise by using premade medications as defaults for commonly prescribed doses can help a great deal, especially if automated dispensing cabinets are highly utilized.  In this scenario, the physician orders the way they want, the pharmacist has a quick verification with no dramatic changes, and the nurse has the medication available to pull from the automated dispensing cabinet in, well 3 minutes.  It is great to reduce the order processing time, but even better to get the medication to the patient in a timely manner. 

Computerized Order Entry
Karl F. Gumpper and William A. Zellmer
[Extract] [Full Text] [PDF] [Reprints & Permissions]   
       

        Computerized Order Entry: The Authors Respond
Jos Aarts and Ross Koppel
[Extract] [Full Text] [PDF] [Reprints & Permissions]   

"We agree that bar-coded medication administration systems will reduce pharmacy dispensing errors. However, the evidence to date does not suggest that such systems are as effective in reducing administration errors because of design and implementation faults and the resulting staff workarounds that mitigate the efficacy of bar-coding."  [Uh, ya!]