The Rx Files
- 17 November, 2000 11:40
Betsy Lehman was admitted to Boston's prestigious Dana-Farber Cancer Institute on Nov. 14, 1994. Lehman, a respected health columnist for The Boston Globe, had volunteered for an experimental high-dose, four-day chemotherapy treatment for her recurrent breast cancer. She would then undergo a bone marrow transplant to restore immune and blood-forming cells. Instead, the 39-year-old mother of two received four times the prescribed dosage of the toxic anticancer medication. Although Lehman complained of weakness and nausea, hospital staff didn't notice that a resident doctor had mistakenly prescribed the total four-day dosage to be given daily for each of the four days. Lehman died three weeks later, not of breast cancer but of heart failure caused by the massive medication overdose.
Six years and several lawsuits later, Lehman's memory still haunts Dana-Farber. On a rainy August afternoon, doctors sit at computer terminals filling out drug and chemotherapy prescriptions with a customised system designed to prevent mistakes. If a doctor types in a 200-milligram prescription instead of the intended 20 milligrams, for example, the computer indicates the possibility of an error. Pharmacists check and double-check the orders against patients' electronic records, and nurses check again, as patients sit quietly awaiting chemotherapy.
"Many organisations would have been in their bunkers," says James Conway, Dana-Farber's COO. "We said, 'There's been an unbelievable tragedy. Let's make sure it doesn't happen again.' We still carry the burden of what happened here."
Dana-Farber is one of a handful of medical centres that has spent years developing an automated system to reduce medication errors. Health-care CIOs and doctors at treatment centres from LDS Hospital in Salt Lake City to Kaiser Permanente Health Plan Inc. in Oakland, Calif., and the Veteran's Administration Hospital in Topeka, Kan., argue that the increasing complexity of treatment and the sheer number of available medications make automation more of a necessity than ever.
The Quiet Killer
After the Washington, D.C.-based Institute of Medicine (IOM) of the National Academy of Sciences published a report in November 1999 highlighting the prevalence and consequences of medical errors, hospitals have been increasingly turning to IT for a safety check. As the national debate over this issue reaches a crescendo, many organisations are preparing to invest millions in computers, bar-coding scanners, robotic dispensers and other technologies designed to help health-care providers navigate the increasingly complex medical landscape.
The IOM report, "To Err Is Human," put forth some disturbing figures. Avoidable medical mistakes kill anywhere from 44,000 to 98,000 people a year-more than breast cancer, highway accidents or AIDS. The report also states that more than 7,000 deaths are caused by medication errors. Just as Lehman's death shook Dana-Farber and other cancer centres, the IOM report has caused widespread soul-searching throughout the medical world.
That report has also pushed the issue to the forefront of national debate. Congress is holding hearings on patient safety, and a group of large employers, including General Electric Co. and General Motors Corp., is using its clout to call for specific changes like computerised drug orders to improve safety. The report offers a wide range of reforms and, most notably, recommends using computerised order entry, pharmaceutical software and other technologies to prevent mistakes. This national attention on increased safety and automation is giving health-care CIOs a broader forum as top administrators increasingly look to new technologies to improve care.
"Those at the leadership level have come to believe that IT is important to them," says John Glaser, vice president and CIO at Partners HealthCare System Inc. in Boston, comprising Brigham and Women's Hospital and Massachusetts General Hospital. "I hope that technology will stay on their radar screen forever."
Although some have challenged the numbers in the IOM report and questioned its methodology, few contest the basic premise that medical errors-and medication errors in particular-can and should be reduced. "In any case, the death toll is higher than it should be," says Dr. David Bates, chief of general medicine at Boston's Brigham and Women's Hospital, which is often cited as a pioneer in the development of a computerised physician order-entry system for prescriptions. "The IOM report has clearly galvanised the industry."
When a doctor wrote the prescription that ultimately led to Lehman's death, computerised order-entry systems weren't available at Dana-Farber. In the aftermath of this and another mistake that left breast cancer patient Maureen Bateman with a damaged heart, Dana-Farber staff members huddled to design a pharmaceutical management system specifically for oncology treatment. With nothing on the market, a team of four programmers developed software that helps doctors and pharmacists check a patient's medication protocol and verify dosage amounts.
"It was a difficult time for everyone, including people in IS," says Dana-Farber's CIO Ben Bembenek. "We felt that we should have been able to prevent this type of error. But at that point, no pharmacy system had dose level limits."
Dana-Farber then integrated its new software with a physician order-entry system designed by and used at neighbouring Brigham and Women's. The system, known as Brigham Integrated Computing System, cost US $1.97 million to develop in 1993 and around US $500,000 a year to maintain. Still, Brigham and Women's officials say it has saved the hospital US $5 million to US $10 million a year by preventing "adverse drug events," suggesting lower dosages and directing doctors to less expensive drugs. Fewer errors can also translate to lower legal fees. "Our system is very quick and easy to use," says Bates, who is nationally renowned for his quality control research. "The vendor community has lagged behind us."
Other teaching hospitals have developed similar systems. LDS Hospital has cut drug-related errors with a system that checks each patient's allergies as well as drug-to-drug interactions through links with the blood laboratory and other data centres.
The IOM study found that 50 percent of hospital medication errors stem from the prescription-ordering process. Still, hospitals have been slow to adopt the technology. "A computerised system costing US $1 [million] to US $2 million could pay for itself in three to five years, while preventing injury to hundreds of patients each year," states the IOM report.
Of the one-third of hospitals nationwide that have installed computerised order-entry systems, only 1 percent require physicians to use them, says Arnold Milstein, a San Francisco physician and national health-care thought leader at New York City-based medical lobby group William M. Mercer. Milstein is on the steering committee of the Leapfrog Group, an association of major health-care purchasers pressing doctors and hospitals to reduce errors.
One of the main reasons for the slow adoption, Bates says, is that vendors haven't been able to provide shrink-wrapped versions of the systems so carefully and expensively designed at the country's major teaching hospitals. That's changing, however, as companies like Cerner and McKesson HBOC develop off-the-shelf versions of order-entry systems and a wide array of technologies ranging from pharmacy robots to handheld scanning devices designed to reduce medication errors.
Over the Counter IT
Julie Morath knows firsthand that medication errors have a devastating effect not only on patients and their families, but on the caregivers themselves. As a young nurse early in her career, Morath, now chief operating officer of Children's Hospitals and Clinics in Minneapolis and St. Paul, Minn., witnessed a 4-year-old die from an anesthesia-related error. "What was most frightening was that everything looked normal and then there was this devastating event," she says. "Nobody even talked about it. The nurse who felt responsible left and never came back."
Morath helped launch a crusade at Children's to eliminate medical errors through a series of several initiatives, leveraging a US $20 million investment in a hospital information network to improve patient safety. Systemwide computerised order entry is part of that network. The hospital chose Cerner's Hospital Information System because of its decision-support functionality, says James Levin, medical director of informatics for the hospital group. For example, caregivers using the new system will have access to a patient's full medical record and will be able to see how certain lab test results have changed over time. The computers will also signal correct drug dosages and possible drug interactions. Over the next year, Children's will progressively roll out the system starting in the Minneapolis center.
Children's is one of a growing number of midsize hospitals buying vendor-supplied computerised systems. Those who have designed order-entry systems in-house say most medical centres can and should consider off-the-shelf versions. "It's a tricky and risky process, and the results can be mediocre if you do it yourself," says Glaser. "The products out there are getting much better."
Morath's approach goes beyond upgrading technology. For example, hospital staff members are required to report all mistakes that harm or come close to harming patients. Also, specially trained doctors and pharmacists are assigned to floors where children get the most complex treatments. She clearly holds great hope for the new computer purchase, which will integrate two separate systems used since the Minneapolis and St. Paul hospitals merged in 1994.
The Children's example shows that while systems are available, most health-care centres need to tailor store-bought versions for their own needs. The Cerner system includes an order-entry module to help providers calculate dosages and check for drug interaction. Children's is adapting the software, however, because many calculations didn't account for the lower body weights of the hospital's young patients.
Saving Patients, Saving Costs
Sitting in his crowded office at Brigham and Women's, Bates boasts of his five computers and Palm Inc. Pilot, and delivers an animated description of Partners' plans to roll out an electronic outpatient records system. About 20 percent of the hospital group's 3,500 doctors are using electronic records, and Partners plans to cover every physician over the next five to six years. The investment is sizeable, but hospital officials estimate annual savings of US $9,000 to US $20,000 a year per doctor by reducing the overhead of writing prescriptions.
"Soon it will be possible for IS to anticipate the needs of clinicians at the point of care," Bates says. For example, if a doctor orders a toxic antibiotic, such as gentamicin, the electronic record-on a secure, Web-based system-will instantly provide information on other medications the patient is taking and indicate possible drug interactions. "In the not-too-distant future, the computer might be able to suggest new trials on the topic," Bates says.
On the other side of the country, Kaiser Permanente is also implementing an outpatient clinical information system to provide caregivers access to electronic medical records with built-in lab and pharmaceutical data and inpatient information. The California organisation is the nation's largest nonprofit health plan, with 8 million members, 11,300 physicians and 80,000 PCs. It operates in 11 states and the District of Columbia and has annual revenues of US $16 billion. It is investing more than US $1 billion a year in IT, much of which is going to the clinical information system.
Kaiser contracted with IBM Corp. to build the system and plans to roll it out over three years, starting in Hawaii and northern California. "No one has built anything like this before in sheer scope," says Tim Sullivan, Kaiser's senior vice president and CIO. He emphasises that IBM and Kaiser's IS department are working together because there is no system large enough to handle the complexity of the databases, which contain lab, pharmaceutical and inpatient information.
Although Kaiser has focused on the outpatient system, officials say the IOM report has accelerated their plans to automate the hospital order-entry inpatient side. "Our outpatient system was designed to improve our quality outcomes," says Dr. Robert Pearle, executive director and CEO of the Permanente Medical Group, a Kaiser subsidiary. "We're constantly looking at ways to take the newest technologies and make them available across a system."
The Elusive Elixir
Doctors have been relatively slow to adopt new technologies, largely because of the complex nature of medicine and a lack of industry standards. "We're still a very young field when it comes to information technology," says Dr. Brent James, vice president for medical research at Salt Lake City's Intermountain Health Care, which owns LDS Hospital. "Only in the past few years have we come to a point where we could design an effective system." Computerised order-entry systems are also a large expense, coming at a time when many medical centres don't have excess capital.
Proponents of information technology also need to prove to the medical community that computerised order entry can be more efficient. "In general, doctors have been willing to embrace all sorts of new technology, including MRIs and lasers, but they haven't seen the value of information technology, and they've often been right," says Levin of Children's. "If folks can see at the end of the day that they've had few interruptions-that things haven't been slipping through the cracks-they'll see the value of the technology."
Levin and others involved in health-care IT emphasise that technology isn't the only critical factor to improving safety. Tracking errors is an essential step. Creating a national system of reporting errors, similar to that used in aviation, is one such step urged in the IOM report. Many health-care professionals also say the most important changes required are cultural since caregivers have often been reluctant to report errors out of fear of litigation or losing their job. "We need a reporting system similar to OSHA [Occupational Safety and Health Administration] or the National Transportation Safety Board so that we can understand patterns in system errors," James says. "We need to shift the focus from blame-based to 'Let's fix the systems.'" Others warn that pharmaceutical software and automated systems don't always prevent errors, and that health-care providers need to remain vigilant even if they're using computerised systems. Sylvia Bartel, director of pharmacy at Dana-Farber, says studies show that 70 percent of pharmaceutical systems have allowed fatal errors to go through. "We need to pressure vendors and the software industry to make improvements," she says. "The data is sobering; among pharmacy managers, the frustration is palpable."
While computerised systems are invaluable for reducing errors, says Dr. James Bagian, director of the Veteran Administration's national center for patient safety, health-care IT leaders need to make sure they are user-focused. "We've done a lot of useability testing, and we have been rewarded for that work," says Bagian, a former astronaut with two space shuttle missions to his credit.
These days, Kaiser and other large health-care networks frequently look to the country's sprawling VA system-once maligned for shoddy care-for inspiration. Sue Kinnick, a former nurse at the VA's hospital in Topeka, Kan., who has since passed away, came across one highly touted safety innovation completely by accident. Kinnick was returning from a convention in Seattle six years ago when she noticed a car rental agent using a handheld check-in device and thought, Why can't we do that in the hospital?
Now the VA is using handheld scanning devices in all of its 170 hospitals as part of its widespread safety campaign. The agency tested an early version of the device in 1994 in Topeka. Four years later, a team, made up of end users and programmers from Electronic Data Systems Corp. and the VA, developed software using the Topeka VA system as a prototype. With the new system, released in August 1999, nurses roam the hospitals with units that resemble laptop computers with tethered scanners. All patients wear bar-coded identification wristbands. All medications also have bar codes. Before giving medicine to a patient, the nurse or staff member laser scans his wristband. The software verifies that the right person is receiving the right drug at the correct dosage at the right time and screens for drug interactions. If there's a problem, the program flashes a warning. If everything checks out, the software generates an electronic record of the event.
The hospitals recorded a 64.5 percent reduction in medication errors from 1993, the year before the system was installed, says Chris Tucker, a pharmacy specialist for the VA's Eastern Kansas Healthcare System. "We're way ahead of the game because very few facilities have these capabilities." The Institute for Safe Medication Practices, a Huntingdon Valley, Pa.-based nonprofit group that works to prevent medication errors through education of health-care practitioners, hopes the scanners will catch on. According to its studies, handheld devices and bar-coded scanning could further reduce medication errors.
One Step Ahead
Bartel navigates Dana-Farber's order-entry system with ease. Demonstrating how the system catches errors, she types in a chemotherapy drug and dosage level. The computer quickly sends a warning message and flashes, "This drug not contained in protocol." To override the computer, a senior physician must provide a reason. Before 1995, doctors wrote out chemotherapy prescriptions by hand, and nurses checked protocols contained in three-ring binders. "It's hard to believe we ever did this another way," Bartel says.
An early adopter of computerised order-entry systems, Dana-Farber is looking to stay ahead by continually updating its systems. In the coming years, hospital officials plan to upgrade the chemotherapy order-entry system in conjunction with Brigham and Women's and Mass. General hospitals. By early 2001, they plan to install a paediatric order-entry system, as well as an electronic medical record on a secure Web-based system. They are also considering bar-coding scanners, similar to those used at VA hospitals.
Even medical centres that have lagged behind in technology adoption may soon have little choice but to follow leaders like Dana-Farber, LDS Hospital and the VA system. "The wave is just starting to build," says Bagian. "There were early adopters, and now a lot of people are coming to the party. The aviation industry and others have learned to use technology as a tool to set up systems that prevent errors. Health care isn't yet on the same map."
Has IT changed your health-care system? Tell Senior Writer Susannah Patton at firstname.lastname@example.org.
Big industry joins forces to make medical errors a thing of the past Medical errors translate directly to higher medical costs. Consequently, some of the country's largest employers, including General Motors Corp. and General Electric Co., are willing to reward hospitals that take specific steps to avoid mistakes. For the last two years, representatives from these and other large employers, known collectively as the Leapfrog Group, have been convincing hospitals to beef up security. In return, the group promises public recognition, more patient referrals and financial rewards.
The Leapfrog Group, sponsored by the Business Round Table, is looking to reward and recognise hospitals that invest in computerised prescription order-entry systems as one way to combat errors. "Technology is a fabulous tool to error-proof the system," says Bruce Bradley (pictured above), director of managed care plans for General Motors. He oversees coverage for 1.2 million current and retired GM employees.
Leapfrog members rate computerised order-entry systems near the top of safety improvements. The majority of hospitals not yet using them may soon hear about it. Leapfrog, whose members include 50 million Americans at organisations ranging from GTE Corp. (Verizon Communications Inc.) and General Motors to the U.S. Office of Personnel Management and the Healthcare Financing Administration, is set to grow as the group opens up to other interested corporations.