July 13, 2006
CONTACT: Karen Kreeger
karen.kreeger@uphs.upenn.edu
Expert Advisory
Commentary on Healthcare Information Technology:
Defining the Limits of Computerized Physician Order Entry Systems
(Philadelphia, PA) - In the July 12 issue of The American Journal
of Managed Care, sociologist Ross Koppel, PhD, of
the Center for Clinical Epidemiology and Biostatistics at the University
of Pennsylvania School of Medicine, analyzes two well-known medical
information technology systems in light of a study published in the same
issue. Researchers from the Colorado Permanente Medical Group (Palen et
al.) found no positive value to computerized reminders for laboratory
tests needed to accompany 25 major medications. These two systems are
CPOE (computerized physician order entry) and DSS (Decision Support Systems).
CPOE is regarded as the major technological solution for the problems
of medication ordering error. It eliminates handwriting errors and instantly
sends orders to the pharmacist. Unfortunately, many of the CPOE software
programs are not responsive to the realities of hospital work; and CPOE
systems are often seen by clinicians as irrational impositions rather
than as helpful tools, according to Koppel.
DSS (Decision Support Systems) is designed to warn physicians about possible
errors and/or provide useful guidelines to prescribing, including reminders
about needed laboratory tests when certain drugs are prescribed. Often,
however, DSS produces obvious and annoying reminders, false alarms, or
useless and constant warnings. Alarm fatigue is a frequent problem, and
many hospitals are forced to shut off the DSS function within hours of
its introduction.
Koppel first points out that DSS is not an integral part of CPOE, as many
who work in health care purport. “Only a very small proportion of
hospitals with CPOE also have DSS; and fewer than 10 percent of hospitals
have CPOE,” he notes. Secondly, he says that by lumping CPOE with
the advantages of DSS, CPOE’s supporters also must take on the problems
of DSS: “CPOE is an imperfect technology that nonetheless has many
virtues, which will increase when it is more fully developed. DSS also
has many virtues, but it has even more problems than CPOE.”
His commentary, entitled, “Defending Computerized Physician Order
Entry From Its Supporters,” addresses the fact that expansive definitions
of CPOE – defining CPOE in ways that claim the benefits of all sorts
of healthcare information technology – might backfire, resulting
in an incorrectly low estimate of CPOE’s efficacy because overarching
definitions of CPOE will unintentionally pick up the problems with the
advantages of other technologies.
“In the article by Palen and colleagues, the DSS failed drastically,”
explains Koppel. “The reminders had no beneficial impact on what
physicians did. But Palen et al., accepting the overly broad definition
of CPOE, conclude that CPOE was shown to be faulty. I argue that their
findings of DSS’s failure have little to do with CPOE’s problems.
That’s why I’m defending CPOE from its supporters.”
In general, Koppel states that CPOE is a very promising technology, but
the supporters of CPOE fail to evaluate its strengths and weaknesses.
“They also expansively accept other forms of healthcare information
technology such as electronic health records and electronic medication
administration records under a CPOE portmanteau. By doing that, they misleadingly
claim a wide range of successes. In the Palen et al study, however, they
picked up a rather resounding failure.”
Koppel argues that defining the scope of CPOE is not just an academic
exercise. CPOE has become a major part of federal healthcare policy, hospital
and investor strategies, and hardball market economics. “In their
passion to promote CPOE, its supporters have both ignored its problems
and have embraced an imprecise and ultimately self-defeating definition,”
he says. “We need a clear definition of the technology and we need
independent analyses of its utility. Currently, we have neither.
“I am a passionate supporter of health information technology and
CPOE,” says Koppel. “I argue, however, that clinicians and
hospitals should seek good healthcare information technology that helps
with patient care and patient safety. Expensive systems backed by promises
and elaborate marketing efforts should not be the defining characteristics.”
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This release is available online at
http://www.uphs.upenn.edu/news/News_Releases/jul06/koppelexadv.htm