Impact of vendor computerized physician order entry on patients with renal impairment in community hospitals

BACKGROUND

Adverse drug events (ADEs) are common among hospitalized patients with renal impairment.

OBJECTIVE

To determine whether computerized physician order entry (CPOE) systems with clinical decision support capabilities reduce the frequency of renally related ADEs in hospitals.

DESIGN, SETTING, AND PATIENTS

Quasi-experimental study of 1590 adult patients with renal impairment who were admitted to 5 community hospitals in Massachusetts from January 2005 to September 2010, preimplementation and postimplementation of CPOE.

INTERVENTION

Varying levels of clinical decision support, ranging from basic CPOE only (sites 4 and 5), rudimentary clinical decision support (sites 1 and 2), and advanced clinical decision support (site 3).

MEASUREMENTS

Primary outcome was the rate of preventable ADEs from nephrotoxic and/or renally cleared medications. Similarly, secondary outcomes were the rates of overall ADEs and potential ADEs.

KEY RESULTS

There was a 45% decrease in the rate of preventable ADEs following implementation (8.0/100 vs 4.4/100 admissions; P < 0.01), and the impact was related to the level of decision support. Basic CPOE was not associated with any significant benefit (4.6/100 vs 4.3/100 admissions; P = 0.87). There was a nonsignificant decrease in preventable ADEs with rudimentary clinical decision support (9.1/100 vs 6.4/100 admissions; P = 0.22). However, substantial reduction was seen with advanced clinical decision support (12.4/100 vs 0/100 admissions; P = 0.01). Despite these benefits, a significant increase in potential ADEs was found for all systems (55.5/100 vs 136.8/100 admissions; P < 0.01).

CONCLUSION

Vendor-developed CPOE with advanced clinical decision support can reduce the occurrence of preventable ADEs but may be associated with an increase in potential ADEs.

Return on investment for vendor computerized physician order entry in four community hospitals: the importance of decision support

BACKGROUND

In-hospital adverse events are a major cause of morbidity and mortality and represent a major cost burden to health care systems. A study was conducted to evaluate the return on investment (ROI) for the adoption of vendor-developed computerized physician oder entry (CPOE) systems in four community hospitals in Massachusetts.

METHODS

Of the four hospitals, two were under one management structure and implemented the same vendor-developed CPOE system (Hospital Group A), while the other two were under a second management structure and implemented another vendor-developed CPOE system (Hospital Group B). Cost savings were calculated on the basis of reduction in preventable adverse drug event (ADE) rates as measured previously. ROI, net cash flow, and the breakeven point during a 10-year cost-and-benefit model were calculated. At the time of the study, none of the participating hospitals had implemented more than a rudimentary decision support system together with CPOE.

RESULTS

Implementation costs were lower for Hospital Group A than B ($7,130,894 total or $83/admission versus $19,293,379 total or $113/admission, respectively), as were preventable ADE-related avoided costs ($7,937,651 and $16,557,056, respectively). A cost-benefit analysis demonstrated that Hospital Group A had an ROI of 11.3%, breaking even on the investment eight years following implementation. Hospital Group B showed a negative return, with an ROI of -3.1%.

CONCLUSIONS

Adoption of vendor CPOE systems in community hospitals was associated with a modest ROI at best when applying cost savings attributable to prevention of ADEs only. The modest financial returns can beattributed to the lack of clinical decision support tools.

Lessons learned from implementation of computerized provider order entry in 5 community hospitals: a qualitative study

Background

Computerized Provider Order Entry (CPOE) can improve patient safety, quality and efficiency, but hospitals face a host of barriers to adopting CPOE, ranging from resistance among physicians to the cost of the systems. In response to the incentives for meaningful use of health information technology and other market forces, hospitals in the United States are increasingly moving toward the adoption of CPOE. The purpose of this study was to characterize the experiences of hospitals that have successfully implemented CPOE.

Methods

We used a qualitative approach to observe clinical activities and capture the experiences of physicians, nurses, pharmacists and administrators at five community hospitals in Massachusetts (USA) that adopted CPOE in the past few years. We conducted formal, structured observations of care processes in diverse inpatient settings within each of the hospitals and completed in-depth, semi-structured interviews with clinicians and staff by telephone. After transcribing the audiorecorded interviews, we analyzed the content of the transcripts iteratively, guided by principles of the Immersion and Crystallization analytic approach. Our objective was to identify attitudes, behaviors and experiences that would constitute useful lessons for other hospitals embarking on CPOE implementation.

Results

Analysis of observations and interviews resulted in findings about the CPOE implementation process in five domains: governance, preparation, support, perceptions and consequences. Successful institutions implemented clear organizational decision-making mechanisms that involved clinicians (governance). They anticipated the need for education and training of a wide range of users (preparation). These hospitals deployed ample human resources for live, in-person training and support during implementation. Successful implementation hinged on the ability of clinical leaders to address and manage perceptions and the fear of change. Implementation proceeded smoothly when institutions identified and anticipated the consequences of the change.

Conclusions

The lessons learned in the five domains identified in this study may be useful for other community hospitals embarking on CPOE adoption.

Relationship between medication event rates and the Leapfrog computerized physician order entry evaluation tool

OBJECTIVE

The Leapfrog CPOE evaluation tool has been promoted as a means of monitoring computerized physician order entry (CPOE). We sought to determine the relationship between Leapfrog scores and the rates of preventable adverse drug events (ADE) and potential ADE.

MATERIALS AND METHODS

A cross-sectional study of 1000 adult admissions in five community hospitals from October 1, 2008 to September 30, 2010 was performed. Observed rates of preventable ADE and potential ADE were compared with scores reported by the Leapfrog CPOE evaluation tool. The primary outcome was the rate of preventable ADE and the secondary outcome was the composite rate of preventable ADE and potential ADE.

RESULTS

Leapfrog performance scores were highly related to the primary outcome. A 43% relative reduction in the rate of preventable ADE was predicted for every 5% increase in Leapfrog scores (rate ratio 0.57; 95% CI 0.37 to 0.88). In absolute terms, four fewer preventable ADE per 100 admissions were predicted for every 5% increase in overall Leapfrog scores (rate difference -4.2; 95% CI -7.4 to -1.1). A statistically significant relationship between Leapfrog scores and the secondary outcome, however, was not detected.

DISCUSSION

Our findings support the use of the Leapfrog tool as a means of evaluating and monitoring CPOE performance after implementation, as addressed by current certification standards.

CONCLUSIONS

Scores from the Leapfrog CPOE evaluation tool closely relate to actual rates of preventable ADE. Leapfrog testing may alert providers to potential vulnerabilities and highlight areas for further improvement.

An instrumented station for the survey of ozone and climate change in the southern tropics

The assessment of changes induced by human activities on Earth atmospheric composition and thus on global climate requires a long-term and regular survey of the stratospheric and tropospheric atmospheric layers. The objective of this paper is to describe the atmospheric observations performed continuously at Reunion Island (55.5 degrees east, 20.8 degrees south) for 15 years. The various instruments contributing to the systematic observations are described as well as the measured parameters, the accuracy and the database. The LiDAR systems give profiles of temperature, aerosols and ozone in the troposphere and stratosphere, probes give profiles of temperature, ozone and relative humidity, radiometers and spectrometers give stratospheric and tropospheric integrated columns of a variety of atmospheric trace gases. Data are included in international networks, and used for satellite validation. Moreover, some scientific activities for which this station offers exceptional opportunities are highlighted, especially air mass exchanges nearby dynamical barriers: (1) On the vertical scale through the tropical tropopause layer (stratosphere-troposphere exchange). (2) On the quasi-horizontal scale across the southern subtropical barrier separating the tropical stratospheric reservoir from mid- and high latitudes.

Perception of nuclear energy and coal in France and The Netherlands

This study focuses on the perception of large scale application of nuclear energy and coal in the Netherlands and France. The application of these energy-sources and the risks and benefits are judged differently by various group in society. In Europe, France has the highest density of nuclear power plants and the Netherlands has one of the lowest. In both countries scientists and social scientists completed a questionnaire assessing the perception of the large scale application of both energy sources. Furthermore, a number of variables relating to the socio cultural and political circumstances were measured. The results indicate that the French had a higher risk perception and a more negative attitude toward nuclear power than the Dutch. But they also assess the benefits of the use of nuclear power to be higher. Explanations for these differences are discussed.

Characteristics and evolution of writing impairment in Alzheimer's disease

Rapcsak et al. (Archs Neurol. 46, 65-67, 1989) proposed a hypothesis describing the evolution of agraphic impairments in dementia of the Alzheimer type (DAT): lexico-semantic disturbances at the beginning of the disease, impairments becoming more and more phonological as the dementia becomes more severe. Our study was conducted in an attempt to prove this hypothesis on the basis of an analysis of the changes observed in the agraphia impairment of patients with DAT. A writing test from dictation was proposed to 22 patients twice, with an interval of 9-12 months between the tests. The results show that within 1 year there was little change in the errors made by the patients in the writing test. The changes observed however were all found to develop within the same logical progression (as demonstrated by Correspondence Analysis). These findings made it possible to develop a general hypothesis indicating that the agraphic impairment evolves through three phases in patients with DAT. The first one is a phase of mild impairment (with a few possible phonologically plausible errors). In the second phase non-phonological spelling errors predominate, phonologically plausible errors are fewer and the errors mostly involve irregular words and non-words. The last phase involves more extreme disorders that affect all types of words. We observe many alterations due to impaired graphic motor capacity. This work would tend to confirm the hypothesis proposed by Rapcsak et al. concerning the development of agraphia, and would emphasize the importance of peripheral impairments, especially grapho-motor impairments which come in addition to the lexical and phonological impairments.

The development of reactions of the public to warning and emergency situations in France, Greece, and the Netherlands

This article describes the different reactions to emergency warning messages among residents living within a 3-km radius of a hazardous chemical complex and by people living at least 10 km from an industrial site in France, Greece, and the Netherlands. Belief in warning, primary and secondary appraisal, emotional response, and adherence to normal routine were assessed by conducting face-to-face interviews in which a four-phase scenario simulating a credible industrial accident was presented. The results showed that respondents who did not reside in the neighborhood of the hazardous site were, in general, more inclined to trust the warning messages than respondents who resided in the neighborhood were. With the exception of primary appraisal, the warning phases evoked very distinct reactions in the respondents from all three countries with regard to warning belief, secondary appraisal, emotional response, and adherence to normal routine.

Interactions among affect, cognition, and visuomotor coordination as measured in words and symbols

The associative frequencies of responses to stimulus words during free and controlled forced-choice word-association tests correlate well with each other and with assessments of the affective character (emotional content) of the stimulus words for the test subjects (Osgood Index) for three samples of volunteer French undergraduate students (ns = 200, 64, and 72). These indices correlate negatively with the subjects' performance on Digit Symbol Substitution tests. Neisser's theory of schemata and Edelman's theory of neuronal group selection may provide insight into this relationship. If the associative frequency of a subject's response decreased, the affective content of the word stimulus (as perceived by the subject) diminished as well. This relationship was associated with a relatively higher score on Digit Symbol Substitution. Conversely, it was observed that subjects whose responses were characterized by high associative frequencies (whether the response was spontaneous or forced-choice) rated the stimulus words as having a relatively stronger affective content or emotional character and performed less well on Digit Symbol Substitution.