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| Richard J. Schaeffer |
For hospitals looking to clinical information technology to improve patient safety, choosing the first system to implement depends on a variety of factors. In addition to the organization’s level of urgency, the system’s likelihood of successful adoption, ability to generate measurable outcomes and potential for growth are important markers.
Early in 2004, St. Clair Hospital, Pittsburgh, Pa., launched a major clinical information technology initiative and implemented an electronic medical record and computerized provider order entry (EMR/CPOE) system and a bar-code-enabled point of care medication administration system at the same time. Because the projects began simultaneously, the hospital gained a unique perspective on which system provided the quicker patient safety payoff. For St. Clair, bar coding delivered the best and most immediate benefits.
Prioritize Impact Areas
To set implementation priorities, organization leaders must be able to predict the system’s impact on patient safety and care quality in order to decide which system is most important to improving patient care. For example, CPOE has the potential to address much more than medication prescribing errors. Bar coding, on the other hand, only targets medication administration errors, but it does so at the bedside, which is an area of greater threat to patient safety.
Early results from both systems were analyzed prior to either system being completely implemented across the organization. The first phase of EMR/CPOE activation consisted of online access to test results, patient lists and historic permanent patient records. The medical staff reaction was positive, and clinicians were willing to move to the next phase.
The reaction to the early findings from the bar-coding system was even more enthusiastic. When the statistics showed that the organization was on pace to prevent more than 5,000 medication errors during the first year of the system’s use, clinicians and administration expressed a desire to deploy the system to all nursing units as soon as possible. One physician was excited to realize that bar coding could prevent the administration of a medication he had discontinued for a patient. Another physician said that he did not want any of his patients admitted to a unit where the bar-coding system was not yet installed.
Anticipate Likely Obstacles
During any system rollout, there are inevitable changes in application look and feel, workflow, and hardware. The first adoption challenge likely will arise from what users perceive as the technology’s limitations. With CPOE, physicians immediately will rebel against inputting their data in the system. Likewise, when nurses first see the handheld device used to scan bar codes, some will say the screen is too small.
The difference between these two problems is that one is real and the other is perceived. Physicians’ ability to efficiently use the keyboard and mouse to navigate the CPOE system varies widely. Some have no keyboard skills, and it would take an unreasonable amount of time to input information such as a patient’s progress note. Structured templates driven by mouse clicks can help, but a voice recognition system may be needed as an alternative to keyboarding.
In contrast, the nurses’ perception of their inability to read the small device screen is a false assumption. Initially, they don’t understand that the characters displayed on the handheld device are large, clear, bright and much more readable than standard print currently found on documents or in everyday reading material such as a newspaper or magazine. Once the nurses actually look at the screen, they realize that it is very readable, even for more senior nurses.
Hybrid records represent another adoption obstacle. With the introduction of the EMR/CPOE system, the medical staff must be willing to obtain and view information in electronic format. But during a gradual implementation of that system, some data will be in the system and some will exist only on paper. This hybrid chart is a challenge to manage. Physicians won’t know where the patient information is located, which can lead to adverse and unanticipated outcomes.
Bar coding has a similar issue. Some nurses on a unit may not adopt the technology and continue to rely solely on the paper medication administration record, while others are using the electronic version on the handheld device. Although both of the hybrid situations can impact patient safety, a hybrid medication administration record is easier to handle because the scope of data is more defined.
Measure Outcomes
With any project that involves a significant investment of time and money, the stakeholders involved want to see quantifiable results. With an EMR/CPOE implementation, the organization expects evidence of increased patient safety and improved quality of care through standardized order sets, evidenced-based medicine, and reduction of redundant tests and errors associated with transcribing handwritten orders.
With the implementation of a bar-code system, the organization expects a reduction in the number of medication errors, administration of discontinued medications and missed medications, and the elimination of wrong-patient errors.
Both systems have the potential to deliver all of the benefits listed above. But with bar coding, the outcomes can be measured. The system is designed to detect, prevent and record every medication incident. Although some outcomes of the EMR/CPOE system are measurable, many are not, and the organization must trust that quality is improved without direct evidence in all areas.
Consider Potential for Evolution
Looking beyond system activation, the hospital should examine which system best serves as a platform for future growth. The EMR/CPOE system can be a springboard--or even a prerequisite--to external efforts such as participation in a regional health information organization. Conversely, the bar-coding system centers on internal efforts, safety at the bedside. That said, there are many possibilities for growth in this area.
The handheld device can evolve into the nurse’s tool for all things related to bedside safety: It likely will follow a fairly predictable progression of bedside patient safety initiatives, including medications, lab specimen labeling, blood transfusion safety, control of smart-pumps, and finally, preventing allergic food reactions.
St. Clair Hospital’s bar coding system represents the first foray into radio frequency identification technology. The hospital uses Socket’s dual scanners to recognize both bar codes and RFID tags. Passive tags now cost less than a dollar, making them appropriate for patient wristbands and caregiver ID badges. They can also be used to identify the patient and ingredients in an IV mixture prior to administration.
Applying an RFID tag to each unit dose medication isn’t affordable yet, but that shouldn’t deter hospitals from embracing the technology. Ultimately, hospitals will want to have a strategy for both passive RFID, as with patient and caregiver IDs, IVs and tubing, and active RFID, for asset tracking, inventory control, patient location and bed management.
Both EMR/CPOE and bar-coding systems advance patient safety and the quality of care. Over time, all should be installed in most hospital settings. But when the organization is setting priorities, each system’s potential impact should be analyzed. Across a broad spectrum of comparison factors, St. Clair found that the bar-coding system had the strongest argument to be the hospital’s number one project priority.
Richard J. Schaeffer is vice president and CIO of St. Clair Hospital, Pittsburgh, Pa.
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This article first appeared on August 2, 2006 in HHN's Magazine online site.
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