Christopher A. Longhurst, Layla Parast, Christy I. Sandborg, Eric Widen, Jill Sullivan, Jin S. Hahn, Christopher G. Dawes, and Paul J. Sharek Decrease in Hospital-wide Mortality Rate After Implementation of a Commercially Sold Computerized Physician Order Entry System Pediatrics published online May 3, 2010 (abstract | PubMed)

Background: Implementations of computerized physician order entry (CPOE) systems have previously been associated with either an increase or no change in hospital-wide mortality rates of inpatients. Despite widespread enthusiasm for CPOE as a tool to help transform quality and patient safety, no published studies to date have associated CPOE implementation with significant reductions in hospital-wide mortality rates.

Objective: The objective of this study was to determine the effect on the hospital-wide mortality rate after implementation of CPOE at an academic children's hospital.

Patients and Methods: We performed a cohort study with historical controls at a 303-bed, freestanding, quaternary care academic children's hospital. All nonobstetric inpatients admitted between January 1, 2001, and April 30, 2009, were included. A total of 80063 patient discharges were evaluated before the intervention (before November 1, 2007), and 17432 patient discharges were evaluated after the intervention (on or after November 1, 2007). On November 4, 2007, the hospital implemented locally modified functionality within a commercially sold electronic medical record to support CPOE and electronic nursing documentation.

Results: After CPOE implementation, the mean monthly adjusted mortality rate decreased by 20% (1.008-0.716 deaths per 100 discharges per month unadjusted [95% confidence interval: 0.8%-40%]; P = .03). With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame.

Conclusion: Implementation of a locally modified, commercially sold CPOE system was associated with a statistically significant reduction in the hospital-wide mortality rate at a quaternary care academic children's hospital.

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Comments:

The computerizing train has long left the station - if your unit's operation is not fully integrated with information technology it soon will be. This is a good thing - evidence such as reported in this paper is mounting identifying clear benefits for safety and quality. However, these implementations are also showing the importance of context and the requirement for unique adaptations and testing to match installed systems with improved processes in addition to custom design modifications for the NICU. It would be tempting to regard CPOE or Bar Code systems as simple therapies that can be ordered and installed out-of-the-box but this would likely be fraught with problems. Attention, anticipation and prevention of unintended consequences is also a wise strategy.

A recent Swiss study compared the potential impact of 10 safety measures and found the cost-efficacy ratio of CPOE to be the worst. The cost of implementing these systems is clearly another reason to proceed with care and to learn as much as possible from others who have undertaken this inevitable upgrade.

If you have implemented or are in the process of implementing CPOE, what can you offer from your experience so far? What would you do differently if you had to do it again? Go to Submit Comments. to chime in.

Jim Handyside