Clinical InvestigationEffect of Electronic Health Record Implementation in Critical Care on Survival and Medication Errors☆,☆☆,★
Introduction
Electronic health record (EHR) has been endorsed by national healthcare organizations such as the Institute of Medicine and the Leapfrog Group to improve patient care, especially computerized physician order entry (CPOE).1 The American Recovery and Reinvestment Act of 2009 allowed for $2 billion in discretionary health information technology funding and $18 billion in investments and incentives through Medicare and Medicaid to adopt and to use EHR technology.2 The Centers for Medicare and Medicaid Services has initiated financial incentives with EHR implementation with the goal of improving healthcare efficiency and quality.1 However, the implementation of this technology is extremely costly for hospital institutions. Furthermore, the data are unclear if this new technology has any direct patient care benefit.
A recent systematic review specifically looking at intensive care unit (ICU) mortality and length of stay (LOS) with EHR did not show any substantial effects because of the small number of studies and heterogeneity of the patient population.3 Another systematic review article looking at 67 studies involving CPOE found that there were positive effects in adherence to guidelines, satisfaction and usability, but the various studies did not find a difference in mortality.4, 5, 6 The EHR studies often look at the effect of CPOE on patient safety outcomes. Schenarts et al7 reported that in patients with traumatic injury, EHR reduced the hospital LOS and ICU LOS, but did not change mortality. The focus on patient safety has expanded the role of technology to minimize the risk of medical errors and adverse events. It has been reported that 1.7 medical errors occur a day in the ICU and that medication errors account for 78% of these errors.8 A systematic review of CPOE implementation in various healthcare settings found a relative risk reduction ranging from 13-99% for medication errors and from 30-84% for adverse drug events.9
However, Weant et al10 reported that medication errors increased to more than 4 times higher in the first month after CPOE implementation in neurosurgical ICU, but that the number of errors causing patient harm decreased. The use of CPOE in a United Kingdom ICU demonstrated significant reduction in overall number of errors attributed to prescribing errors.11 Although research shows that administration errors are the second most common cause of medication errors, to date, administration and dispensing errors with CPOE implementation have not been evaluated.
Various studies have shown variable results regarding EHR implementation and EHR with CPOE. Different mortality results were published by 2 commonly cited studies done in the pediatric ICU. The University of Pittsburgh study showed an increase in mortality with EHR implementation, and a similar study done at Montefiore Medical Center found no mortality difference with EHR implementation in the pediatric ICU.12, 13 These studies are more than 8 years old and original research in adult ICU has not been performed recently. Therefore, this study evaluates the effect of EHR with CPOE implementation on mortality, medical ICU (MICU) LOS, hospital LOS and medication errors in critically ill adults.
Section snippets
Design
This prospective, observational study evaluated the effect of EHR with CPOE on patient care outcomes from July 2010-June 2011. The study was reviewed by Emory University Institutional Review Board as well as the hospital Research Oversight Committee, and was exempted as a quality improvement study.
Setting
The study was conducted in the county MICU in Atlanta, GA, (Grady Memorial Hospital). Before implementation, medical records were used for each patient where notes and orders were manually prescribed
Results
A total of 797 critically ill medical patients admitted from July 2010-June 2011 were included in the study. There were no significant differences across all groups in race, sex, age and disease category (Table 1). As a marker of illness severity, the APACHE II score increased from the preimplementation (mean = 18.6 ± 8.51) to the immediate postimplementation period 4 months (23.29 ± 10.54), and slightly decreased thereafter at 8 months (21.13 ± 9.74), (P < 0.0001, Table 1). The median APACHE
Discussion
This study reports an association between severity-adjusted reductions in mortality with the implementation of an EHR with CPOE in a critical care setting. In support of these benefits, the reductions in mortality were accompanied by reductions in ICU LOS. In addition, this study documents the systematic changes in medication errors with EHR implementation, noting an overall increase in medication errors but, importantly, significant reductions in more severe errors. It is noteworthy that the
Conclusions
Our study indicates that there is an association between improved ICU survival and implementation of an EHR, which has not been previously reported. As EHR implementation continues to expand in multiple healthcare settings, this study documents the clinically relevant changes in ICU care following EHR implementation and supports the hypothesis that EHR may improve outcomes in critically ill patients.
Acknowledgments
The authors would like to thank the National Institutes of Health and the Atlanta Clinical and Translational Science Institute for their support in this study.
References (17)
- et al.
The impact of computerized physician medication order entry in hospitalized patients—a systematic review
Int J Med Inform
(2008) - et al.
Improving modern cancer care through information technology
Am J Prev Med
(2011) - et al.
The effect of electronic prescribing on medication errors and adverse drug events: a systematic review
J Am Med Inform Assoc
(2008) - et al.
Vitamin D: modulator of the immune system
Curr Opin Pharmacol
(2010) - et al.
The state of the evidence for computerized provider order entry: a systematic review and analysis of the quality of the literature
Int J Med Inform
(2009) - The Leapfrog Group Fact Sheet. http://www.leapfroggroup.org/about_leapfrog/leapfrog-factsheet; Accessed April 23,...
- Ledue C. Healthcare Finance News Physicians to receive incentives for EHR use....
- et al.
Impact of the Electronic Medical Record on mortality, length of stay, and cost in the hospital and ICU: a systematic review and metaanalysis
Crit Care Med
(2015)
Cited by (20)
Quality improvement of Dutch ICUs from 2009 to 2021: A registry based observational study
2024, Journal of Critical CareA systematic review of the implementation of electronic nursing documentation toward patient safety
2021, Enfermeria ClinicaCitation Excerpt :According to Han et al. and Mills, the implementation of EHR helps nurses to provide efficient services to patients, especially to improve the safety of alerted medicines (p < 0.001).11,19 It could also save money due to the implementation of preventive guidelines against errors in the administration of drugs.19 Fourth, the implementation of EHR has a large impact on the use of operating rooms, which affects overall hospital profitability.12
Errors and causes of communication failures from hospital information systems to electronic health record: A record-review study
2018, International Journal of Medical InformaticsCitation Excerpt :Correct implementation of electronic health records leads to immediate access and easy communication of patients’ information between health care providers and patients [35]. Despite its numerous benefits and advantages, it is an expensive intervention for hospitals and care institutions [36]. However, if it is implemented correctly much of the expenses will be paid off soon.
Advocating for Greater Usability in Clinical Technologies: The Role of the Practicing Nurse
2018, Critical Care Nursing Clinics of North AmericaCitation Excerpt :This generally means that the interface, use steps, audible alarms, and so forth differ from technology to technology, further adding to the complexity of technology use in ICUs. These technologies are integral to providing health care in the digital age and have led to many positive outcomes related to patient safety.15–18 Unfortunately technology does not prevent all patient harm and can even facilitate nursing errors.19,20
OmniPHR: A distributed architecture model to integrate personal health records
2017, Journal of Biomedical InformaticsCitation Excerpt :Electronic Health Record (EHR) is a standardized information model, enabling integration among multiple healthcare providers, and this integration is considered their main advantage [24,25]. EHR has several benefits, ranging from supporting medical prescriptions [26], improving disease management [27] and contributing in the reduction of severe medication errors [28]. However, EHR has limitations regarding interoperability, e.g when health organizations adopt international but heterogeneous standards [29].
Methods for studying medication safety following electronic health record implementation in acute care: A scoping review
2024, Journal of the American Medical Informatics Association
- ☆
The authors have no conflicts of interest to disclose.
- ☆☆
This work is supported in part by National Institutes of Health, United States, Grant Numbers T32 AA013528 and UL1 TR000454 to JEH and UL1 TR000455 to GSM.
- ★
Prior presentations: American Journal of Respiratory and Critical Care Medicine, 2012;185:A4009; Published abstracts: Critical Care Medicine 2011;39(S12).