Clinical Investigation
Effect of Electronic Health Record Implementation in Critical Care on Survival and Medication Errors,☆☆,

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Abstract

Background

Electronic health records (EHR) with computerized physician order entry have become exceedingly common and government incentives have urged implementation. The purpose of this study was to ascertain the effect of EHR implementation on medical intensive care unit (MICU) mortality, length of stay (LOS), hospital LOS and medication errors.

Materials and Methods

Prospective, observational study from July 2010-June 2011 in MICU at an urban teaching hospital in Atlanta, Georgia of 797 patients admitted to the MICU; 281 patients before the EHR implementation and 516 patients post-EHR implementation.

Results

Compared with the preimplementation period (N = 43 per 281), the mortality risk at 4 months post-EHR implementation (N = 41 per 247) and at 8 months post-EHR implementation (N = 26 per 269) significantly decreased (P < 0.001). In addition, the mean MICU LOS statistically decreased from 4.03 ± 1.06 days pre-EHR to 3.26 ± 1.06 days 4 months post-EHR and to 3.12 ± 1.05 days 8 months post-EHR (P = 0.002). However, the mean hospital LOS was not statistically decreased. Although medication errors increased after implementation (P = 0.002), this was attributable to less severe errors and there was actually a decrease in the number of severe medication errors (both P < 0.001).

Conclusions

We report a survival benefit following the implementation of EHR with computerized physician order entry in a critical care setting and a concomitant decrease in the number of severe medication errors. Although overall hospital LOS was not shortened, this study proposes that EHR implementation in a busy urban hospital was associated with improved ICU outcomes.

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)

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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).

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