Yale New Haven Health System
Assistant Professor of Medicine
Yale University School of Medicine
Clinical information systems can be utilised for a number of purposes within hospitals: for example, for computerised provider order entry, clinical decision support and documentation of patient care. At Yale New Haven Health System in the USA, computerised physician order entry components were first installed about 10 years ago – mainly driven by the need to improve patient safety. Before that, approximately 15–20% of errors were the result of illegible handwriting and transcribing errors when transferring orders from the entry system to the pharmacy system. The intention was also to accomplish clinical decision support, which has been gradually developed over the years.
Current clinical information systems
Nearly every order is entered into the computer system by the provider, usually a doctor. Relatively advanced decision support is built into the order entry system – screens guide the user through the drug ordering process, for example in terms of ordering the appropriate dosages for the right indications, and so on.
The current decision support system was built into the provider order entry system internally and is relatively advanced, but it is not as sophisticated or intelligent as what the hospital is aiming for. Specific areas that have been identified as particularly problematic, such as misdosing, antibiotic usage and serious drug–drug interactions, have been targeted, with the system alerting the provider to potential problems when entering an order.
Problem areas were initially identified using pharmacy and clinical expertise, anecdotal reports of errors, and analysis of the literature. A multidisciplinary group evaluated where the main problems were likely to occur, and a repository was built to analyse the frequency and level of risk of interactions, and to prioritise those that needed to be addressed.
A relatively advanced documentation system is in place in which nurses record new patient evaluations and intake documentation. The hospital does not use online physician documentation at the moment, although a lot of results and studies are available for retrieval online. Physicians’ and nurses’ notes are still written on the paper chart.
Everyone goes through a rigorous training programme when they first start using the systems, with the amount of training they receive dependent on their role within the organisation. Nurses, doctors and technicians will receive training tailored to their subsequent in-job requirements. Users aren’t given codes to access the system until they have successfully completed their training.
Physician order entry is available on the main hospital computer system and available throughout the whole hospital. All of the resulting systems are tightly integrated and interface with the main system. Lab results, diagnostic imaging results and pathology results are accessed on the main system. A picture archiving and communications (PAC) radiology imaging system, currently being introduced, will also be available throughout. Clinical decision support is partly integrated into the system, but more advanced functionality is external to the system and goes directly to the pharmacists rather than to the providers. Documentation is also integrated.
Benefits and disadvantages
The main advantages in the implementation of computerised clinical information systems lie in improved patient safety and quality of care. The system does not give obvious time-saving benefits – it probably takes an equivalent amount of time to the old paper-based system. The time taken to create an individual order is much longer than previously, but being able to enter orders or look up lab reports on the system from anywhere in the hospital, or even from an office outside the hospital, certainly saves time.
The current older system is not very user-friendly – it takes a while to learn, and if you don’t use the system frequently it is a challenge to remember how to use it. Even once a month, it can be much more of a challenge. On the very rare occasions when the computer system is down, people forget how to use the old paper-based system.
Provider satisfaction and patient safety are key reasons for trying to improve upon the current system. There is an ongoing changeover to a different system, which provides the capability for real-time, active decision support, with rules that are evaluated according to the individual patient’s condition. When an order is entered using the newer system, it will find additional information on that patient and provide appropriate alerts accordingly.
A barcoding system for medicines management is being evaluated. The use of these systems in US hospitals has been limited up until now as companies have been slow to barcode unit-dose products. However, the FDA is pressing the industry to change, and many hospitals are now looking towards the prospect of introducing barcoded medication management. Barcoding is not necessarily the panacea that some people hold it to be – there is still plenty of opportunity for introducing errors into the system. It will be an enhancement, improving documentation and reducing administration errors, but it should be pointed out that administration errors are not usually as significant or dangerous as prescribing errors, despite being much more frequent. To improve the quality of care, both types of errors need to be addressed.
The situation in the USA as a whole
Yale New Haven Health system is unusual – it is rare for US hospitals to have full provider order entry in place for all studies and all drugs. People have been working very hard to change this situation over the past five years – hospitals and other healthcare providers realise that they have to do something to reduce the error rate, but it is very hard , very expensive and takes a long time to implement these systems.
A lot of physicians, particularly older physicians, are not enthusiastic about using computers to enter orders. In a large academic medical centre such as ours there are a lot of residents who can enter orders into the system; however, in community hospitals physicians often have to enter the orders themselves and are often not sufficiently computer-literate or don’t have time to learn the system. The good news is that more user-friendly systems that don’t take long to learn and are easy to remember are at last becoming available.
Looking to the future
Everyone embraces the concept of clinical decision support, particularly real-time decision support to help people make decisions that are becoming ever more complex. It is important to recognise that there are several hurdles still to be overcome – these systems need to be fast so the user is not waiting to receive the information, and they have to provide pertinent information. It is often difficult to set system sensitivity appropriately so as not to overload the user with meaningless information that may ultimately cause them to ignore an alert.
Many of the success stories that have generated a lot of literature have used home-grown systems, and most have large academic informatics departments. The Veterans Administration has done a lot of work in this area and has been successful. However, these successes are not typical of the 6,000 or so hospitals in this country, which are limping along, hoping that someone will show them how to do it. The next few years will be a very interesting time, and we could see some dramatic changes.
In the next issue we will be looking at the current state of play with regard to clinical information systems in European hospitals.