Customization

Customizing the electronic medical record can produce a visual spectrum of workflow, depending on how the information is entered into the system; to the way data are presented. Computing capabilities allow different users who log onto the system to view different types of information and in a presentation more suitable for their needs. Thus, an infectious disease consultant may wish to see pertinent information regarding cultures, white count, and fever on the same screen, whereas a nephrologist may want to be presented with electrolyte and metabolic data, as well as fluid balance initially. With a customizable system, complex order sets can be created and easily prescribed according to unit, procedure, or surgeon’s protocol. The use of protocols and routine prescriptions may improve standardization and compliance with evidence-based procedures.

Complex Alerts

Computerized alerts can improve needed clinical activity. Paltiel et al. (7) showed that an alert presented by computers throughout the hospital for a low potassium level could reduce the time to treatment of hypokalemia. We looked at the impact of an electronic alert in a computerized patient record, and showed that when implementing this alert, the proportion of blood glucose measurements within the desired range significantly increased whereas the proportion of elevated glucose measurements decreased. This was achieved without an increase in the proportion of hypoglycemic episodes (8). We also showed that an alert that notifies the clinicians of a low potassium level reduces the time to treat the patient. There are programs designed to deal with specific topics and clinical problems. Juneja et al. (9) showed that a program dedicated to treating patients who require insulin while in the ICU to maintain tight glucose control led to better results compared to the situation before the program was implemented.

Decision support can improve the use of various resources. Fernandez-Perez et al. (10) used decision support to reduce the use of blood products in an ICU. Rood et al. (11) showed that using an alert system designed to improve glycemic control in an ICU improved the time to achieving desired glucose control (Fig. 9.2). In fact, a computerized system can enable the application of many types of alerts. In our ICU, the computerized system alerts staff when a patient is receiving vancomycin and a blood level has not been drawn; when a patient’s PaO₂ is high when the FiO₂ is greater than 0.3; and if a patient has not had a bowel movement in 3 days. All of these alerts are relevant to our daily clinical practice and help decrease variability in our work.

Alerts can be provided to clinicians in various ways. In a surgical ICU, a wireless system sent pages to the respective physicians, notifying them of abnormal physiologic and laboratory results. The alerting system identified patients with a higher risk of death and longer stay in the ICU (12). The ability to identify high-risk patients and alert clinicians to critical events may enable earlier intervention and improved outcome.

EFFECTS ON WORKLOAD

The implementation of a computerized system may generate concern over the increased workload associated with the transition. Certainly an initial effort at customizing the system to fit the local clinical workflow is required, which may vary for different commercial systems. The time required for training of staff should also be considered when deciding on a computerized system. Even when the system is in place, there are clinicians who feel uncomfortable working with a keyboard and mouse rather than with pen and paper. These concerns, however, are decreasing as work with computers increases in everyday life, as well as the fact that computers are commonly used even in ICUs that have not yet implemented a complete electronic patient record. Hospital information systems, radiology, and laboratories are often computerized, but in many ICUs, clinicians still copy results from these various systems onto a paper flow sheet. In a computerized system, significant portions of the charting workload are eliminated for the clinicians, and thus more time is available for more sophisticated charting and reporting and also for direct patient care. Bosman et al. (13) showed that implementation of a computerized system decreased the time nurses spent on charting information on critically ill patients following cardiothoracic surgery. The time saved by the computerized system was spent on direct patient care, increasing the time at the bedside.

When clinicians work with computerized patient records, there are changes in the characteristics of the work, and new types of distractions may occur. An observational study of clinicians working with a computerized order entry system showed that there are distractions in working with the computer that may, in some cases, lead to potentially significant errors (14). The issue of the quality of notes written in a computerized system is also an issue as the “copy–paste” functionality of the computerized record system may lead to long, yet less than useful notes.

COMPUTERIZED PHYSICIAN ORDER ENTRY

Despite the evidence regarding the advantages of computerized provider order entry systems, only 5% to 10% of hospitals in the United States use them, according to various reports (15,16). It has been proposed that implementation of CPOE in hospitals in the United States would have a beneficial effect on societal health parameters (17). This paper calculated dramatic improvement in QUALY as well as substantial savings in money. The anticipated increase in CPOE adoption between 2009 and 2015 is expected to achieve savings of 133 billion dollars nationwide. Adoption of CPOE has significantly increased over the last years. In a more recent look at electronic health record (EHR) adoption by hospitals in the United States, the numbers had gone up from 59% in 2013 to 75% in 2014 with respect to use of a basic system (18). In Belgium, a survey of ICUs demonstrated that more than 40% use CPOE, and the majority of tertiary and academic hospitals use them (19).

TABLE 9.1 Types of Errors That Should Be Prevented by CPOE with Decision Support

Despite this, Milstein et al. (20) showed that CPOE is adopted relatively late in the time course of EHR implementation. Although applying meaningful use criteria would lead to earlier implementation of CPOE, in the hospitals surveyed, they found that only 27% had implemented CPOE, whereas 85% had implemented electronic tools for patient demographics and for radiology reports.

CPOE has been proposed as a tool to decrease prescription errors due to handwriting legibility, mistakes in dosage, incompatibility, and allergy alerts. The implementation of CPOE can significantly impact the daily work of physicians and nurses (21). The use of a computerized database as part of the prescription process can lead to improvement, since orders can be evaluated by the database and provide alerts regarding drug–drug interaction, double prescription, drug allergies, and effects of disease processes on drug dose. This is true when a decision-support capability is part of the CPOE (Table 9.1).

There are more basic forms of electronic information systems. Computerized systems that do not have decision support as part of the available tools will only provide information regarding the drug–drug administration and dosage, but may not be able to alert when prescriptions have mistakes in them. The Leapfrog Group designed a Web-based test for CPOE and requires hospitals to prove that their CPOE can detect at least 50% of common drug prescription errors (22).

The types of prescription errors differ when CPOE is compared to handwritten prescriptions. Shulman et al. (23) evaluated the medication errors that occurred before and after the implementation of a computerized system. They found that there was a reduction in the number of errors, which was time-related. After an initial increase in medication errors, the numbers decreased substantially. Garg et al. (24), in a review of the effect of computerized systems on clinical performance, found that of 29 studies that looked at the effect of drug dosing systems on clinical performance, 19 (66%) showed a favorable outcome.

Despite these findings, the importance and capability of CPOE to decrease harmful medical errors remain debatable. Berger and Kichak (25) reviewed the basis for the claim that CPOE can decrease significant medical errors and concluded that:

The available objective data, which are scant, suggest that, at best, there is a potential for these systems to decrease ADEs (adverse drug events) and their additional medical costs.

QUALITY IMPROVEMENT

Quality, as measured by both surrogate markers, such as adherence to best practice protocols and clinical outcomes, may be improved by computerized systems. Obviously, the use of checklists and “bundles” to improve quality can be improved when using computerized systems to alert and remind the clinicians of the various diverse tasks that are required by the particular bundle.

Using CPOE in patients with stroke has been shown to reduce the time it takes to assess the patient, increase the number of patients who receive thrombolysis, and decrease time to therapy (26). Others have shown that a computerized system can enable evaluation of antibiotic prophylaxis use during surgery (27). When patients were not given appropriate antibiotics according to recommended protocols, the outcome was significantly worse. These systems allow analysis of drug use and enable decisions regarding quality improvement (28).

ERRORS AND THEIR PREVENTION

Errors are a major issue in intensive care medicine. Donchin et al. (29), more than 20 years ago, reported drug errors to occur 1.7 times a day per patient in an ICU. However, in a review of medication errors, Wilmer et al. (30) analyzed 29 papers and found that due to great variability in definitions and detection techniques, the reported incidence of medications errors varied between 8.1 and 2,344 per 1,000 patient-days.

The impact of medical errors on patient outcomes was emphasized in the famous “To err is human” report by the Institute of Medicine (31). The use of computerized systems has a potential of reducing error by improving standardization and reviewing databases of information about the patient’s baseline diseases, drug allergies, previous procedures, and tests. There is also an advantage to improving compliance with protocols and unit procedures, which computerized systems can enable (32).

Drug errors range from illegible prescriptions to mistakes in patient identification and lapses in knowledge of patient allergies, drug–drug interactions, and dosing considerations. Many of these types of errors can be reduced or completely eliminated using computerized systems. Vardi et al. (33) showed that using CPOE as part of an electronic patient record can completely eliminate drug order mistakes in a pediatric ICU when they applied it to resuscitation orders, which, in pediatrics, are particularly prone to mistakes because of the diversity in patient size and the urgency of the situation. More recently, Hernandez et al. (34) showed in an orthopedic service that implementation of a CPOE reduced prescription errors by 92%, and administration errors by more than 17%.

THE REMOTE ICU AND TELEMEDICINE

The requirements for physician staffing of ICUs calls for 24-hour coverage by trained physicians. The ICU should be directed by a dedicated trained intensivist who is in-house during the day, available for answering pages within 5 minutes, and able to provide physician or physician extender presence within the requirement for intensivist coverage of all critically ill patients as recommended by the Leapfrog Group. Coupled with the increasing shortage of intensive care clinicians, the desire for ICU coverage by trained intensivists has led to an interest in remote systems that enable direction of patient care in remote ICUs. These kinds of systems allow for a central hospital or critical care physicians group to assume responsibility for patients who are cared for in a peripheral ICU. There are reports of improved clinical outcomes, including mortality and length of stay, while caring for a higher-severity population of patients (35). Breslow et al. (36) described their experience with a remote ICU that was involved in the care of patients in two adult ICUs and provided 19 hr/d of monitoring by physicians and physician extenders. During the period of remote ICU work, they observed a reduction in ICU mortality, a decreased length of stay, and cost reduction, which more than compensated for the costs of the system; the effectiveness of this technology has been shown (37,38).

Vespa et al. (39) used a robotic tele-presence system to respond to nursing pages in a neuro-ICU. They showed that during the use of the robot system, the time for an attending face-to-face response to nursing page was significantly decreased for all types of calls. More than that, they had a decrease in the length of stay of 2 days for patients with subarachnoid hemorrhage (SAH) and 1 day for patients with head trauma. ICU occupancy increased by 11%, with a substantial cost savings.

Tang et al. (40,41) described their experience with a remote ICU with respect to physician and nurse work flow. They found that the clinical team providing remote support used most of the time for monitoring and integration of monitored data. There were many interruptions during the routine work due to the need for observing or dealing with an unstable patient or due to a request for intervention from the local team. They also found that while physicians attended to specific problems that were primarily self-initiated, the nurses were alerted by automatic alarms in 80% of the cases. Also, nurses were required to spend a significant portion of their time recording bedside notes into the remote ICU chart. They conclude that when implementing these technologies, the different work flows of physicians and nurses have to be considered.

In a survey of critical care organizations in the United States, Pastores et al. (42) noted that 14% of hospitals surveyed had coverage by telemedicine.

RISKS OF COMPUTERIZED SYSTEMS

Dangers of IT implementation in critical care may be due to several factors (43). There may be complaints regarding increased workload, required changes in clinical work flow, persistence of paper components, and some emotional issues and problems with communications. There may also be issues related to blind dependence on the computer, so that if a default dose of drug was incorrectly customized into the drug database, clinicians might not be aware and prescribe the inappropriate dose. This has led to the creation of the term “e-Iatrogenesis” (44).

Han et al. (45) published a worrisome report of an increase in mortality—from 2.8% to 6.6%—in a pediatric ICU following the implementation of CPOE. This may have been due to problems with the integration of pharmacy and clinical work flow into the system using the CPOE. For example, drugs could not be provided even in extreme situations unless prescribed through the CPOE. Other investigators have not found this phenomenon (46); in fact, a group from Seattle found a reduction in mortality as well as in risk-adjusted mortality, although these effects were not statistically significant. Keene et al. (47) also did not find an increase in mortality after implementing CPOE in a pediatric ICU.

When describing the future of critical care—ICU2020, Bauman and Hyzy (48) describe different applications of computers in critical care which have been delineated above—the use of computers to enable checklists, to reduce drug prescription errors, to promote adherence to guidelines and protocols, and to generate patient-specific and procedure-specific alerts are all capabilities by which the computerized system can improve the safety and quality of the care delivered in the ICU.

RETURN ON INVESTMENT

A significant question raised when considering the purchase and implementation of a computerized system is that of cost. These systems are not inexpensive, and thus their economic utility needs to be analyzed. On the one hand, costs of the system include not only the hardware and software of a system, but also the burden of time invested in customizing the system, training of personnel, and the maintenance required. It is unrealistic to expect a computerized system to run perfectly “right out of the box.” To achieve optimal results, a local “champion” of the system must be identified and appointed, with involvement of all components of the ICU team in the process. On the hospital level, when implementing a computerized system, pertinent management officials and IT quality and risk management should all take part in the assessment, customization, and follow-up.

The potential financial rewards of a computerized system (Table 9.2) range from an improvement in standardization of care, which may lead to better clinical outcomes, to a reduction in errors and adverse events, with a consequent decrease in malpractice litigation. Moreover, the ability to defend against malpractice claims may be improved with an accurate record that is easily retrievable, and therefore, should lead to improved risk management activities. Smaller but not inconsequential cost savings may be due to the lower cost of archiving computerized records versus paper charts. Additionally, adherence to protocols that suggest use of more cost-effective procedures can decrease the use of unnecessary more expensive drugs.

TABLE 9.2 Potential Cost Savings with Computerized Records

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