A cold, hard look at the paperless medical practice

Computerized physician order entry (CPOE) systems and clinical decision support systems (CDSSs) got a rigorous review of their ability to improve clinical care in a recent issue of the Journal of the American Medical Association (3/9/05). While much of the recent literature heralds the promise of these information technologies, the two studies in JAMA provide cautionary data that help balance the reports of success.

In one study, "Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors," Koppel and colleagues found 22 situations in which a CPOE system used in an urban tertiary-care teaching hospital increased the likelihood that a medication error would occur. The situations cited were common, occurring repeatedly on a weekly basis or more.

The researchers found, for example, that the CPOE system studied actually increased the likelihood that a user would order the wrong drug or a duplicative or conflicting medication, because the system often requires the user to view up to 20 separate screens to see a list of one patient's medications. Additionally, the CPOE system provides feedback on patients' drug allergies only after a medication has been ordered; this delay may unintentionally shift responsibility for making drug-allergy checks from the physician to the pharmacist.

In the other JAMA study, "Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes: A Systematic Review," Garg and associates reviewed randomized and nonrandomized controlled trials that looked at the effect of CDSSs on clinical practice. The researchers found that 62 out of 97 trials (64%) showed that this technology improved practitioner performance. The improvement was seen in diagnosis, preventive care, disease management, drug dosing, or drug prescribing, and was associated with systems that automatically prompted users versus those that required users to activate them.

When it comes to patient outcomes, the news was not as favorable. Just seven out of 52 trials (13%) showed improved patient outcomes when using this technology. None of the studies reported benefits for outcomes such as mortality.

An editorial in the same issue noted that the primary challenge of CPOE systems and CDSSs is capturing the complexities of medicine. After all, as Wears and Berg noted in their editorial, "Computer Technology and Clinical Work: Still Waiting for Godot," these information technologies will not be productive unless they are tailored to the needs of health-care practitioners and their work processes.