Hurricane Katrina Highlights Need for Electronic Medical Records Systems, But Do EMRs Improve Patient Safety?

In the wake of the Hurricane Katrina crisis, untold numbers of medical records may have been lost. Many evacuees forgot or misplaced their medications, and some do not remember the names of all their medications. With no access to previous medical records, the evacuees' doctors have no way of confirming medications, immunizations, test results, and other past history. The storm has led to increased demands for electronic hospital records.

In the event of another natural disaster or a large-scale terrorist attack, electronic medical records (EMRs) could allow health care professionals to access patients’ histories and avoid compromising patient safety. Many hope that in the future EMR systems will be used to create a nationwide network that allows quick access to the medical history of a patient, paperless prescriptions that may cut drug errors, and other features that would increase patient safety and clinical effectiveness.

While EMRs have the potential to improve patient care and save billions of dollars in health care costs, surprisingly few physicians have invested in the technology. According to a September 2005 report by the RAND Corporation, the delay is due to the initial cost of adopting computer systems. RAND estimates that $81 billion a year could be saved-$77 billion from improved efficiency and $4 billion from improved patient safety with medications.

But the transition from paper records to a highly connected electronic national network could take about 15 years at an expense of $98 billion for hospitals and $17 billion for physicians.[1]

Adverse Drug Events

Many have argued that one way EMRs and computerized hospital systems would cut health care costs is by reducing the number of adverse drug events (ADEs). Adverse drug events result in as many as 100,000 deaths per year; they account for about 40% of all hospital admissions and $2 billion of inpatient costs per year.

According to many studies, interventions like computerized physician order entry (CPOE) may reduce ADEs by as much as 25%. These projections have led to a widespread belief that CPOE and other electronic systems are essential factors in reducing the incidence of ADEs.[2]

Recently, however, concern has been raised over the potential risks EMRs may pose to patient safety. In a May 2005 article, Nebeker et al report that computerized medication systems that lack support for drug selection, monitoring, and dosage may actually result in higher rates of ADEs.[2] They reviewed the frequency and type of inpatient ADEs that occurred in a Veterans Administration (VA) hospital. The VA hospital system has implemented CPOE, bar code-
controlled medication delivery, a complete EMR system, automated drug-drug interaction checking, and computerized allergy tracking and alerting. More than 900 hospital admissions in a 20-week period were studied.[2]

During this period, there were 52 ADEs per every 100 inpatient admissions to the hospital. One-third of the admissions resulted in at least one ADE. For ADEs with at least one error, there was an average of 1.4 errors. There were more planning errors than execution errors. Errors occurred in ordering (61%), monitoring (25%), administration (13%), and dispensing (1%). No errors occurred during transcription.

Failure to provide prophylaxis for expected adverse drug reactions occurred frequently. For example, many of the errors were failure to prescribe an as-needed or routine bowel regimen for narcotics and failure to prescribe potassium with diuretics. Failure to start or complete adequate monitoring for common ADEs was another common error. Prescription of improper doses or inappropriate medications accounted for 40% of the errors.

While most of the ADEs were moderate, 9% resulted in serious harm to the patient. Of all of the ADEs, 22% resulted in additional monitoring and interventions, 32% in interventions alone, and 11% in monitoring alone. Only discontinuation or dose-adjusting of the offending drug was required in 27% of the ADEs. Importantly, 27% should have resulted in either additional monitoring or interventions but did not.

According to the medical record, 24% of the ADEs were not recognized. Only 1% of all ADEs were documented in the allergy or adverse drug reaction section of the medical record. In fact, medical residents often reported that they assumed documentation was necessary only for hypersensitivity reactions.

Many of the ADEs occurred from drug-drug interactions. Additive drug-drug interactions, where two or more drugs have similar physiologic effects, accounted for almost 40% of the ADEs. For example, cardiovascular and diuretic combinations resulted in 10 occurrences of hypotension. Drug-condition interactions accounted for another 30% of the ADEs. For example, beta-blockers may exacerbate congestive heart failure, or renal failure may increase a drug's effect.

The VA computerized interventions appear to have been effective in reducing error where it was intended to do so: transcription and bar code medication administrations. However, lack of decision support for drug selection, dosage, and monitoring resulted in many more errors in these stages. Annually, the 110-bed VA hospital expects 40 deaths from ADEs. The incidence density of 70 ADEs per 1,000 patient-days reported by Nebeker et al is 5 to 19 times higher than that reported in previous studies. This led the authors to conclude that CPOE systems that do not have decision-making support for drug selection, dosage, and monitoring may actually lead to higher rates of ADEs.[2]

Other researchers agree that highly computerized hospitals do not necessarily have lower rates of ADEs. For example, Koppel et al found that a widely used CPOE system facilitated 22 types of medication error risks in one hospital. Risk factors included, but were not limited to, fragmented CPOE displays that prevent a logical picture of patients’ medications, pharmacy inventory displays mistaken for dosage guidelines, and inflexible ordering formats generating wrong orders.[3]

Missed Opportunities

Researchers in this area report several missed opportunities for patient safety, including specific features that will improve safety. One is that bar code medication administration information on dosage and efficacy for insulin for diabetes or narcotics for pain could automatically input into computerized algorithms for medication titration. Another is that computerized records could better allow for complete ADE information to be recorded.

While a national network of computerized medical systems would have gone a long way to relieving some of the medical problems that developed in the wake of Katrina, the new types of errors that electronic medical systems appear to create cannot be ignored. When buying CPOE systems, clinicians and hospitals should not assume that generic systems will reduce ADE rates. Instead, they should consider specific features of computerized systems that would address the most worrisome aspects of the medication administration process in their hospital.

References:

1. Hillestad R, Bigelow J, Bower A, et al: Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Affairs 24(5):1103-1117, 2005.

2. Nebeker JR, Hoffman JM, Weir CR, et al: High rates of adverse drug events in a highly computerized hospital. Arch Intern Med 165:1111-1116, 2005.

3. Koppel R, Metlay JP, Cohen A, et al: Role of computerized physician order entry systems in facilitating medication errors. JAMA 293:1197-1203, 2005.