Only 5% to 15% of all healthcare facilities now have electronic record systems, according to Dr. Paul Tang, chair of the Institute of Medicine (IOM) panel commissioned to study this problem and chief medical information officer for the Palo Alto Medical Foundation. Furthermore, a patient’s various health providers often use electronic record systems that are incompatible and therefore cannot communicate. The lack of data standards continues to be a key obstacle to the implementation of an electronic medical records system designed to provide the most complete and up-to-date information to the healthcare provider, and to further assist providers in reducing errors and improving care.

Although it is widely agreed that a properly designed and implemented medical information system would improve patient care, hospital departments, physician offices and other providers have hesitated to invest in such systems. Oftentimes, these data systems are incompatible with the organization’s current medical record systems, leading to further difficulties in exchanging important patient information with local pharmacies, other hospital systems and physicians.

The Society of Critical Care Medicine (SCCM) continues its work in developing solutions to address these complex challenges.

Medication Errors on the Rise
The number of medication errors in U.S. hospitals increased by 82% in 2002, according to a report produced by U.S. Pharmacopeia. The report findings explain that hospital staff members detect many medication errors before patients receive treatment and that most of the errors did not have a serious impact on patients. According to the report, patients 65 and older were twice as likely to experience injury from a medication error than those in other age groups in 2002. In addition, about 10% of medication errors occurred because of errors in computerized order entry and approximately 17% occurred because hospital staff members failed to adhere to protocols.

Nancy Stonis, SCCM’s director of program development and project coordinator for the Society’s ICU Safety Reporting System (ICUSRS), states that “the large upsurge in medication errors found in the report could be due to better internal reporting procedures at the hospitals and a change in culture at those facilities that encourages the reporting of such errors. This type of change in reporting behavior is exactly what we need; identifying where the errors occur is the first step in designing systems to ensure they don’t occur again.”

Two years ago, the Society in partnership with The Johns Hopkins University School of Medicine, launched the innovative ICUSRS program to improve ICU safety. Its goal is to present an alternative method for reporting adverse events and near misses over the traditional mandatory incident report. The hypothesis was that people would feel safe and comfortable reporting to a system that was anonymous, confidential and focused on addressing system failures not blaming individuals.

Currently, 23 ICUs participate in the study, with over 1488 report submissions to date. Most of the incidents the ICUSRS Team analyzes involve two or more system factors, supporting previous evidence regarding the negative impact of complex work structures on safety. The finding that many medication events started outside the ICU, and that 65% of incidents reported were caused by poor communication, further illustrates the need for interactive and interconnected medical information systems. (See Page 5 in the February issue of Critical Connections to learn more about ICUSRS and patient safety.)

Some patient safety groups advocate barcode systems that match the patient to the prescription to reduce medication errors. The Leapfrog Group, a coalition of large employers, supports the use of computerized physician order entry (CPOE) systems that allow providers to access patients’ medical records and information about potential adverse drug events.

CPOE/CPOF Systems Help Reduce Errors
The Society’s Coalition for Critical Care Excellence has placed an emphasis on the assumption that CPOE and computerized physician order fulfillment (CPOF) systems will reduce medical errors, improve quality of care and reduce costs in the ICU. Although preventable medical errors occur throughout the healthcare delivery system, it is generally accepted that the negative impact of errors is greatest in patients with life-threatening conditions. Because the most seriously ill patients are cared for in the ICU, it is reasonable to conclude that a properly designed and implemented CPOE/CPOF system in the ICU would result in error reduction and improved outcomes.

Significant efforts are underway throughout hospitals nationwide to develop and implement hospital-wide CPOE/CPOF systems. Understandably, these systems are primarily developed for the general outpatient and inpatient hospital areas. However, the ICU presents challenges unique to critical care. Consequently, a CPOE/CPOF system that can accommodate such complexities should be fully integrated in the ICU.

Two documents outlining CPOE and CPOF implementation in ICUs are available from the Society. Developed by the Coalition, “CPOE System Requirements for Intensive Care Unit Use” describes the essential elements for a CPOE system to be functional in the ICU. A subsequent document, “CPOF System Requirements for Intensive Care Unit Use,” addresses ways to document the status, execution, and completion of all patient orders. Companies responsible for developing these systems and administrators considering purchasing and implementing CPOE systems will find these documents valuable. Access both documents (CPOE and CPOF) on SCCM’s Web site.

In addition, the American College of Critical Care Medicine’s (ACCM) theme to this year’s Town Hall Meeting, held at SCCM’s Congress, is “Computerized Physician Order Entry (CPOE): Achievements and Challenges.” Learn from critical care colleagues about the successful implementation of and challenges associated with CPOE.

IOM Report Urges Creation of National Electronic System

While much emphasis has been placed on single systems such as CPOE and CPOF, the IOM reported in November 2003 that U.S. hospitals and other health providers should adopt a standardized, interactive, interconnected, electronic records system that would reduce medical errors. The first step to accomplishing the “health information infrastructure” recommended by IOM’s 16-member panel requires health providers to voluntarily begin using electronic medical records that contain access to patient information from all providers and alerts to possible adverse drug reactions.

The report recommends that use of such systems and participation in a nationwide system defined by government standards is necessary for providers to receive reimbursements from programs such as Medicare. The federal government would set technical standards for the exchange of medical information, clarify which types of “decision support” systems would assist health providers in treatment, create definitions of medical errors, and instruct hospitals on how to collect, analyze and distribute error data and solutions. Although the plan would give the federal government an unprecedented role in medicine, IOM’s report describes the network as a “public-private partnership” that would lead to a large, “more seamless” structure for disease surveillance and patient treatment.

SCCM Hosts Technology Expert Roundtable

In the spirit of the IOM report and in further demonstration of SCCM’s commitment to ICU technology solutions, the Society recently hosted a groundbreaking technology meeting. Computers in the ICU: An Expert Roundtable was an innovative, invitation-only meeting of physicians, nurses, hospital administrators, hospital information officers, and information systems vendors during which frank, open and challenging dialog occurred among all parties involved in the implementation of ICU information systems.

The three-day meeting was organized and led by SCCM Members Mitchell M. Levy MD, FCCM and William J. Sibbald, MD, FCCM, FRCPC, CHE and was made possible through the generous support of Clinicomp Intl., Journal of Critical Care (JCC) and Seimens.

The meeting allowed users and vendors of ICU computer systems to present their current uses, future needs and desired capabilities in an interactive setting. Highlighted topics included a retrospective of computers in the ICU, the impact of information technology on various ICU team members, relational databases, and computerized physician order entry (CPOE) systems. Expert speakers delivered information about their experiences and entertained questions, suggestions and criticism from the attendees.

The key messages from the conference included the value of computerization to research, patient safety and outcomes, staffing, and organization within the ICU. The results of the meeting will be published in the Journal of Critical Care. An executive summary is also planned for publication. In addition, a resource guide for SCCM members who may be considering computerizing their ICUs is planned for inclusion in an upcoming issue of Critical Connections.

The Society continues to advocate the integration of information technology into ICUs. These efforts will ultimately enhance patient care and serve as the basis for future SCCM policy development. Through interaction with government agencies, the results of these activities will be a health information infrastructure designed in part to ensure that patient safety efforts and the needs of ICU practitioners are fully met.