This study confirms the premise that POE can be an effective tool for the delivery of health care. Previous studies have simultaneously compared nursing units with and without POE or, in some cases, established a baseline prior to implementation.8,9
We have compared the effects of POE before and after implementation on the same nursing unit and thus compared similar patient populations. Although there has been speculation as to the combined effects of POE and eMAR, this is the first report that demonstrates them.
Despite the major cultural change and introduction of new technologies, we did not experience any significant negative results from implementation. In fact, work flow accuracy and efficiency were actually enhanced in many instances (Figures 1 to 3). The observed increase in cost or length of stay in specific services is being further investigated. Potential variables that may influence the successful outcome of POE implementation include technical system design, extent of education and training, diversity of the patient population, clinician users, and method of POE deployment.
The accurate administration of medication requires the completion of four interdependent steps—order placement by the physician, transcription by the nurse, verification and dispensing by the pharmacy, and administration by the nurse.1,16
Errors introduced at any step of the process can be unwittingly transmitted to the next step. The percentage of medication errors occurring in the four stages of the medication process have been categorized: Physician ordering constitutes 39 to 49 percent of the reported errors, nursing administration 26 to 38 percent, medication transcription 11 to 12 percent, and pharmacy verification and dispensing 11 to 14 percent.1,16
Physician order entry affects physician ordering and pharmacy verification and dispensing by the decision support tools incorporated into the ordering process and the subsequent clarity of the printed order. The eMAR addresses the nursing transcription phase of the medication cycle.
The combined effects of POE and eMAR in our system account for improvements in all phases of the medication cycle, including ordering, nursing transcription, pharmacy verification, and dispensing and administration. In addition, the incorporation of clinical decision support tools in our system, such as screening for drug allergies and drug–drug interactions, reduces error reduction and prevents adverse events.
The implementation of an integrated online MAR with POE led to complete elimination of nursing transcription errors, while POE with manual medication charting resulted in a transcription error rate of 11.3 percent (Figure 4). The implementation of POE greatly decreases but does not eliminate order transcription. If left as a paper process, the MAR still requires order transcription. When online eMAR and POE are integrated, the need for order transcription is eliminated. Thus, the entire process of entering, communicating, transcribing, and documenting the order becomes electronic. Total elimination of transcription leaves little room for errors associated with interpretation and translation. In this study, unlike other studies, we examined the effects on nursing transcription and administration errors associated with the implementation of online eMAR integrated with POE.
In our study, the time that it took for an order to be communicated to pharmacy was significantly reduced by POE, from 3:57 to 0:33 hr (Figure 1left). We expected to see increased efficiency at this stage in the process, since the multiple steps required by manual medication ordering and subsequent delivery of the paper order to pharmacy are eliminated with POE. The medication order verification and dispensing process in pharmacy obviously remains manual, providing an opportunity for error. Unexpectedly, we discovered that POE also shortened the dispensing-to-administration phase of the medication cycle, from 3 hr 16 min pre-POE to 1 hr 22 min post-POE (Figure 1right).
In retrospect, we think that POE provided the tools for timely and accurate patient care. The nursing work lists, nursing order notification displays, and the eMAR served to provide a heightened awareness among the nursing staff of the need for timely medication administration. The use of POE also increased nursing expectations for drug delivery, as the orders were immediately visible to nurses.
Academic medical centers have a wide diversity of caregivers—such as registered nurses, medical students, physician assistants, and other licensed clinicians—who have varied and limited order-writing authority. Countersignature of such orders is a significant issue, particularly from the perspective of regulatory requirements, such as those of JCAHO. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) reports that as many as 25 percent of reported errors arise from confusion over the similarity of drug names. This can be especially true with verbal orders. The NCC MERP has a number of initiatives and recommendations to reduce medication errors associated with verbal orders. Two of their recommendations involving verbal orders are that verbal orders should be written and signed by the individual receiving the order and should also identify the prescribing physician and that verbal orders should be documented with the patient’s medical record and should be reviewed and countersigned by the prescriber as soon as possible.17
Physician order entry records the name of the ordering physician and the user taking the verbal order electronically, fulfilling the first requirement. It promotes heightened awareness by providing built-in reminders to the physician when orders remain to be countersigned and also prevents the physicians from writing a discharge order if there are orders that remain to be countersigned. Statistically significant improvements in the physician countersignature rates of verbal and telephone orders at both OSUH and the James were noted following implementation of POE. A higher degree of compliance was seen at the James both pre-POE and post-POE, because of a large number of chemotherapy orders. The mandatory countersignature of chemotherapy orders is of particular importance because of the greater risks involved in the administration of cytotoxic agents. This has created a culture of compliance at the James, which explains the different improvement rates between the OSUH (43.1 percent) and the James (26.15 percent).
Previous studies have reported that up to 30 percent of all hospitalized patients experienced delays in their care, with the average length of the delay being 2.9 days. This represents 17 percent of all hospital days. The delays are attributable to delays in decision making by physicians while they wait for results, in the scheduling of diagnostic tests, and in discharge planning.18
In addition, delays in therapeutic or prophylactic administration of antibiotics have a major effect on clinical outcomes. For example, the timing of prophylactic antibiotics for abdominal or cardiothoracic surgery within a narrow window has a significant effect on the incidence of postoperative infection, length of stay, and cost.19,20
Patient outcomes can be significantly enhanced by greater timeliness of care if physicians have access to critical laboratory results, showing that information technologies that facilitate the transmission of important patient data can potentially improve the quality of care.21
Following the implementation of POE, we demonstrated reductions in the time between the order and administration of the medication, the time for completion of radiology procedures, and the time for reporting the results of laboratory tests. Despite the improvement we were unable to demonstrate a consistent effect on length of stay or cost.
Because of a number of limitations, the benefits outlined above may not be generalizable to other institutions. Variations in POE applications may contribute to difficulty in data comparison across different institutions. Because of the nature of our studies, pre-POE data collection of all required data points was resource intensive with respect to time and personnel. This resulted in smaller sample sizes, especially in the radiology turn-around time study. Pharmacy and radiology turn-around time studies were done on one nursing unit and would need to be repeated in other areas.
We recognize that length of stay and cost are affected by a number of variables, including patient acuity, seasonal variations, and clinical environment. Case mix index adjustment of both length of stay and total cost should correct for patient acuity variations, and the length of the study comparison (10 to 12 mo) should minimize seasonal variations.
The initial positive effects observed immediately following the implementation of POE can be viewed as the first-stage benefits. Our objective was to move toward the Institute of Medicine goals for patient care quality and safety. The data indeed demonstrate that the introduction of POE with eMAR improved health care in a manner that was safe and timely.
The broad approach to this study was favored over an in-depth analysis, to allow the institution to validate the promise of POE. The sharing of this information not only facilitated our continued deployment but also resulted in increased acceptance by our clinical users. These methods are repeatable and could serve as benchmarks for any institution embarking on this initiative.
It is important to note that physician order entry provides a historical record for ease of analysis and long-term observation of trends. Although we used the data to assess the process of care in this study, it is equally applicable to disease management.
The immediate benefits of POE are abundantly clear. We are at the beginning of appreciating the long-term benefits of POE with the power and tools available to us to facilitate clinical practice changes. We see POE as an integral application for us to facilitate continuous quality improvement by decision support mechanisms and to monitor effects and compliance.