Case Study: Cincinnati Childrens Hospital

The first set of errors, in communications or coordination, can result if the system overwhelms a clinician with information. At Cincinnati Childrens, a doctor examining a patient picked up an abnormal heart rhythm. One way to get the heart back to normal is to use a medication called Adenosine, a drug that if not administered carefully could stop a patients heart. The doctor, who wanted a tiny dose—a fraction of a cubic centimeter—mistakenly wrote into the system a prescription for a dose 10 times stronger than what he had intended. The computer system has alert messages that flash on the screen when an overdose is suspected, but this doctor ignored the warnings.

The drug was administered, but luckily that patients body flushed the drug without suffering any harm. Dr. Craig Hallstrom, a physician at the hospital who tracked the unintended consequences of the patient care system, said one of the problems in this instance was that the system had too many alerts. Physicians were coming across warnings for allergies, drug interactions and other potential problems almost every time they ordered a drug. Before long, doctors become desensitized to the alerts.

Data entry and retrieval problems can result from something as simple as a poor screen design, such as those with "pick and click" interfaces that allow doctors to check boxes to order medications and tests.

These screens often cram too many options into too little space, making it easy for time-harried physicians to pick the wrong medicine or dosage. For instance, another Cincinnati Childrens doctor, when ordering a mild pain reliever, was given the choice to order the medication in pill or liquid form. The physician mistakenly hit "tablets" instead of "milliliters" when clicking off dosage options, ignored subsequent warnings to reconsider, and ended up prescribing 325 tablets of Tylenol to be administered to a child. The amount of Tylenol ordered was a potentially harmful dose, but was so out-of-bounds that a pharmacist easily caught the error.

"The only people who think [this is] easy are the people who havent done it," Johnson says.

The difficulties of electronic record-keeping and order-processing are so substantial that, to date, only 159 of 5,794 U.S. hospitals—around 2.7%—have live order entry systems that doctors use, according to KLAS Enterprises, a research company specializing in health-care information technology.

Yet early this year, ignoring the odds, President Bush won support from both Democrats and Republicans in Congress when he launched his own "moon shot" program: a call to create a national electronic health-records system within 10 years that would allow patients to own and share their medical information with hospitals and other health-care providers. He appointed a coordinator, Dr. David Brailer, and budgeted $150 million for research and development to get the job done.

Next Page: The project to unify record-keeping and exchange could cost as much as $1 trillion to install.

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