ZIFFPAGE TITLEFirst Databanks DB
Cincinnati Childrens team used a database from a company called First Databank that contains information on the properties of all drugs approved by the U.S. Food and Drug Administration, plus information on the characteristics of herbal and dietary supplements. Then it tied the database into an electronic list of the drugs the hospital uses, and added a homegrown program to make sure the doses doctors ordered were in line with their pediatric patients weight and age. That was the easy part.What took time and effort was setting the error warnings. Cincinnati Childrens recruited a team of doctors to figure out the trigger points for the alarms.The hospital has some 3,800 drugs listed in its system, with 470 considered potentially toxic. While a doctor might prescribe 20 milligrams of morphine to a terminal cancer patient in severe pain, a 20-milligram dose of the drug could be fatal to an infant. It took the hospital three to four months to check all of the drug possibilities. "Its quite onerous," says Johnson. Considering the effort, its somewhat ironic that the alerts were partly responsible for the incidents in which doctors mistakenly ordered the 325 tablets of Tylenol and the overdose of Adenosine. Granted, thats just two incidents out of 4.2 million drugs ordered since the system went live in 2002, but they forced the hospital to confront such unintended consequences head-on. For instance, Jacobs, who was the ICIS project leader, says it became clear early on that the system generated too many alerts. A poll of physicians found about 75% of the alerts were useless. Oncologists, for instance, didnt need to see a warning every time they ordered 20 milligrams of morphine. Since then, Jacobs and his team have been going through the program and simply suppressing those alerts they think extraneous. But in a follow-up poll, doctors said they still found 50% of the alerts useless. "Its well known that if you have too many alerts, people just dismiss them without reading," Johnson says. With that in mind, he explains, the team realized it needed to build "blocks" into the system that would not allow doctors to prescribe excessive doses of dangerous drugs. The hospital put blocks on 105 of its 470 toxic drugs. Today, if a doctor mistakenly tries to order a harmful dosagesay, 2 milligrams of the anesthetic Lidocaine for each kilogram of the patients weightthe system will not let the order go through. If the doctor really wants the drug, he has to call down to the pharmacy and explain why the dose is necessary. The measures appear to be working, but the hospital had to come up with its own metric for determining that. The reporting of errors and near-misses is voluntary in most hospitals. So Jacobs says Cincinnati Childrens began to track the use of drug antidotes as a measure of the systems success. By looking at the number of orders for Narcan, a morphine overdose medication, for instance, the hospital can back into a count of morphine medication errors. The hospital says there were eight Narcan orders in the six months leading to the launch of the system, but only one in the six months after it was deployed. Meanwhile, the team working on the ICIS computer interface redesigned the screen for ordering a drug. Where once a doctor had a pull-down menu to choose between administering a drug as a liquid or tablet, the physician now has to type in his preference. This eliminates "form errors. "Weve eliminated a lot of those form options because mistakes were made," says Gayle Lykowski, a registered nurse now working as a systems analyst in the information-systems department. But as hard as the staff worked to fill the gaps and get the system right, the hospital in some ways is just scratching the surface, Johnson believes. For instance, after a doctor prescribes a medication, the system sends the request to a printer in the pharmacy. The druggist takes the printout and rekeys the order into the pharmacys own inventory control system, called Worx. According to John Hingle, operations specialist in the department of pharmacy at Cincinnati Childrens, Siemens owns the proprietary code needed to integrate ICIS with outside pharmacy systems and does not share it. Siemens says it often shares code, but has not yet created software that will connect its application to the hospitals pharmacy system. Tying its systems together, especially as it tries to create a holistic view of patients in its care, is a challenge for Cincinnati Childrens. According to James, the hospital has a dozen systems. One system tracks cardiology patients, another tracks psychiatric patients, and yet another tracks cancer outpatients. In one case, the struggle to tie the Siemens-based ICIS to a GE critical-care notation system has delayed a long-standing plan to electronically document the care of critically ill patients. "Its tough sometimes to get [the vendors products] to work together," says James. In the critical-care units of Cincinnati Childrens, doctors and nurses use a large piece of paper called a flow sheet to track their patients progress. The document includes vital signs, readings of ventilator settings and details on the medications and liquids delivered to the patient. The single sheet allows clinicians to quickly determine the next course of treatment. A digital version of this would allow clinicians to view data in side-by-side graphs and also automatically chart data, so they can more quickly spot changes in patients health. Cincinnati Childrens chose to bring in GEs Centricity Acute Care package to keep track of vitals, medications and treatment because it felt the GE package could clearly present data such as the relationships between factors like medications and vital signs. Siemens was working to bolster its critical-care product, but Donald Rucker, a medical doctor and Siemens chief medical officer, admits the software had its "limits" when Cincinnati Childrens was making its decision in 2002. The challenge now is that while doctors will be planning care with the GE package, theyll still need access to the ICIS system to order painkillers, antibiotics and other medications. Next Page: Going with third-party software for linking systems.