FDA evidence shows the downside of poorly implemented CPOE

This shouldn't surprise veterans of the health IT industry, but a review of FDA reports by the Huffington Post Investigative Fund shows that poorly implemented CPOE systems can lead to fatal medical errors.

In one instance, small type on a computer screen led to a patient suffering a heart attack from being administered 10 times the prescribed dosage of a drug. Another FDA report documents a serious software glitch that caused delays in treatment and potentially put hundreds of patients at risk. In all, the Investigative Fund says 237 health IT-related adverse events have been voluntarily reported to the FDA in the past two years, most of which were related to CPOE, clinical decision support or results reporting. Eighteen reports since December involve Cerner systems, and generally criticized poor design and user interfaces.

Dr. Jeffrey Shuren, director of the FDA's Center for Devices and Radiological Health, said in February that such safety concerns "may represent the tip of the iceberg." (Shuren has been mentioned this month in FierceMobileHealthcare for suggesting that the FDA could regulate some smartphone apps and in FierceHealthcare for rejecting a plan to fast-track approval of some radiotherapy devices.)

CPOE, of course, is one of the key requirements for earning federal EMR subsidies, based on the current CMS proposal for "meaningful use" of health IT. National health IT coordinator Dr. David Blumenthal says he hasn't seen any compelling reason to weaken the CPOE provisions, but acknowledges that his office is studying the issue.

Others don't mince their words. "Computers are strong medicine. Done well, they are wonderful; done poorly they can kill people," says Dr. Justin Starren, CMIO of Marshfield Clinic in Wisconsin. "Simply pushing CPOE as an unalloyed good has a great potential to negatively influence quality and increase cost," he adds.

For more:
- take a look at this Huffington Post Investigative Fund story
- read Dr. Pauline Chen's New York Times column about another unforeseen consequence of EMRs

Related Articles:
Study: Inconsistent records in CPOE systems cause medication errors
Study: CPOE can cut prescribing errors 57 percent

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