Using computerization to reduce medication errors

      USING COMPUTERIZATION TO REDUCE MEDICATION  ERRORS

INTRODUCTION
Changes occurring in Health care delivery and Medicine are the result of social, economical, technological, scientific forces that have evolved in the 21st century. Among the most significant changes are shift in disease patterns, advanced technology, increased consumer expectations and high costs of health care. These factors have redefined nursing practices to fit into the changing health delivery system. Thus, nursing profession is ‘accountable’ to the society. i.e., obliged to the laws regulating the professional activity. This ‘accountability’ is usually spelt out in “Patient Care Documents” established by hospital associations and medical associations or councils of every country (Suzanne, 2004). In addition, the nursing profession has defined its standards of accountability through a formal code of ethics.

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Patient’s perceptions of health care, particularly disagreements and researches of various kinds with medical professionals have caught the attention of every one since 1980s. These disagreements have turned often into legal complaints (Ellen Annandale 1998). These disagreements turned legal complaints lead to long medical litigations.

                                          PROBLEM ADDRESSED
USING COMPUTERIZATION TO REDUCE MEDICATION ERRORS

                                                                                                                                                                                    With increased patient awareness of the health care delivery situations, media flare up and public opinions, medical practice has become more accountable today and there is a radical departure from the traditional medical practice which draws upon the personal experiences, case studies and research of the physician and not the health care delivery system as a whole entity. Modern Science has bestowed Health care delivery system with excellent technological innovations. One such innovation is the Computerization of the entire health care delivery system. Computerization has contributed enormously towards the reduction of medical errors and the problems associated with such errors. This includes computerization of the medical records popularly known as the Electronic Medical Record System (EMR) in digital format, Electronic Prescriptions, Personal Digital Assistants, Computer automated cancer detection and Computerized theatre management applications.

                                    THE PROBLEM QUESTION
The PICO format is a convenient way to frame and design problem questions. As per PICO format the

Patients: The patients to be addressed are patients under all categories who will be benefited by computerization of medical procedures.
Intervention: Using computerization to reduce medical errors.
Comparison: The intervention will be compared with the current method of medical procedures in practice that contributes to or reduces medical errors.
Outcomes: The expected outcome of using computerization in medical procedures is to reduce medical errors of all kinds.
Based on the PICO format, the question of this paper is: Does using computers in medical procedures reduce medical errors?

      SEARCH STRATEGY

Absence of support structures for sustained evidence, lack of commitment to the process, insufficient evidence for too many problems do pose some challenges in the search for literature in computerization of medical procedures.. Hence, a search for systemic evidence was necessary for the care practice. Goggle with a wide range of academic materials was searched for current research article on the chosen care aspect. Cochrane was another source for extensive Journal search. Questia was another wonderful source where one could have access to the textbooks related to the problem. Journal of Advanced Nursing, International Psycho geriatrics, Nursing Standard, Western Journal of Nursing Research, Journal of Clinical Nursing were the journals, which had published articles on the chosen aspect and hence searched in detail for research. Medical Records – Frequently Asked Questions and US code of Federal Regulatons were valuable information sites.

  A REVIEW OF COMPUTERIZED MEDICAL PROCEDURES BASED ON

                                       PUBLISHED LITERATURE

ELECTRONIC MEDICAL RECORDS SYSTEMS
An  electronic medical record (EMR) is a medical record in digital format. Electronic medical record keeping facilitates access of patient data by physicians at any given location ,accurate  claims processing by insurance companies ,building automated checks for drug and allergy interactions,clinical notes and laboratory reports.The term electronic medical record can be expanded to include systems which keep track of other relevant medical information. Although an EMR system has the potential for invasion of  a patient’s medical privacy,EMRs can serve a great purpose when monitored effectively.

The Technology:

Five levels of an Electronic HealthCare Record (EHCR) keeping can be classified as follows;

1.The Automated Medical Record ,which is a paper-based record with some computer-generated documents. 2.The Computerized Medical Record (CMR), which makes the documents of level 1 electronically available. 3.The Electronic Medical Record (EMR) which restructures and optimizes the documents of the previous levels ensuring inter-operability of all documentation systems.4.The Electronic Patient Record (EPR) which is a patient-centered record with information from multiple institutions.5.The Electronic Health Record (EHR) adds general health-related information to the EPR that is not necessarily related to a disease. The development of standards for EMR interoperability is vital because of the fact that without interoperable EMRs, practicing physicians, pharmacies and health care institutions cannot share patient information, which is necessary for timely patient-centered care.There are many standards relating to specific operation of  EMRs in the USA and across the globe. These include “ASTM International continuity of care record ” in which patient health summary is based upon XML; “ANS1 X12”,which is a set of protocols used for transmitting any data including billing information; “CEN”,which is the European Standard for EMR; “DICOM”,A popular standard in radiology record keeping and “HL7” which is commonly used in clinical document architecture applications (Hallvard Lærum et.al.,2003)

There are many software programs specially developed for electronic record keeping. This includes ‘Doctors partner’, an advanced Electronic Medical Records (EMR) System with Integrated Appointment Scheduling Billing, Prescription Writer, Transcription Module, Document Management and Workflow Management built to meet HIPAA standards. ‘Practice Partner Patient Records’ is an award winning electronic medical records (EMR) system, allowing practices to store and retrieve patient charts electronically. There are innumerable such branded medical record soft wares available today (Ringold et.al.,2000)

The American Medical Association and 13 other medical groups representing 500,000 physicians have signaled their intention to go electronic with the AMA formed Physicians’ “Electronic Health Record Coalition” to recommend affordable, standards-based technology to their constituents. President Bush has also promoted a nationwide computerized medical records system in a recent visit to a children’s hospital at Vanderbilt University.

The documentation includes,

 1.Diagnosis and Treatment Report which very Health Care delivery center today provides to the patient on the details of the diagnosis of the disease with follow up instructions, the Medicine information and the allergy reactions that could follow; dietary restrictions, dos and don’ts, restrictions and exercises prescribed. They take an acknowledgement either from the patient or an authorized person after receiving the report. This documentation serves a key purpose in medical practice (Brennan et.al, 1991)

2.The Health Record which is the proper documentation of records of all treatments and medications, as well as a record of a patient’s reactions and behavior. The health record is the written and legal evidence of treatment. This reflects only facts and not the judgment of the doctor. Careful and accurate documentation is vital for patient welfare and that of the doctor. Documentation includes, medication administered, treatments done with date ; time, factual, objective and complete data, with no blank spaces left in charting, on flow sheets or on check lists, calls made to health care team, client’s response, signature of the nurse in every entry and consent for treatment. A private hospital in Milan, Italy, has been asked to handover for police verification of the medical records of at least twenty one cases who had heart valve surgery, following complaints that the surgeon replaced heart valves even in patients who did not need them replaced (Brennan et.al, 1991)

3. Informed Consent, which is a document, recorded before any terminally ill person receives his chemotherapy or an invasive procedure. The patient or his/her health attorney should give a well-documented informed consent before such procedures. Informed consent means that tests, treatments and medications have been explained to the person, as well as outcomes, possible complications and alternative procedures. Any medical hospital can be pushed into a center of a litigation storm after allegations without informed consent (Brennan et.al, 1991)

4.Medical Billing and Insurance, which are part of the health care system in USA.

The cost:

The National Academy of Sciences report states that the health care industry spent between $10 and $15 billion on information technology in 1996. Much of this expenditure is attributable to creating electronic records systems and converting conventionally stored data to electronic formats. The running cost of a medical record keeping in a hospital is proportional to the number of computer systems involved and the operators. A typical health care organization has a centrally controlled computer department, which maintains the entire medical records of all the patients. In large organizations, every department is connected by a local area administrator, LAN to a central terminus. To summarize, electronic medical record keeping does not add up any significant financial load on the health care institution and is very much part of the computerized office automation process like in any other organization. RED medic Inc., a California based firm have introduced a cheap online medical record service with an annual membership of about $35.The company Web site will collect, store and access everything ever wanted by health-care professionals to know about a patient’s medications, allergies, immunizations, conditions, doctors, emergency contacts and insurance providers. The system will store and transmit more complex information such as advance directives, EKGs and other essential medical documents and diagnostic imaging techniques. This health information service is capable of delivering information to any doctor or hospital, anytime, within the United States. Thus, Electronic Medical Record Keeping has reached a stage where high technology is available at an affordable cost.

                                ELECTRONIC PRESCRIPTIONS

Prescription error is a problem in current medical practice and the rate of error in prescriptions is significantly high. Communication has been cited as the single biggest block in such prescription errors leading to wrong reading by the pharmacist. Errors seem to be more in the dose of the medicines prescribed. Electronic prescription systems have been designed as a total remedy to this problem (Hallvard Lærum et.al, 2003).

                               PERSONAL DIGITAL ASSISTANTS

Personal Digital Assistants popularly known as PDA is literally a handheld computer that helps patient management. Using a PDA, a doctor can access a patient’s laboratory reports and refer the latest information on relevant therapies, tests and treatments. The PDA automatically can be used for billing and updating patient visits. The PDA can also provide map and directions to the patient’s homes. Using a PDA, a doctor can instantaneously transfer prescriptions to the patient’s pharmacy, answer patient e-mail, refer to medical textbooks, drug databases, and journals, and updates (Hallvard Lærum et.al.,2003).

                  COMPUTER AUTOMATED CANCER DETECTION

A ThinPrep Processor Model 2000 has been recently approved by the FDA for the automatic preparation of PAP slides making it easier for screening atypical cells in female patients suspected with cancer of the cervix. The ThinPrep system has been found to be especially effective for detecting low-grade squamous intraepithelial lesions known as SILs and severe lesions. The ThinPrep system provides for better detection of cancer cells (Heuther et.al, 2004). PAPNET, is another innovation that uses neural net computer technology, where, the computer provides guidelines for identifying abnormal cells from a series of digital images of PAP smears fed priori. AutoPap 300 QC is another Pap test re-screening system that uses image interproduction and pattern recognition techniques for identifying abnormal cells (Heuther et.al, 2004).

        COMPUTERIZED THEATRE MANAGEMENT APPLICATION

Use of applications like MEDITECH’s Theatre Management application helps anaesthesiologists, consultants, nurses, and other operating room personnel for scheduling theatre sessions, scheduling of patients and consultants, recording pre-operative and post-operative data, recording operating room reports and statistics and Tracking and scheduling theatre inventory and equipment. Such applications can be integrated with the Hospital Information Support System (HISS) and should conform to the National Health Service (NHS) standards (www.meditech.com).

Thus, there is an increase in the quality of patient care as the time and potential for errors associated with redundant data collection is virtually eliminated. MEDITECH’s Theatre Management application can automatically record   patient information like Demographic and financial data ,Visit history with dates, procedures, and performing and attending providers ,Care records with clinical highlights and patient status ,surgical data including proposed, type, actual, and severity and Risks stored for reference in the event of future surgical procedures. The most important aspect of such applications is that they facilitate the management of patient supplies with associated refill lists. The system helps to monitor and track the use of implant and surgical items utilized during operative procedures. It alerts purchasing agents when inventory stock is low and re-ordering is necessary. The application allows the theatre staff to create PICK lists which give full information on the necessary equipments and surgical instruments required in the operating theatre for a surgery specific to a surgeon or specialty. Such applications also alerts the care providers if there arises a need to fix or change a piece of equipment (www.meditech.com).

                                RESEARCH FOR BEST PRACTICE

Evidence based practice is the conscientious, explicit and judicious use of current best evidence in making decisions about the case of individual patients (Sackett, 1996). The practice of evidence-based practice is the integration of individual clinical expertise with the best available external clinical evidence from systemic research. Individual clinical expertise is the proficiency and judgment that nurses acquire through clinical experience and practice. External clinical evidence is the relevant patient centered clinical research from the science of medicine. This includes the accuracy and precision of diagnostic tests, prognostic markers, therapeutic, rehabilitative and preventive regimens. External evidence sometimes replaces previously accepted treatments by virtue of accuracy and safety. Evidence based practice takes patient’s perspective also into account.

     This question building process gives the idea on the most important question, the question which is encountered very often in practice and the question’s relevance very often in practice and the question’s relevance to the patient situation. Evidence based practice is probably best understood as a decision – making framework that facilitates complex decisions across different and sometimes conflicting groups. It involves considering research and other forms of evidence on a routine basis when making health care decisions. Such decisions include choice of treatment, tests or risk management for individual patients, as well as policy decisions for large groups and populations (Baum, 2003). At a broader level, evidence based practice works by providing a safe framework in which different groups can make tough decisions by safe guarding their concerns by a fair and scientifically sound process. Of course, the best evidences are based on the conviction that a systematic documenting of a large number of high quality RCTs (Randomized with Concealment, Double blended, complete follow-up, intention to treat analysis) gives the least biased estimate. Thus, this becomes level 1 evidence and recommendations based on level 1 evidence are Grade A. Various terminologies aid evidence based medical practice such as ‘Clinical practice guideline’ which assists practitioner and patient make decisions about appropriate health care and ‘Randomized controlled clinical trial’ where a group of patients is randomized into an experimental group and a control group. These groups are followed up for the variables and outcomes of interest.

            CONCLUSION
Changes in financial incentives and health care delivery structures are producing new threats to health care quality .The retributive measures for medical errors are cumbersome and expensive. Hence, there is a need for more accountable health delivery system, which will enable application of modern scientific approaches to careful patient care in a health care system. In this context, quality of the medical care depends on promotion of quality medical care by managed care organizations. There should be regulations, which will apply the principles of quality management and improvement. These regulations integrate knowledge from modern scientific fields with quality management.

In case of litigations on account of such medical errors, the court will decide based on the findings whether the treatment was given in the best interests of the patient. The Bolam test is used to determine the best interest standards, which confirms if a responsible body of medical opinion would affirm that the treatment was in the best interests. Rights for advance directives, doctrines such as informed consent have created a new dimension to medical litigations in USA, other Arabian and Asian countries. Greater public awareness of medical errors, loss of confidence in health care delivery system, technological advancement, increased expectations of medical care and reduced interest of the plaintiff in accepting compensations outside the preview of the jury due to higher compensation chances through jury (Brennan.T 2004) have further enhanced this process. On account of the above-discussed factors, there has been a departure from traditional approach to management of medical errors based on strong scientific evidence and Computerization of such medical procedures have contributed to reduction in medical errors.

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