August 26, 2008
Pattern Recognition and CPOE
We’ve done several previous columns which have focused on the importance of pattern recognition in influencing the thinking of physicians and other healthcare workers (see Patient Safety Tips of the Week for May 27, 2008 and August 12, 2008).
The transition to computerized physician order entry (CPOE) has often been particularly difficult for pharmacists. From our discussions with them, it’s apparent that one of the key reasons is the loss of pattern recognition that often occurs with CPOE. Previously, pharmacists would either see the whole patient chart or would get a faxed copy of the admission orders. Now, with CPOE, they may simply get several order strings for individual medications.
Consider the following set of admission orders:
· Admit to Medicine A (Attending: Dr. C)
· Diagnosis: pneumonia
· Condition: fair (CAP Risk Class IV)
· Activity: Out of bed to chair 3 times daily with assistance.
· Fall precautions
· Vital signs and pulse oximetry every 4 hours.
· Call house officer for respiratory rate greater than 20 or O2 saturation less than 88%.
· Strict Intake and Output monitoring.
· Daily weight
· Diet: 1800-calorie ADA diet
· Allergies: latex (contact allergy), no other known drug allergies
· O2 via nasal cannula at 2 liters/minute
· Heparin 5000 units subcutaneously every 8 hours
· Metformin 1000 mg. by mouth twice daily
· Lisinopril 10 mg. by mouth daily
· Lipitor 20 mg. by mouth daily
· Influenza and pneumonia vaccinations as per protocol
· IV’s: ½ normal saline with 10 mEq. KCl at 100 cc. per hour
· Ceftriaxone 1 gram IV every 24 hours
· Levofloxacin 500 mg. IV every 24 hours
· Labs: blood glucose today at 9 PM; blood glucose, lytes, creatinine, CBC & diff in AM
· If patient has not voided by 8 PM, straight cath and record volume. Send specimen to lab for routine U/A and Legionella and pneumococcal antigens
· PT consult: ambulation evaluation
· Advanced directives: copy of Health Care Proxy in chart
This single page of orders conveys an incredible amount of information and provides a “snapshot” of the patient. You can see the patient is a diabetic admitted because of pneumonia. But there is far more information in the “pattern” recognized. They convey the image of a patient with a certain amount of frailty. The physician put him on fall precautions. Perhaps he has a diabetic neuropathy causing ataxia or a diabetic autonomic neuropathy causing orthostatic hypotension. The pharmacist then recognizes to be alert for drugs that might further increase the patient’s fall risk. The physician was also concerned enough about the patient’s ambulation that she ordered a physical therapy evaluation. Sounds like he might be headed for a prolonged length of stay or maybe a trip to a subacute unit. Better keep an eye on the antibiotic duration – he might be a candidate for a C. difficile nosocomial infection.
And he’s on an ACE inhibitor. Don’t know if that is for hypertension or CHF or for diabetic nephropathy but better pay attention to his renal function to see if any medication dosage adjustments will be needed. And the metformin could be risky if he has renal dysfunction. Will have to monitor his IV fluids and I&O’s, too. And may need to hold the metformin if he needs a radiology study with contrast.
And he needs to be straight-cathed if he hasn’t voided by 8 PM. Wonder if he has a diabetic neurogenic bladder or BPH. He could get a drug-resistant UTI if he needs a Foley. Better get his pneumonia antibiotics focused on a specific pathogen as soon as possible so we can get him off those broad spectrum antibiotics.
Looks like Dr. C remembered DVT prophylaxis and the screen for flu and pneumonia vaccinations. Better check on that vaccination status in a couple days. And he’s on subcutaneous heparin prophylaxis. Better check the old records to see if he had any heparin exposure in the past 100 days – that might require more frequent platelet count monitoring for “HIT”.
Don’t see an order for aspirin. Wonder if that’s an oversight in this diabetic patient with other CAD risk factors or whether Dr. C thought there is a contraindication. Will look for aspirin in the old chart and call Dr. C to discuss.
So you can see that seeing the whole order set is a lot different than seeing isolated orders for metformin, lisinopril, Lipitor, IV fluids, and the antibiotics!
Note that the same loss of pattern recognition may affect nurses and physicians to a lesser extent. Nurses used to take off all the physician orders so they had the opportunity to see that “patient snapshot”. Now the medication orders go directly to the pharmacy, PT orders to the therapy department, etc. and nursing may only see the nursing orders. Nurses often tell us that the admission orders plus the “face sheet” tell them much more than the admission H&P does!
So how do we deal with this lost opportunity to use pattern recognition? We need some way to restore that patient “snapshot”. One way is by customizing the computer screens for pharmacists and nurses, much the same way we allow physicians to customize the screen layouts to their liking. Most CPOE screens have the patient name, date of birth, other identifiers, room number, physician name or name of service, and allergies listed at the top of each screen. But the view can be customized to show select laboratory data, a problem list (though you’d be surprised at the difficulties generating and maintaining good working problem lists!), and a full medication list. You can also show select data relevant to a specific order. For example, when a physician orders digoxin, we show him/her a popup screen with the most recent K+ level, creatinine or GFR, and any recent digoxin levels. No reason we can’t popup that same screen for the pharmacist when he/she opens that order for digoxin.
But neither of those solutions provides all the things we saw when the full admission order set was visible. Therefore, ensuring that anyone can get a printout (yes, even a “paperless” facility can use paper sometimes!) or full screenshot of the full admission orders is advisable. The key point is that you need to work with your end-users when you are planning your CPOE rollout to find out what is important to them.