The speed with which Middle East clients implement 100%Computerized Physician Order Entry (CPOE) is to be admired. Hamad Medical Corporation (HMC) implemented 100% CPOE and has set the benchmark for global enterprise electronic medical record deployments. With this achievement comes value for patients and the wider organization. This blog focuseson the value of CPOE extrapolated from research literature. Academic papers were reviewed for the impact of CPOE in healthcare environments. The results of these peer-reviewed papers were extrapolated out for the HMC Enterprise Clinical Information System (CIS).

Predicted value of Computerized Physician Order Entry (CPOE) at HMC over 15 months

• 3679 Adverse Drug Events prevented
• Saving due to reduction in preventable Adverse Drug Events USD 17 Million (QAR 64 Million)

Literature Review

Computerized physician order entry (CPOE) is the process of a medical professional entering medication orders or other physician instructions electronically instead of on paper charts. A primary benefit of CPOE is that it can help reduce errors related to poor handwriting or transcription of medication orders. While CPOE on its own has an impact on safety by ensuring legible orders, it is the addition of clinical decision support systems (CDSS) that drives the value of this functionality. This key component gives providers real-time support on a range of diagnosis and treatment related information as well as tools aimed at improving patient care. In addition, decision support may add rules to check for drug-drug interactions, allergies, medication contraindications, as well as renal- and weight-based dosing.

Cost of a Preventable Adverse Drug Event

The cost of a preventable Adverse Drug Event (pADE) is difficult to quantify in the region. In USD, in 2014, studies have suggested a pADE cost of between USD 3,408 (Classen 1997) and USD 6,931 (Bates et at) (Classen 1997 and Bates et al 1997 in Pan et al 2015) The Institute of Medicine estimates cost of an ADEs at USD 4,800.

Incidence of a preventable Adverse Drug Event

Lazarou et al (1998) conducted a meta-analysis of 39 qualifying studies. 153 studies dating between 1966-1996 were included in the initial sample. They reported an overall incidence of serious ADE of 6.7% (95% confidence interval, 5.2%-8.2%) and of fatal ADEs was 0.32% (95% CI, 0.23% - 0.41%) for hospitalized patients. Bates et al (1998) reported 10.7 ADEs per 1000 patient days. These figures are similar to those by Davies et al (2009) who reported 524 ADEs out of a population of 3695 patient episodes (14.7%). Half of these were deemed to be preventable ADEs.

Impact of CPOE

Ammenwerth et al (2008) found that of the 25 studies analyzing the effects of CPOE on medication error rate, 23 showed a significant relative risk reduction of 13% to 99%. Their conclusion was that electronic prescribing can reduce the risk for medication errors and ADE. Bates et al (1998) reported that Non-intercepted serious medication errors decreased 55% from 10.7 events per 1000 patient-days to 4.86 per 1000 patient-days (P=.01). The decline occurred for all stages of the medication-use process. Preventable ADEs declined 17% from 4.69 to 3.88 (P=.37), while non-intercepted potential ADEs declined 84% from 5.99 to 0.98 per 1000 patient days (P=.002).

For this blog I have taken a pragmatic approach to calculating incidence of pADEs and costs associated to an pADE in the Middle East.

We assume cost of an pADE to be USD 4,800 = QAR 17,500 (currency www.xe.com 21 August 2016)

Incidence of pADE in non-CPOE clinical environment is 10.7 events per 1000 patient-days

Incidence of pADE in CPOE environments is 4.86 per 1000 patient-days

Based on Bates et al (1998) this constitutes an absolute risk reduction of 55%

These figures are broadly in line with reviewed studies.

HMC Data

Hamad Medical Corporation currently manages 8 Hospitals across the State of Qatar and serves a population of over 2 million people. HMC have undertaken an ambitious implementation of a full suite of Cerner software with the first go-live in 2013. They have full CPOE in all inpatient environments and across the enterprise.

HMC Admission and Length of stay data was pulled in a report run on 22 August 2016

Average Length of Stay was 2.765 for period Q1 2015 – Q2 2016

Predicted Reduction in ADE’s was calculated as follows:

(Number of Admissions x Average LOS)/1000 x Number of Preventable ADEs x Percentage prevented

Predicted Value calculated as follows:

Predicted reduction in ADE’s x Average Cost per ADE

Analysis

Using the HMC admission data and incidence, cost and impact of ADEs based on our literature review we are able to extrapolate the predicted value of CPOE for Hamad Medical Corporation over the period 1 January 2015 to 31 June 2016 (Q1 2015 – Q2 2016)

As the implementation of 100% CPOE rolled out across the enterprise the number of admissions/quarter rose from 22 500 to 53 000.Using the equation and assumptions outlined above we calculated that the number of predicted prevented adverse drug events totaled 3670 equating to a predicted cost avoidance of QAR 64 Million (USD 17 Million).

If the academic assumptions supporting these calculations are close to reality this is will be a major return on investment for the organization.Even if we take a conservative position and accept only 25% of the impact, it still returns the possibility that 900 patients have avoided an adverse drug event due to 100% CPOE.Primum non nocere.

Acknowledgements

I wish to sincerely acknowledge the contribution of the following individuals:

• Dr Ali Al Sanousi, Executive Chief Medical Information Officer HMC for his encouragement and formal endorsement.
• Dr Colin Fincham, Chief Medical Officer Cerner Middle East

References

Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U (2008) The Effects of Electronic Prescibing on Medication Errors and Adverse Drug Events: A Systematic Review Journal of the American Informatics Association Vol 15 No 5 585-600

Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, Burdick E, Hickey M, Kleefield S, Shea B, Vander Vliet M, Seger DL (1998) Effect of computerized physician order entry and a team intervention on prevention of serious medication errors JAMA. 1998 Oct 21;280(15):1311-6.

Davies, E. C., Green, C. F., Taylor, S., Williamson, P. R., Mottram, D. R., & Pirmohamed, M. (2009). Adverse Drug Reactions in Hospital In-Patients: A Prospective Analysis of 3695 Patient-Episodes. PLoS ONE, 4(2), e4439. http://doi.org/10.1371/journal.pone.0004439

Lazarou J, Pomeranz BH, Corey PN. Incidence of Adverse Drug Reactions in Hospitalized Patients: A Meta-analysis of Prospective Studies. JAMA. 1998;279(15):1200-1205. doi:10.1001/jama.279.15.1200.

Pan J, Mays R, Kane-Gill S, Albert NM, Patel D, Stephens J, Rocha-Cunha C, Pulgar S (2015) Published Costs of Medication Errors leading to preventable adverse drug events in US hospitals ISPOR 20^th Annual Meeting May 18-20 2015 Abstract #PHP73