From the June 26, 2003 issue

Information is key to preventing medication errors. As demonstrated almost a decade ago, lack of information about patients or their prescribed medications contributes to over half of all serious, preventable adverse drug events (Leape LL, Bates DW, Cullen DJ et al. Systems analysis of adverse drug events. JAMA 1995; 274: 35-43).

Today, automated clinical decision-support systems are available to help bring the most crucial information to the attention of clinicians so they can provide the best care. For example, a physician who prescribes an antibiotic using an automated system with decision support may be alerted to the need for a dose adjustment based on the patient's most recent laboratory values. A pharmacist who enters an order for a diuretic into a pharmacy computer system that is integrated with the laboratory system may be alerted to a patient's low potassium level. Clearly, these systems help ensure that clinicians have the right information to make the right decisions. However, most systems cannot ensure that clinicians receive crucial information at the right time.

One of the limitations of most clinical decision-support systems is that the provision of crucial information occurs only when the clinician is actively engaged in their use. In that regard, their effectiveness is limited to an episodic encounter. For example, if a physician prescribes an antibiotic early in the day before a patient's lab results are available, he may not be alerted to an elevated creatinine level and the need for a dose adjustment until the next day, when he again logs into that patient's profile. What's needed is technology that brings this type of crucial information to the clinician as soon as a potential problem is detected.

That's exactly what a new line of clinical data-monitoring technology can do. For example, automated systems offered by Misys (Insight), VigiLanz (Dynamic Pharmacomonitoring), and Cerner (Discern Expert for Cerner Millennium and Classic systems), can "listen" to a wide variety of information sources across the organization, "watch" for specific problems that can be predefined by the organization, and "notify" clinicians of situations that may represent a risk to their patients as soon as this information becomes available.

The technology utilizes computer industry data-compatibility standards (HL7 compliant) to constantly communicate information from various hospital clinical departments' computer systems (e.g., radiology, laboratory, pharmacy, nutrition), tying it to the hospital's patient information database and proprietary software in a central system server. Each piece of data is then checked to see if a relationship exists among pre-established clinical rules to trigger an alert. If an imminent or existing adverse clinical or drug event is detected, the system sends a critical message via PDA, pager, cell phone, e-mail, or fax, to alert the appropriate clinician(s) to the problem.

These alert messages can be sent to a department or designated individuals (e.g., physicians, clinical pharmacists, nurses) as determined by the professional staff in each hospital. Notification can be provided in real time for situations deemed critical, or the system may allow for a specified time interval before notification while scanning to see if appropriate action has been taken.

The powerful impact of these clinical data-monitoring systems is clear. Hundreds of rules can be designed to alert clinicians immediately to safety issues such as elevated liver enzymes in a patient receiving a drug that is metabolized in the liver, an abnormal potassium level in a patient taking digoxin, a decreased platelet count in a patient receiving heparin, or signs that an allergic response or drug interaction may be occurring. The system could even alert staff about a patient with pneumonia who didn't receive the first dose of antibiotic within 8 hours of admission, or prompt a change in antibiotic for a patient on vancomycin with a culture and sensitivity report that doesn't support its continued use. The failure to act on these types of data in a timely fashion can have serious consequences for both patients and staff. A case in point from a hospital that uses this technology was the rapid notification of a positive acid-fast bacilli result, which led to the immediate isolation and treatment of the patient, and significantly reduced staff exposure to tuberculosis.

Arguably, most hospitals have a call system in place for these types of "panic" values or other acute situations. However, non-automated call systems are quite fallible and, too often, the appropriate clinician does not receive the information in a timely fashion. Also, meaningful changes in physiologic state due to disease or drug therapy may not be noticed quickly if staff relies on "panic" lab values. More often, health systems rely on nurses, pharmacists, and physicians to detect problems, each of whom must navigate through massive charts, large sets of daily lab results, and multiple computer systems to collect this information. Added to these challenges is the reality of staffing shortages and budget restraints that can stretch the organization to levels that threaten success with this labor-intensive process.

There's no question that automated decision-support systems can be successful in reducing the risk of medication errors. The key is making sure these systems provide timely advice that is tailored to the needs of each individual patient, and that the advice is provided unobtrusively to the clinician who is best able to fix the problem quickly. To this end, clinical data-monitoring technology represents a powerful tool to effectively manage the dynamically changing relationship between the patient's underlying physiologic state and corresponding medication orders. And its use is not limited to health systems where computerized prescribing is available and used. Working seamlessly to provide an early warning system in an environment that is chronically under stress, this technology may well result in vastly improved patient outcomes, and at a cost most hospitals would find affordable.(Installation costs approximate that of a bedside bar-code scanning system.) It's also likely that these systems will pay for themselves through savings realized by preventing adverse events and improving drug utilization and staff efficiency.

Surprisingly, most clinical staff we spoke with recently were not aware of this technology. To learn more, visit the vendor websites (e.g., www.cerner.com; www.misyshealthcare.com; and www.vigilanzcorp.com).