Hospital Heeds Doctors, Suspends Use of Software
Cedars-Sinai Medical Center, the largest private hospital in the West, is suspending use of a multimillion-dollar computerized system for doctors’ orders after hundreds of physicians complained that it was endangering patient safety and required too much work.
Ironically, the computer software was designed to do the opposite: Reduce medical errors, allow doctors to track orders electronically, and warn them about dangerous drug interactions and redundant laboratory work.
But, from the start of its rollout in October, the Patient Care Expert program, dubbed PCX, has been plagued with problems, many doctors said.
“The PCX system is presenting too many safety issues in the care of our patients,” said cardiologist Dr. Mark Urman. “The only logical, prudent and safe thing to do is to put it on hold until it can be made better.”
The uproar is a case study in what can happen as hospitals belatedly modernize record-keeping on a large scale. Years behind other industries, many hospitals are on the cusp of converting from paper to electronic ordering systems to increase efficiency and accuracy.
Interest in computerized physician-order entry software accelerated in 1999 after the influential Institute of Medicine concluded that up to 98,000 patients die annually in hospitals from avoidable medical errors. Large employers, working through a coalition called the Leapfrog Group, began pressuring hospitals to install electronic ordering systems.
A 2000 California law requires hospitals to implement formal plans, including new technologies, to eliminate or substantially reduce medication-related errors by Jan. 1, 2005.
Hospitals and experts are watching Cedars-Sinai because it has developed a customized system they may want to emulate or purchase. Most hospitals buy a commercially available product, but Cedars-Sinai decided to create its own, following the example of other major hospitals such as Brigham and Women’s Hospital in Boston and Latter-Day Saints Hospital in Salt Lake City.
Several doctors said they had been told that Cedars-Sinai spent $34 million on the electronic order system, but hospital officials said that estimate was too high. They declined to provide a precise figure.
This week, Cedars-Sinai suspended the ordering system after more than 400 physicians confronted hospital administrators at a tense staff meeting Friday. The doctors voted nearly unanimously to urge the hospital to halt the system until the problems are fixed.
More than a dozen Cedars-Sinai physicians interviewed by The Times said they experienced problems ordering medication, tests and supplies using the PCX software. One patient with heart failure did not receive the pills his physician ordered until he mentioned it to a nurse. Another patient did not receive a walker until three days after it was ordered. A baby was given local anesthetic for a circumcision one day early.
Similar stories of delays and inconvenience abound, although none involved deaths or permanent injuries, doctors said.
Officials at Cedars-Sinai said they do not believe the computer order system, which covers patients in the hospital but not outpatients, posed a threat to safety. Rather, hospital leaders said, PCX was not easy enough to use and it took too long to enter orders.
“We thought it would be best for the ultimate success of the project to take a hiatus,” said Cedars-Sinai President and Chief Executive Thomas M. Priselac.
The suspension of the order-entry software does not affect other computer systems at the hospital, including electronic laboratory reports, admission and discharge summaries, consultations, and medical records for patients in intensive care.
Chief of Staff Dr. Michael Shabot said the hospital does not have a timeline for when the PCX system will go back online.
The concept behind PCX and similar programs is simple: Instead of writing orders for medications, lab tests, therapy and dietary restrictions on paper, physicians put them into a computer system.
The software compares the orders to standard dosing recommendations, checks for allergies and drug interactions, and alerts physicians to alternatives or potential problems. It has been shown to reduce medication errors by 60% to 80%, and to cut the number of lost orders.
But Dr. Stephen Uman, an infectious disease expert, said that although it used to take him five seconds to write an order for the powerful antibiotic Vancomycin, it now takes him up two minutes to log on to PCX, select his patient’s record, search through several screens and warnings about Vancomycin, and then justify his decision to protect against overuse of the drug. He then has to reenter his password to confirm the order.
Uman said he can have 15 to 20 patients in the hospital at any given time. “If I have to add five to 10 minutes to each patient, that adds hours to my day,” he said. “That’s time that I either can’t read, I can’t be with my family, or I can’t be with my patients.
“We’ve been told that that’s the cost of practicing at Cedars-Sinai,” said Uman, a former hospital chief of staff who has organized doctors seeking changes to PCX.
Dr. Jack Coburn, a nephrologist at Cedars, said the system’s complexity has caused doctors to delay writing orders or to enter them imprecisely.
“I know that we’re doing things much less efficiently because it’s so inefficient. It’s so slow and so frustrating,” he said.
Those who support PCX said it is a work in progress. “This is just two curves crossing,” said Dr. Scott Karlan, a surgeon at Cedars-Sinai. “The curve reflecting discontent is going to drop steadily as the software developers make it more user-friendly.”
The complexity of this change “is enormous,” said Jane Metzger, research director for First Consulting Group, which evaluates computer physician-order systems. “It is not uncommon for there to be delays and midcourse corrections.”
Dr. Donald Nortman, a nephrologist, said he hopes Cedars-Sinai’s corrections will address physicians’ concerns.
“In science and in medicine, we don’t change to new treatment systems until the new system has been shown to be as good as the old system, and better in some ways,” he said. “It’s the overwhelming perception of people using it that this system is worse.”
Times staff writer Peter Hong contributed to this report.