Hospitals find new medication controls

Even though it would have been faster, Dr. David Osborne did not write an order for Ramos's emergency asthma medications. Instead, he logged on to a computer in the middle of the urgent care bay, and ordered Albuterol and Prednisone using software programmed to warn him if Ramos, 38, had dangerous drug allergies. A tiny box popped up: "No known allergies."

A dark red border immediately appeared around Ramos's electronic medical chart, alerting nurses to start the medications. In 30 minutes, if they have not done so, the border will turn purple -- a second alert, added after nurses were so busy last year they didn't see the initial order for a blood transfusion for a patient who later died. Now, anyone who sees a purple border tracks down the patient's nurse.

According to the hospital's own research, Brigham and Women's Computer Physician Order Entry system has reduced medication errors, such as overdoses and allergic reactions, by more than 80 percent.

Even so, just 5 percent of US hospitals have installed electronic drug-ordering systems. Brigham and Women's was one of the pioneers of electronic drug ordering 10 years ago.

But now, under increasing pressure from health plans and employers and growing evidence that the systems reduce patient deaths and injuries, more large hospitals are devoting millions of dollars to electronic safety systems. Partners HealthCare, the Brigham's parent organization and the largest hospital and doctor network in Massachusetts, plans to spend $30.5 million over five years to expand Computer Physician Order Entry to all its hospitals and electronic medical records to all its doctors.

Dr. James Mongan, Partners' chief executive, said the electronic systems are the cornerstone of all Partners' major initiatives, including improving patient safety and the quality of medical care at the hospitals. In a new four-year contract with Partners, Tufts Health Plan agreed to give the hospitals financial bonuses for meeting deadlines for installing the electronic systems.

Children's Hospital trustees voted in the summer to spend $35 million over three years to install similar systems throughout the hospital, where physicians now order only chemotherapy drugs electronically. Even hospitals that are losing money, such as Beth Israel Deaconess Medical Center and Tufts-New England Medical Center, are spending the millions of dollars required to install these sophisticated systems.

"I've been at this a long time," said Dr. Stephen Bohan, 60, clinical director of the Brigham emergency department. "If you rely on your memory for a patient's allergies or rely on the patient telling you, or on looking up a dangerous drug interaction in a book, it just doesn't happen. A computer doesn't forget. It's fail-safe."

While health care specialists believe these systems are proven to reduce dangerous errors, they have gaps. The reason the Brigham's system, one of the first and most sophisticated, does not catch all medication errors is that doctors and nurses sometimes forget to enter a patient's allergies into the system.

Or, they prescribe a dose that's fine for most patients but too high for a particularly sensitive patient.

Doctors have rebelled at some hospitals, most famously Cedars-Sinai Medical Center in Los Angeles. The hospital installed physician order entry in the summer of 2002, requiring doctors to demonstrate their ability to use the system -- or lose their privileges to treat patients. Hundreds of doctors opposed the move, arguing that the system was too time-consuming, and the hospital abandoned the project.

The tremendous cost also has slowed implementation nationally and in Massachusetts, particularly in community hospitals. The Leapfrog Group, a coalition of employers that lists hospitals on a public website that do and don't have electronic medication ordering, said just 5 percent of hospitals have computer order entry now, and 17 percent have plans to install systems in the next five years.

Leapfrog estimates that the systems can cost up to $15 million to set up and as much as $2 million a year to maintain, depending on the hospital size and whether it's starting from scratch. However, the group says, a part of the cost eventually is offset by savings of hundreds of thousands of dollars a year from not treating patients who've been harmed by an overdose or allergic reaction.

Hospitals with the financial resources are moving forward, if slowly. As the price of the systems has fallen, even small community hospitals, such as Saints Memorial Medical Center in Lowell, are putting together plans to spend $2 million to $5 million over the next three years to purchase systems and train doctors and nurses.

In the Brigham emergency department, doctors and nurses who first see a patient write a narrative of his problem in a paper chart, an old-fashioned method that the hospital will do away within the next two years. They enter the most pertinent information -- the patient's illness and severity -- in his computer chart, which links to his electronic medical record, if he has one, and a set of orders for the best way to treat his particular problem.

Patients whose charts have green borders are waiting for a hospital bed; two patients Wednesday afternoon had been waiting 17 and 20 hours.

The computer contains 40 sets of orders for major problems from asthma to internal bleeding, reminding doctors to order even the simplest medicines, such as aspirin for chest pains.

On Wednesday, William Angelone's wife brought in her husband, who had fainted at their Methuen home the day before and was bleeding in his intestines. After Dr. Laura Bontempo told him she planned to keep him overnight for a colonoscopy, she called up his electronic chart on the computer and was reminded to order a heart monitor for her 69-year-old patient.

The system, Bohan said, is designed to stop doctors and get them to think about their orders for patients. When an error occurs at the Brigham or another hospital, the hospital's physicians and computer programmers often use the failure to add another safety level to the electronic ordering system.

The Brigham added a reminder, "please order chronic medications," into electronic charts after a patient with chronic heart failure didn't receive her heart medications. She was in the hospital for kidney failure, so doctors were busy prescribing drugs for that condition.

"This is definitely the hot-button item for hospitals these days," said Dr. Daniel Nigrin, chief information officer at Children's Hospital. "It's the top item on all our lists."

Liz Kowalczyk can be reached at kowalczyk@globe.com.