Troubling evidence has emerged in recent years from Canadian and American studies that many seniors in nursing homes are overmedicated, at high risk for adverse drug events because they're often on several medications, and not receiving the most appropriate drugs that have the lowest risk of side effects. The nursing home is one of the most complex pharmacotherapeutic settings in all of medicine and potentially places elderly residents at greater risk for drug-related injury than any other patient population. Research has shown that medication errors resulting in preventable adverse drug events occur most often at the time the drug is being prescribed and in the follow-up.
This fall, Baycrest completed the rollout of a state-of-the-art computerized physician order entry system (CPOE) with clinical decision support (CDS) -- throughout its hospital and adjacent nursing home. The aim is to improve the quality of medication prescribing with regard to choice of therapy, medication dosing and monitoring of drug therapy. This is expected to reduce prescribing decisions that lead to adverse drug events.
The project was challenging from the outset because clinical decision support software specifically tailored for the long-term care setting did not exist! Baycrest had to "homegrow" a software program (with Meditech) that would meet the unique needs of physician prescribing for the geriatric population -- a population that often presents complex and multiple health challenges. Baycrest also upgraded its facility-wide servers to increase the system speed and installed a wireless network. This enables Baycrest doctors to access the CPOE/CDS system from anywhere in the building using mobile and stationary computers (laptops and PCs). They can also place orders through the system from their outside offices or homes.
As a result of this leading effort, Baycrest will be the site of a 'landmark study' (funded with a prestigious grant from the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality) to benchmark how effective CPOE/CDS is in reducing adverse drug events in the long-term care setting and how cost-effective it is for a long-term care facility to install and operate the system. The dearth of evidence about the value of health information technology in the care of nursing home residents and uncertainties about return on investment continue to delay the adoption of this technology in the long-term care setting in Canada and the U.S.
Baycrest geriatrician and senior scientist Dr. Paula Rochon will lead the on-site study in collaboration with principal investigator Dr. Jerry Gurwitz of the Meyers Primary Care Institute of the University of Massachusetts Medical School. Drs. Rochon and Gurwitz have extensive experience studying the quality of medication use and the occurrence of adverse drug events among the elderly in the community and nursing home settings in their respective countries. They have collaborated on previous studies.
"Baycrest is ahead of the curve in adopting health information technology in the long-term care setting to improve prescribing practices," says Dr. Gurwitz. "There are few places like Baycrest in all of North America in which to carry out such a study."
Baycrest has a 300-bed complex, continuing care hospital and a 472-bed long-term care facility (The Apotex Centre, Jewish Home for the Aged and The Louis and Leah Posluns Centre for Stroke and Cognition). It is a fully affiliated teaching site of the University of Toronto and includes an on-site pharmacy.
"Previous research has suggested that as many as half of all adverse drug events occurring in the nursing home setting may be preventable," says Dr. Rochon. "CPOE with clinical decision support provides potentially critical information to the physician close to the moment of decision-making. We have an exciting opportunity now to put this technology to the test and see if it makes a significant difference in reducing adverse drug events."
How CPOE/CDS works?
The physician enters a prescription for the patient directly into a computerized system (known as computerized physician order entry or CPOE) and receives instant feedback on selected high-risk prescribing decisions (known as clinical decision support or CDS). For example, adverse drug events in long-term care are most frequently related to the use of psychoactive medications and anticoagulants. Using CPOE/CDS, a physician ordering an anti-psychotic can now be alerted to any potential interactions that may occur as a result of that patient being on additional psychoactive medications. Once the physician has determined the appropriate prescribing decision, the order is sent and the nurse reviews the printed order, acknowledges the electronic version of the order and updates the medication administration record sheets. Finally, the pharmacist dispenses the medication and sends the drug to the unit. The nurse gives the medication to the patient. The electronic order also eliminates the risk of the nurse or pharmacist misinterpreting a physician's handwritten prescription.
The Canadian-American research team for this study includes Dr. Paula Rochon, site principal investigator, and Monica Lee, research pharmacist; and on the American side Dr. Jerry Gurwitz, principal investigator, Dr. Terry Field, co-principal investigator, and Dr. David Bates, co-investigator. The three-year grant for the collaborative project is worth $1.5 million US.