Don’t Automate Bad Processes

In my last post, I talked about how technology alone will not eliminate medication errors in hospitals caused by bad processes.

This week I found essentially the same thing being said by someone far more knowledgeable about these matters than I am, Dr. John Halamka, Chief Information Officer of the CareGroup Health System, and Chief Information Officer and Dean for Technology at Harvard Medical School.

He writes an excellent blog called Life as Healthcare CIO. His latest posting is about his experience in implementation of computerized provider order entry (CPOE) systems. (I assume that ‘s the same thing as the “computerized PHYSICIAN order entry” system I wrote about.)

Dr. Halamka presented a list of 10 lessons he learned about implementing such systems, some of them technical, some focusing on cultural and management issues. However, one in particular jumped out at me.

Automating a bad process does not improve anything.

When I was a resident, I was told that heparin should be dosed as a 5000 unit bolus then an infusion of 1500 units per hour for every patient. I was not taught about relating heparin dosing to body mass index, creatinine clearance or the presence of other medications. Unfortunately, it often took days to get the heparin dosing right because 5000/1500 is definitely not a one size fits all rule. Creating an automated CPOE order for 5000/1500 is not going to improve the safety or efficacy of heparin dosing. Implementing a new protocol for dosing based on evidence that includes diagnosis, labs, and body mass index will improve care.

Our experience is that it is best to fix the process, then automate the fixed process. By doing this, no one can blame the software for the pain of adapting to the process change.Our experience with CPOE over the past 7 years is that it has reduced medication error by 50%, it paid for itself within 2 years, and clinicians have embraced it. In 2008-2009 we're completing the bar coding for all our unit dose medications (including repackaging every dose of Tylenol in bar coded baggies) so we can scan the patient wrist band, scan the medication, and scan the nurse, achieving a completely automated medication administration record. Once this is complete, the last causes of medication error will be removed from our hospital and we hope to achieve a truly zero rate of adverse drug events.

I am skeptical of that last claim, that implementation of a bar coding system will remove the “last causes of medication error.”

However, Dr. Halamka clearly understands the broader issue, that it’s the process, stupid. Remember the old acronym about computer systems, GIGO? It stood for garbage in, garbage out. Automating a bad process – and the need to avoid doing that – is simply a different version of that old truism.