By Design: CPOE Falls Short

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“The problems are multiple—the presentation of information is often confusing or invisible, the pull-down menus don’t always make sense,” says Ross Koppel, PhD, who serves on the faculty of the University of Pennsylvania and has studied and written about CPOE extensively. “The alerts that come are almost always overwritten. They’re written by the legal team who don’t want to get sued for anything, so they warn of every drug interaction...”

Physicians who suffer “alert fatigue” sometimes overlook something, or the alerts miss potential problems they should have caught. The CPOE interfaces look like “the state of art, circa 1992,” in part because they were developed on an accounting software platform and their development hasn’t yet achieved that of clinical systems, Koppel says.

The user interfaces create a “hostile user environment” and are often difficult to read and easy to populate with misinformation, says Scot Silverstein MD, adjunct professor at Drexel University’s College of Information Science and Technology and a healthcare journalist. The confusing user interfaces “actually promote user error,” he says. “Some of these interfaces are guaranteed to cause user confusion and create mistakes—not just CPOE but other (IT) systems, as well...”

[CPOE vendor contracts require physicians to] sign non-disclosure agreements prohibiting them from publicly discussing problems with the software. Physicians can tell a colleague about a problem they have been having with CPOE, but contractually they cannot publicly present that information at conferences or bring it up in online discussion groups...

via HIT Exchange

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HEALTH CARE INFORMATION TECHNOLOGY (HIT) vendors enjoy a contractual and legal structure that renders them virtually liability free—“hold harmless” is the term of art—even when their proprietary products may be implicated in adverse events involving patients. This contractual and legal device shifts liability and remedial burdens to physicians, nurses, hospitals, and clinics, even when these HIT users are strictly following vendor instructions. Vendors avoid liability by relying on the legal doctrine known as “learned intermediaries” and on warranties prohibiting claims against their own products’ fitness. According to this doctrine and legal language, HIT vendors are not responsible for errors their systems introduce in patient treatment, because physicians, nurses, pharmacists, and health care technicians should be able to identify—and correct—any errors generated by software faults...

Vendors retain company confidential knowledge about designs, faults, software operations, and glitches. Their counsel have crafted contractual terms that absolve them of liability and other punitive strictures, while compelling users’ nondisclosure of their systems’ problematic, even disastrous, software faults...

~ Ross Koppel

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Leapfrog’s Binder says hospitals “tend to be prehistoric in their thinking” when it comes to healthcare IT, and their vendors have not put interoperability in the forefront of product design. Other industries embrace technology and allow it to work across national and international systems, but some CPOE applications can only talk to themselves...

...scholars say the “hold no harm” clause should be removed, a move that would quickly improve the software, and the government could prohibit vendors from requiring physicians to sign confidentiality oaths. Providers should be able to share best practices, problems, and data with others using the same software across the country, not just with colleagues down the hall.