Should Hospitals Install Bar Coding or CPOE First? Why I’ve Changed My Tune

This is one of the most commonly asked questions in IT World, and my answer has always been “CPOE first” – largely because that has always been David Bates’s (the world’s leading IT/safety researcher) answer. But I’ve changed my mind. Here’s why.

Before I start, I promised that I’d let you know if I ever blogged on a topic in which I have a financial conflict of interest. On this, I do: I serve as a paid member of the Scientific Advisory Board of IntelliDOT, a company that makes a stand-alone bar coding system. If that freaks you out, stop reading. But recognize that if you had asked me the “bar coding or computerized provider order entry?” question last week, I would have answered “CPOE”.

That’s because the evidence supporting CPOE is substantially stronger than the evidence for bar coding. For example, a search of “CPOE” on AHRQ Patient Safety Network (AHRQ PSNet) turns up several studies (for example, here and here) demonstrating substantial reductions in serious medication errors, and one documenting an impressive return-on-investment for CPOE. Although we and others have noted that this evidence can be challenged for its lack of generalizability (most of it came from studying the Brigham’s home-grown CPOE system, not the commercial systems that the rest of us are buying) and its impact on proxy outcomes (error rates) rather than on true patient harm, these are mostly quibbles: a good CPOE system does appear to decrease errors at the prescribing phase. Which makes sense.

The literature supporting bar coding is wimpier. The only rigorous study of bar coding I can find is one showing impressive safety gains after implementation of a bar coding system – in the clinical pharmacy, not at the point of care. In fact, a search of PSNet looking at the efficacy of bar coding turns up more studies showing unintended consequences and mischief – including a wonderful paper written for our Quality Grand Round series involving a case in which two patients (one a diabetic, the other not) ended up with each others’ wrist bands through an ED mix-up. Patient B would have gotten a (probably fatal) slug of insulin for a sky-high blood sugar (drawn from patient A, who was wearing B’s bracelet) had an alert doc not overheard a nurse telling a colleague that she was going into Patient B’s room to give him his insulin. Other papers have made the point that clunky bar coding systems can lead to nurse workarounds that subvert the safety features. Clearly, these systems are not panaceas, and – like CPOE (see here and here) – they can easily be undermined by bad design and inattention to human factors.

This week, I had the pleasure of giving a keynote speech at a national bar coding conference, a quirky affair called the “unSummit”, run by two charming bar coding evangelists, Mark Neuenschwander and Jamie Kelly. Mark, in particular, is an unusual guy: a former minister – no Reverend Wright jokes, please – who has a preacher’s passion for bar coding. At the unSummit, I gave a big picture patient safety talk to the 400 bar coding groupies, and then focused on why the uptake of bar coding by American hospitals has been so painfully slow. “If you’re a hospital, there are certain things you have to do, like passing JCAHO and doing anything CMS tells you to do,” I explained. “So you’re competing for limited bandwidth against a bunch of other non-mandatory safety-oriented interventions: teamwork training, simulation, rapid response teams, preventing diagnostic errors, and CPOE. Right now, bar coding lacks the evidence to win that competition.”

But on my flight home, I started thinking about the big, high profile errors I’ve heard about in the last year or two, both at UCSF and nationally. And I had an epiphany. Or maybe it was the turbulence. But here goes.

At UCSF Medical Center (which has a very good paperless chart but neither CPOE nor bar coding; the former is slated to launch soon, with bar coding to follow), virtually every terrible medication error case I can recall in the past couple of years involved a nurse administering a medicine. And talk about “the business case for safety”: these days, really nasty errors get reported to the state health department, whose dour investigators come swooping in, turning over every rock in the building and threatening to shut you down if they find one glitch too many. Believe me, this is not fun. Nor cheap.

Then I began thinking about the People Magazine/60 Minutes-type errors over the past few years – Linda McDougal‘s unnecessary mastectomy because of a path lab mix-up, Dennis Quaid’s twins‘ massive heparin overdose, the fatal error in Madison in which a nurse infused an epidural anesthetic intravenously into a pregnant woman. It hadn’t dawned on me previously, but all of these cases represent identification errors that probably would have been prevented by a decent bar coding system.

Thinking about this drumbeat of tragedies, I tried to recall a major medication error in the last few years that would have been prevented by CPOE… and I couldn’t. Not that there aren’t any, but it does seem like today’s Oh-My-God-How-Could-This-Happen med errors are now disproportionately administration, not prescribing, mistakes.

What is going on? I suspect that some of the prescribing errors that CPOE can prevent are now avoided because so many docs are using handheld prescribing aids like Epocrates, and because Joint Commission regs, such as banning high risk abbreviations like “10U insulin” and “qd”, are eliminating some of the worst offenders. Moreover, with everybody now on their toes about medication safety, an errant prescription has many downstream opportunities (pharmacist, nurse, even patient or family) to be caught before it kills.

On the other hand, there is generally nothing that stands between the busy nurse who makes a dose calculation error or confuses a vial of heparin for insulin – and tragedy. The nurse has only one chance to get it right, and no safety net if she gets it wrong. Add to this the effects of the nursing shortage (busier nurses, more temps, more young grads), patients on more and more complex meds, fuller hospitals… and you inch ever closer to disaster.

Why did CPOE gain so much more momentum than bar coding over the past decade? Here’s my theory: because it involves physicians. Think back to the early days of clinical IT. Many of the movers and shakers were physician-informaticists, and they had to sell the case for change (and considerable investment) to their fellow physicians if there was to be any hope of their hospital taking the IT leap. It is logical that they would have deemed prescribing errors to be the main culprit: those are the ones that they themselves had committed and witnessed. As for public demand, doctor’s handwriting has been fodder for Jay Leno jokes for decades. Have you ever heard a stand-up comic prattle about the nurse who gave a patient the wrong med?

In other words, medication administration errors (and laboratory/pathology specimen errors) tend to be out-of-sight, out-of-mind to physicians and the public. Moreover, they involve assembly-line processes and simple execution (no pun), all kinda boring. As for bar coding, how exciting could something be when they’ve had it at the checkout counter at Safeway for decades?. And so, despite their importance, administration errors (which represented more than one-third of all med errors in Bates’s seminal study) were largely ignored… by researchers, by early IT adopter healthcare systems (the VA is an exception but for some reason didn’t focus on studying this intervention), by physicians, and by the public. And nurses, I think, have been ambivalent about bar coding – hopeful that it might prevent mistakes but worried that it would create workflow hell.  

So CPOE became the darling of the healthcare IT set, winning all the accolades and getting most of the push. And since bar coding is much less expensive than CPOE, there wasn’t as much corporate energy put into developing systems and promoting them.

Now, I could be wrong about this. After all, whatever the reasons, the fact remains that bar coding has not been researched very much or very well. But, with all the medication administration errors I’m hearing about, this is now an area in which I am willing to relax my evidence standards a bit – it is beginning to seem like the equivalent of barricading the cockpit doors after 9/11, a “relatively” low cost, low complexity (at least when compared with CPOE) and commonsensical intervention that can potentially save a lot of victims – both patients and nurses.

A few weeks ago on NBC’s Today Show, Dennis Quaid discussed (the first half of this clip is on his kids’ medication error, the last half on his new movie; it is morning television, after all, and they have to sell soap) his new foundation, set up to prevent the kinds of errors that nearly killed his twins. “We’re going to concentrate on one thing at a time: bedside bar coding… A lot of times patients end up getting the next door neighbor’s medicine… nurses are so overworked… and mistakes occur.” Quaid noted that he was suing the heparin drug manufacturer but had not yet decided whether to sue the hospital, Cedars-Sinai. “Isn’t the hospital going to institute [bar coding]?” asked host Meredith Vieira.  “They have not said they’re going to as of yet,” said Quaid, clearly implying that he might soon remove his high-priced lawyers’ muzzles.

I’m the last person to argue for health policy by Hollywood heartthrobs, but I think that similar cases are occurring all-too-often out of the klieg lights, and that many of them can probably be prevented. The question is whether we wait for better evidence and better systems. I’m pretty sure that our friends at Cedars-Sinai wish they hadn’t.

Ultimately, of course, we need both bar coding and CPOE, and we need rigorous studies looking at what works and what doesn’t. But you have to start somewhere. Even though the evidence continues to trail, based on what I know today, if I was a hospital ready to get into the IT game, I’d go with bar coding first.

10 Responses to “Should Hospitals Install Bar Coding or CPOE First? Why I’ve Changed My Tune”

  1. menoalittle May 3, 2008 at 6:00 pm #

    Bob,

    Another excellent post…should be required reading for all healthcare professionals. I am glad to see that your thoughts have evolved to focusing on the root cause of medication associated patient endangerment, injury, and death. You have seen the light and not for one minute do I believe that your financial conflict had an impact.

    I wish the same could be stated about the business dealings between the CPOE device manufacturers and the CPOE device purchasers. The CPOE device manufacturers have paid champions lauding the supposed virtues of CPOE devices. An undetermined number of hospital purchasers of CPOE devices have equity investments (a kickback if you will, or at least a financial conflict) in the manufacturer whose device they buy. Using paid “unbiased” staff, they then defend (their investment) the forced use of CPOE devices despite the pleas from the nurses and doctors who report adverse unintended consequence of the altered care so imposed. The C-suite folks blame the CPOE device caused patient endangerment on human error.

    As expressed previously in comments to your prior excellent posts (January 27, February 3, March 1, March 3, March 17), the CPOE device deployment constitutes an experiment in the alteration of care as there is not any scientific data showing overall outcomes of hospitalized patients whose care is directed by CPOE devices are better than without these devices. There is only one CPOE device outcome study in the literature and you have referenced it. It shows a three fold higher death rate in 9 month old babies. Not unexpectedly, England’s NHS efforts to deploy CPOE and other health it devices is slogging along (e-healthinsider, April 4, 2007 and July 10, 2007).

    Since CPOE devices have not been tested for safety and efficacy nor approved by any regulatory agency, it is surprising, from an intellectual perspective, that expensive unapproved CPOE devices gained a foothold over simple bar coding technology (which incidentally has been approved by regulators). But when one learns of the business dealings of the CPOE device corporate interests and their influence on our lawmakers and the “not for profit” hospitals (your post, Dec. 7, 2007), the promotion of CPOE devices and the associated nationwide experiment in altering care is not a surprise.

    Best regards,

    Menoalittle

  2. btruax May 3, 2008 at 7:51 pm #

    Bar coding and CPOE are two very complementary technologies. There are many opportunities to make your CPOE implementation more rewarding if you already have a good bar coding system up and running. Remember that you can, and should, bar code a lot more than just your patients and medications. If you bar code your Foley catheters (don’t be surprised if your inventory control folks are already doing this!), tie them to specific patients and then let your rules-based clinical decision support system flag this for your physicians during CPOE. This can help avoid the surprises that catheters inserted in the ER or the OR or after a procedure have not been removed. Sanjay Saint, M.D. and colleagues at the University of Michigan (1) found that 56% of hospitals did not have a system for monitoring which patients had urinary catheters placed, and 74% did not monitor catheter duration. Bar coding can only help make your CPOE system a much better patient safety tool.

    (1) Saint S, Kowalski CP, Kaufman SR, et al. Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study. Clinical Infectious Diseases 2008; 46:243–250 http://www.journals.uchicago.edu/doi/abs/10.1086/524662

  3. etrain May 5, 2008 at 9:25 pm #

    Incremental change regarding IT overhauls would be better served with bar coding first and CPOE second. Physicians are notorious for killing CPOE implementation efforts, but if the nurses go fully paperless first, which would mean barcoding and the end of MAR, then the CPOE would probably go over better.

  4. Matiasm May 7, 2008 at 7:58 pm #

    Nice discussion Bob,
    anyway I don’t see much evidence coming out favoring bar coding since, as you wrote, it is mainly a commonsense intervention and on the other hand administration errors are very difficult to detect.

  5. Bob Wachter May 14, 2008 at 2:55 am #

    FYI, a new article supporting the value of bar coding appears in today’s JAMA — it amplifies many of the points I made in this post.

  6. RDTURNER May 15, 2008 at 10:47 pm #

    I could not agree more with Dr Wachter – and I am glad he has reconsidered the position he initially expressed in his keynote in Austin two weeks ago.

    My healtrh system has adopted a strategy for system wide implementation of bar coded medication administration (BCMA) before CPOE. I think that Bates et all demonstrated a nearly equal number of errors leading to potential ADEs would be intercepted on the dispensing/admin side relative to the # of errors on the ordering/transcription side. And I have yet to find anyone who thinks CPOE is easier to implement than BCMA – the degree of culture change, expense, and time is much less with BCMA. Additionally, the degree of risk is less – even if you do it right, wouldn’t we agree that “spooking” community physicians who might be skitterish about CPOE (still) is a possibility – and can’t we improve safety by an equivalent amount by adopting the less risky BCMA approach?

    The other issue realtive to CPOE is the number of errors in the orderig/transcription process that are discovered by pharmacists and nurses in the current state/ While all to many get through to the patient, some are dicscovered. In contrast – nearly all errors in dispensing/administration DO get through to the patient.

    Don’t get me wrong – I am an advocate of the “closed looped” medication process – but I know how difficult and risky CPOE is, and I think most hospitals are making a huge mistake in not implementing BCMA first.

    Lastly, at the risk of sounding like a conspiracy theorist, I think there is at least the possibility that the initial cachet of CPOE was due to a focus on academic centers, spreading to Leapfrog, and then supported by a legion of consulting firms and vendors sensing a gold mine of billable hours implementing an extremely complex application. I don’t sense and equivalent interest in this group to drive BCMA forward – perhaps because not as many hours can be billed.

  7. Marshall Maglothin August 17, 2008 at 7:13 pm #

    Cudos Bob!

    Bar coding, a 100% accurate technology, should have always been a slam-dunk CQI application in healthcare to avoid errors (and I have no financial interest). Now, with Word bar codes fonts and USB laser pens, cost is not a barrier.

    For almost 20 years, FedX has been able to tell us where our package was in route…and we still misplace patients in hospitals, give them the wrong medications, and operate on the wrong site…

    Marshall <—a former minister with a preacher’s passion for CQI in healthcare

  8. rxerist August 26, 2008 at 4:07 pm #

    We have been utilizing BCMA at our hospital (500 bed, tertiary care, tax-paying)
    for 4 years & were fortunate to be backed by a multi-hospital corporation to assist in the rollout (laptops, barcode printers, barcode packagers, technical expertise, funding, etc). We are convinced that, while not perfect, the system is one of the safest in existence. The computer system vendor is Meditech & utilizes both wired & wireless connections to provide real time info to the bedside nurse.

    That being said, the technology is just part of the story. Implementing such a radical change in medication delivery & documentation requires a massive cultural change on the part of all involved: physicians, nursing, pharmacy, respiratory care, IT, finance, administration, patients (some pts don’t like to be scanned like they’re grocery store items) & payers.

    In our hospital system, we are also rolling out a CPOE system that is requiring much more time & re-design than BCMA. This obviously requires a massive cultural change also mainly for physicians, but again, the CPOE piece isn’t perfect.

    From our viewpoint, BCMA provides a much greater safety net when it is implemented & accepted by all players so that the work-arounds are minimal & the
    culture recognizes the benefits & limitations of the system. This is assuming that there is adequate funding & clinical/techical support for the rollout. We were able to benefit from a strong support effort from the corporate mandate, but not everyone has that situation. The CPOE systems provide welcome relief from bad handwriting & instant availability to order review, as well as editing & clinical messages/warnings to improve patient safety. The extent of their value is determined by the acceptance of the new technology by the medical staff.

    So, if there are adequate funds & technical/personnel support, BCMA would be my choice for improving pt safety to the greatest extent if I had to choose. Obviously, having both is the best of all worlds, but as we all recognize, it’s still an imperfect world. The systems still depend on people taking the time to make intelligent clinical decisions & understanding the limitations of our technology.

  9. John Poikonen September 26, 2008 at 6:10 pm #

    Today, there was a very good teleconference with David Bates and Robert Wachter where the moderator addressed the topic of CPOE versus BCMA was met head on. Dr Wachter restated his view from this post.

    Dr. Bates disagreed on two fronts. First the epidemiological studies are clear – more harm is done from mistakes in prescribing. Second, the best evidence for safety is with CPOE. There was agreement that optimally both should be done.

  10. Joanie guy January 2, 2010 at 9:32 am #

    I would like to add that there are many errors that do occur because we dont have CPOE…Most doctors rarely hear or see these errors…Those of us in Nursing leadership see all the errors that would have been caught with CPOE.

    These are the errors where medications never get sent to pharmacy for a shift, meds dont get D/C as ordered, wrong doses are ordered and given etc etc…

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