Article Content


By studying medication orders that are withdrawn ("discontinued") by physicians within 45 minutes of their origination, researchers at the University of Pennsylvania School of Medicine have demonstrated a systematic and efficient method of identifying prescribing errors. The method is of value in screening for medication errors and as a teaching tool for physicians and physicians-intraining. The report was published in the July/August 2008 issue of the Journal of the American Medical Informatics Association.


Dr Ross Koppel and colleagues at Penn's Department of Biostatistics and Epidemiology used a hospital's computerized physician order entry (CPOE) system to track prescriptions that were discontinued within 45 minutes. They found that the rate of errors among the quickly stopped orders was 66%. Although the prescribing error might have been detected by the ordering physician, another physician, a pharmacist, or a nurse, the prescribing physician was responsible for the stop order. The University of Pennsylvania team examined each order stopped within a 2-hour time period and, when relevant, each subsequent order. Then they interviewed the prescribing physicians, asking about why they stopped the orders-looking at who caught the error and the physician's own explanation for the change. Often the reason for the change was obvious; for example, a medication for the wrong eye or a dose that was far too large. Sometimes, the reasons were more subtle, such as a more appropriate antibiotic. Doctor Koppel noted that the classes of drugs most likely to be quickly discontinued made sense because they were often among the most difficult to prescribe: low-therapeutic-index drugs, insulin, antiretrovirals, antineoplastics, and immunosuppressive drugs.


Professor Koppel (a sociologist by training) said that although they originally focused on the 2-hour period, they found that 45 minutes was the most efficient time cut for the measure. By analyzing the discontinued orders within 15-minute time blocks, researchers were able to determine the most efficacious time parameter to help identify ratios of inappropriate-to-appropriate medication orders. Orders that were stopped within the first minute, possibly the result of typographical errors and the kind of errors equivalent to tearing up a flawed paper prescription as it was written, were not included. The researchers had a live transmission of every medication order as it was written and were able to interview the ordering physicians within hours, often within minutes. The team conducted the research over the course of 2 months, selecting times and days that reflected the physicians' ordering patterns at the hospital.


Currently, methods of identifying prescribing errors are plagued with inaccuracies stemming from several systematic biases. Self-report and reports by colleagues are known to substantially underrepresent reality. Examining medical records misses errors linked to undocumented diagnoses and is time-consuming and expensive. According to the researchers, other manifestations of medication error go unrecognized because symptoms are often complex, patients have multiple problems, and polypharmacy may obscure causes and outcomes. The article identified eight methods of detecting a medication error and summarized their shortcomings. The measure proposed here, although preliminary, indicates that 66% of prescriptions discontinued within 45 minutes after their origination are inappropriate. Even beyond the ratio comparisons, the value of this measure is severalfold: When linked to a CPOE system, it is rapid and constant and does not depend on possibly biased evaluators, self-report, or others' reports. Data collection is also costfree as part of a CPOE system.


Difficulties in identifying and measuring medication errors are a constant theme of hospital patient safety literature. Many scholars indicate that such difficulties are critical barriers to addressing medication errors. The researchers stressed that this method does not replace the others but may add a technique that appears both efficient and objective in helping physicians who are having problems with a particular group of medications or patient types or in helping postgraduate medical educators focus on areas that require additional training.


PENN Medicine is a $3.5-billion enterprise dedicated to the related missions of medical education, biomedical research, and excellence in patient care. PENN Medicine consists of the University of Pennsylvania School of Medicine (founded in 1765 as the nation's first medical school) and the University of Pennsylvania Health System.




1. Koppel R, Leonard CE, Localio AR, et al. Identifying and quantifying medication errors: evaluation of rapidly discontinued medication orders submitted to a computerized physician order entry system. J Am Med Inform Assoc. 2008;15(4):461-465.



The US Department of Health and Human Services (DHHS) recently announced a long-awaited proposed regulation that would replace the ICD-9-CM code sets now used to report healthcare diagnoses and procedures with greatly expanded ICD-10 code sets, effective October 1, 2011. In a separate proposed regulation, the DHHS proposed adopting the updated X12 standard, version 5010, and the National Council for Prescription Drug Programs standard, version D.0, for electronic transactions such as healthcare claims. Version 5010 is essential to the use of the ICD-10 codes.


In 2000, under authority provided by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the ICD-9-CM code sets were adopted for use in the administrative transactions by both the public and private sectors to report diagnoses and inpatient hospital procedures. Covered entities required to use the ICD-9-CM code sets included health plans, healthcare clearinghouses, and healthcare providers who transmit any electronic health information in connection with a transaction for which a standard has been adopted by the DHHS. Developed almost 30 years ago, ICD-9 is now widely viewed as outdated because of its limited ability to accommodate new procedures and diagnoses. ICD-9 contains only 17,000 codes and is expected to start running out of available codes next year. By contrast, the ICD-10 code sets contain more than 155,000 codes and accommodate a host of new diagnoses and procedures. The additional codes will help to enable the implementation of electronic health records because they will provide more detail in the electronic transactions.



In September 2008, nine research teams from across the country unveiled innovative prototypes of personal health record (PHR) applications that provide a glimpse of the "next generation" of PHRs. The PHR applications are the result of 18 months of intensive research and design by multidisciplinary teams from some of the most prestigious institutions in the nation. The prototypes range from a medication management system (housed in an age-appropriate form such as a stuffed animal or cellular phone) to help children with cystic fibrosis manage their disease to a sophisticated "conversational assistant," a computerized tool that helps people with congestive heart failure manage their health from home through a series of voice-activated questions and responses that they can quickly share with their medical providers.


The nine design teams received funding from Project HealthDesign, a program sponsored by the Robert Wood Johnson Foundation (RWJF). The program aims to revolutionize the purpose and potential of electronic PHRs. Each team created applications that help move the perception of PHRs from static repositories of health information to dynamic, tailored applications that allow people to easily and actively manage their health as they go about their daily lives. The project also ensured that these PHR tools readily share common technical functions and operate on a common technology platform. Based at the University of Wisconsin-Madison, Project HealthDesign is funded through RWJF's Pioneer Portfolio, which supports innovative ideas that may lead to significant breakthroughs in the future of health and healthcare. Additional support is provided by the California Health- Care Foundation.


"We challenged the grantee teams to aggressively push the boundaries when it came to the role that PHRs could play in people's daily lives," says Patricia Flatley Brennan, RN, PhD, national program director and professor of nursing and industrial and systems engineering at the University of Wisconsin-Madison. "Their success has helped create a fundamentally different and more powerful model of PHRs-one that will stimulate new innovation and creativity throughout the PHR arena."


The teams' PHR application designs run the gamut of patient populations and needs, but all marry technology with useful information recorded from users' daily lives to produce action-oriented feedback for managing their health.


* Stanford University and Art Center College of Design designed a set of multimedia PHR tools to help adolescents with chronic illness communicate with their providers and others about their health. By tapping into teenager behaviors such as sending text messages and sharing music, the applications help teenagers track their progress and stay on top of their treatment in ways that fit seamlessly into their lives.


* TRUE Research Foundation designed a personal health application to help people with diabetes understand and track their self-care. Their application interprets a range of relevant health data, illustrates online how people's daily behaviors affect their condition and how they feel, and provides specific recommendations for improving their typical routines.


* A team at Vanderbilt University designed a PHR application to help children with cystic fibrosis play a larger role in taking care of themselves. Team members developed a device that can be incorporated into different "skins" (such as a stuffed animal or cellular phone) to work with the PHR to help kids take the right medications at the right times, alert parents and caregivers if doses are missed, manage refills, and so forth.


* RTI International designed a PHR tool to help sedentary adults become more physically active. Through an interactive Web portal, patients input personalized information on their activity level, lifestyle, and goals. They then receive customized plans to increase activity levels in ways that are tailored to their daily routines, such as taking the stairs or parking further from the office.


* The University of California San Francisco team designed a PHR application to help patients with breast cancer gain control over the overwhelming process of treatment. The PHR tool helps the women to better understand and coordinate their care plan by integrating information on upcoming physician appointments, prescriptions, questions to ask, and so forth, and synchronizing those data with their personal electronic calendars. It also provides links and prompts with more information.


* A team at the University of Colorado at Denver and Health Sciences Center designed a portable touch-screen tablet computer that older patients with complex medication regimens could receive upon hospital discharge. The tablet helps users organize prescriptions, stay on track with taking doses, and avoid medication errors while also synchronizing information with their physicians' records. Other components can help schedule prescriptions, order refills, and prepare for physician visits.


* The University of Massachusetts Medical School team designed a PDA to help patients with chronic pain tightly manage their medications. The team's PDA prototype enables users to easily track their pain symptoms throughout the day in ways that make sense for them and draws on the medication regimens prescribed by physicians to generate convenient, understandable prompts. Based on how they are doing, patients could receive tailored alerts for when they should or should not take medications and at what doses.


* The University of Rochester team designed a prototype system that uses a "conversational assistant" to provide patients with congestive heart failure with a "daily checkup." Through voice-activated questions and responses or text-typed chat, patients share information relevant to their condition. The computer interprets that input to provide personalized recommendations based on established guidelines and collects longitudinal data to share with the patients and their care providers.


* A team from the University of Washington designed a PHR system to help people with diabetes record blood glucose levels and other information such as blood pressure, food intake, and exercise levels. The application wirelessly uploads these readings over a cellular phone to the person's PHR and his/her medical provider. Providers, in turn, review the information and provide feedback and counsel to the patient through the PHR application.



In addition to the design prototypes, Project HealthDesign worked with a technical team from Sujansky & Associates in San Carlos, CA, to develop and release a set of functional requirements and technical specifications that allow different PHR applications to securely share medical and other information, with the consumer controlling who has access to what information. The program also funded a group of experts led by Kenneth Goodman, PhD, founder and director of the University of Miami's Bioethics Program and associate professor of its School of Medicine, to ensure that ethical, legal, and social implications associated with innovative PHR systems were kept in the forefront throughout the entire design process. Over the next several months, the Project HealthDesign grantee teams will work to publish details about their findings and extend the use of their applications to the clinical practices connected to their institutions.


The RWJF is the nation's largest philanthropy devoted exclusively to improving the health and healthcare of all Americans. The foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful, and timely change. Visit for more information.


The California HealthCare Foundation is an independent philanthropy committed to improving the way healthcare is delivered and financed in California. By promoting innovations in care and broader access to information, its goal is to ensure that all Californians can get the care they need, when they need it, and at a price they can afford. Visit for more information.


Founded in 1848, the University of Wisconsin-Madison is one of the nation's oldest public research universities, with more than 41,000 enrolled students participating in 136 undergraduate degrees, 155 master's programs, and 110 doctoral programs and with a research enterprise that generates more than $700 million in annual extramural support. Visit for more information.



Thomson Reuters released a major upgrade to Reference Manager for Windows in September 2008. The only citation management software with a true multiuser network version, Reference Manager also provides a tool for publishing Reference Manager databases on the Web or an intranet. Reference Manager 12 delivers expanded file management, "Cite While You Write" integration with Microsoft Word 2007, and enhancements to Web Publisher that simplify collaboration.


New features include the following:


* Link PDFs and other files to a reference and store with your Reference Manager database for easy organization.


* Cite While You Write with a Reference Manager tab on the Microsoft Word 2007 ribbon provides immediate access to frequently used commands.


* Collaborate with colleagues using the enhanced Web Publisher to share databases over the Web or an intranet.


* Use new reference types such as Edited Book, Online Source, and Grant and new fields in many reference types, including the NIH-required PMCID.



With Reference Manager, authors can save time by exporting references directly from online resources such as ISI Web of Knowledge. Manuscripts formatted by Reference Manager can be submitted easily for publications using Manuscript Central, an online manuscript and peer review system for scholarly publishers from ScholarOne.


For Reference Manager 12 pricing and availability, visit


About Thomson Reuters

Thomson Reuters provides intelligent information for businesses and professionals, combining expertise with innovative technology for the financial, legal, tax and accounting, scientific, healthcare, and media markets. Thomson Reuters employs more than 50,000 people in 93 countries. For more information, go to