German medication specialists back decision support

Two leading members of the medication commission of the German National Chamber of Doctors have urged German hospitals to implement “intelligent” computerised physician order entry (CPOE) with decision support systems to improve patient safety. They also advocated personal electronic medication lists in chronically ill patients.

The CPOE-topic was high on the agenda at the “Hauptstadtkongress”, an annual gathering of health policy leaders in Berlin. Daniel Grandt, head of internal medicine at the hospital of Saarbrücken, presented data from a government-backed study on medication errors in people aged 65 or older who were referred to the hospital’s emergency department.

“Every third patient did have a medication-relevant reduction in renal function. And more than half of these patients needed a dose-reduction for this reason”, said Grandt, who is on the board of directors of the national medication commission. The study also showed that two out of three elderly patients seen in the emergency departments of German hospitals take five or more different pills every day, and every third takes eight or more.

The clinical pharmacologist Bruno Müller-Oerlinghausen, head of the medication commission for twelve years until he recently stepped down, calculated that there is likely a six figure sum of medication induced complications in German hospitals every year. His colleague Jürgen Frölich, former head of pharmacology at the Medical School of Hannover University, recently presented calculations based on international studies that would translate into between 30,000 to 50,000 medication-related deaths in German hospitals annually.

Grandt and Müller-Oerlinghausen strongly advocated the introduction of CPOE systems that automatically generate warnings when possible medication errors occur. “But the actual effects of electronic order entry software strongly depend on the system and on the implementation”, Grandt told E-Health Europe.

A particular problem, he said, was that many alerts that are based on standard medication databases were completely irrelevant in clinical practice. This results in doctors clicking away the alerts without actually thinking about them. For this reason, Grandt has developed a different CPOE software named “rp-doc” that is now commercially available. It does not rely on standard medication databases, but only generates alerts that have been individually defined as clinically relevant by an expert panel.

Grandt cited as an example the co-administration of ACE inhibitors and acetyl salicylic acid (ASA) which is extremely common in patients with coronary artery disease. “This combination will become problematic only if the ASA-dose is very high, because then the effect of the ACE-inhibitor will be annihilated.” Grandt’s software, thus, only gives a warning for very high doses of ASA.

Grandt and Müller-Oerlinghausen jointly argued for a broader implementation of this kind of “intelligent” CPOE in German hospitals. In fact, this goal is also part of the national action plan on medication safety that was launched by the German ministry of health in autumn last year.

“The problem is, though, that we need some high quality studies on the efficacy and the success factors of CPOE systems. But currently, nobody is willing to pay for these studies. The national action plan is an important step into the right direction. But what we need in addition to that is some special funding of the German ministry of research. This would be the logical consequence of the national action plan”, said Grandt to E-Health Europe.

Remarkably, Bruno Müller-Oerlinghausen, a “grand old man” of the German medical establishment, took the chance of the Berlin event to publicly criticise the hostility of German doctors towards the smartcard project. Only weeks ago, this hostility once again became obvious with another critical resolution at the Ärztetag, the official national summit of German doctors.

“I am not happy with this hostility, and neither are other members of the medication commission”, said Müller-Oerlinghausen. He stressed that, in his view, smartcards were indeed a means to increase medication safety, in particular in the ambulatory setting.