CPOE

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Computerized physician order entry (CPOE) is defined by the Healthcare Information and Management Systems Society (HIMSS) dictionary as an "order entry application specifically designed to assist clinical practitioners in creating and managing medical orders for patient services and medications". [1]. It is an electronic medical record technology that allows physicians to enter orders, medications, or procedures directly into the computer instead of handwriting them. [2]

CPOE systems are becoming integral additions to electronic health records, being used by more practitioners in all areas of healthcare. Studies show that CPOE use can reduce medication errors and treatment orders, along with errors that often come when misreading providers’ handwriting. [3] The system transmits the order to the appropriate department or individual so the order can be carried out. [4] The most advanced implementations of such systems also provide real-time clinical decision support such as dosage and alternative medication suggestions, duplicate therapy warnings, and drug-drug interaction checking. [4]

History of CPOE

1969 was the founding of the Regenstrief Institute in Indianapolis. Dr. Clement McDonald, MD introduced the idea of a longitudinal medical record encompassing inpatient and outpatient patient encounters. The Regenstrief medical record system (RMRS) began in 1972 with 35 of Dr. Charles Clark's MD diabetic patients. In 1984, physician order entry also known as computerize provider order entry (CPOE) of outpatient medicines was initiated at a collaborating facility called the Wishard Memorial Hospital. Physician order entry was expanded to inpatient medication orders in 1990. [5]

Purported benefits of Electronic Prescribing have included:

E-RX enhances pharmacy efficiency. For sure, electronic delivery of the prescription eliminates the tried and true problems of doctors scribbling and enables the pharmacist to prepare the prescription to ease patient pickup. E-RX promotes formulary adherence. Managed care organizations find that physicians choose the drugs for which they have contracted for cheaper purchase, thus it enhances their profits and perhaps promotes some quality where their pharmacy and therapeutic committee decision-making in all intents and purposes well assesses efficacy and cost-effectiveness of the various entities on the formulary. E-RX enhances prescribing errors by physicians being caught. Pharmacy software can check for the proper drug being prescribed at the right dosage in many cases so medication errors may be minimized. E-RX reduces adverse drug reactions (ADRs) by electronic entry into the pharmacy’s computer allowing patient allergies, past bad experiences with certain drugs, and drug-drug interactions to potentially be identified, also pending pharmacist intervention. E-RX may catch dosage errors, particularly in light of the differences between pediatric formulations and adult dosage levels. This can also be part of the assessment done electronically before the pharmacist prepares the prescription. E-RX decreases drug-drug interactions. Much existing pharmacy software already checks the patient’s profile (assuming that patients use just a single pharmacy) to raise flags to the pharmacist before dispensing about any potential of multiple drugs interacting. E-RX helps prevent injuries and reduce health costs. Alerts given to physicians reduce the likelihood and severity of ADRs, according to one study in the Archives of Internal Medicine. E-RX improves quality of care and reduces malpractice claims. Again, it is asserted to yield a reduction in medication misadventuring, reducing both physicians’ and pharmacists’ making mistakes. Most of these depend upon the pharmacist’s vigilance in interacting with a well-designed clinical software system with a caring professional role. EMRs in one study in the Archives of Internal Medicine saw an association with “a significant reduction in malpractice claims against physicians.” E-RX increases patient pickup from the pharmacy and patient compliance. This benefit is assumed by a few reports that patients arrive at the pharmacy to receive their drugs more so when delivered electronically, rather than when they carry a piece of paper. Patients with electronic prescribing allegedly pick up their drugs and take them more assiduously than those with paper prescriptions. Add-on programmed dispensing devices for patients have been found to work best to alert providers of non-compliance [6].

Security configuration

The security system should be configured correctly.

Dealing with Patient Transfers

Dealing with Patient Transfers

Pre-Admission Order Policies

Pre-Admission Order Policies

Creating Order Sets

Creating Order Sets

Initial Selection of What to Alert on

During a CPOE) pilot, one organization discovered how much people communicate with those yellow sticky notes. For example, they found notes that said "Oxygen is up for renewal" or "you’ve got a narcotic that’s going to expire in twenty-four hours." Everybody just stuck sticky notes all over the chart.

One of the known disadvantages of CPOE is that not as many people are touching the patient's chart. Many physician's log in from home, and just place their morning orders. They are not looking at that paper chart with those sticky notes on it.

One way of deciding which alerts and rules to put in place is to replace the world of sticky notes. The organization developed alerts that said, "Your twenty-four hours are up with oxygen. Do you want the patient to continue?" or "narcotics are up for renewal." They started with basic alerts that helped with communication and work flow. Physicians expected to get an alert that says, "A narcotic’s getting ready to expire." They were used to it in the paper world, so they commented, "Okay, this is okay."

Standardized dictionaries

Standardized dictionaries from the Unified Medical Language System (UMLS) are essential. There are many controlled vocabularies to choose from.

Co-signing

Orders must be co-signed within a brief time period, usually less than 48 hours. Doctors often do not date and time their orders or their signatures, and it is common for physicians to sign orders weeks or even months after the fact. CPOE will allow the regulator to see the time to the second that the order was entered and signed.

Payne et al proposed creating a model of the life cycle of clinical documents to serve as a framework for discussion of document workflow. The model of the life cycle of a clinical document can be view: [2]. The life cycle model has 3 axes: Stage, role and action.[7].

AMDIS Response to the Federal Tamper-Resistant Rx Law

AMDIS Response to the Federal Tamper-Resistant Rx Law

Physical computing environment

A great selection of computers help facilitate CPOE.

Success Factors

Success Factors

After evaluating multiple CPOE systems using 40 + parameters, my conclusion is that the success factors can be easily classified to fall under three major categories as follows.

Productivity (intuitive, ease of use, speed, context sensitive help)

Care Quality (error reduction, reliability, Interaction accuracy, Overrides)

Security (programmed timeouts, role based authorization, authentication, access control, granularity of data acce

If the competing systems are still using green screens like RMRS or BICS (text based and keystroke or function key driven and not windows based and mouse driven), those fall out of favor against the more recent, Windows/web based systems like Practice Fusion or NextGen.

Clearly, the CPOE systems will need to integrate the Order Entry piece of their functionality with the Decision Support Systems (DSS) that create operational intelligence, so it can be brought out in real time during an encounter.

Studies reveal that very large Health Plan sponsors like Humana, Aetna, United Health, all have acquired companies that specialize in decision support.

To give specific examples, Humana has acquired Anvita and Aetna has acquired ActiveHealth. They claim that they have 1,200 health monitored events and 9,000 clinical rules that fire on the patient's cleansed, normalized and aggregated data to create operational intelligence that can be shared with the Physician during the encounter for optimizing care, cost of care and to influence both patient's as well as the physician's behavior.

Another major success factor is the reduction of over medicating. Urban 2015 shows that CPOEs can reduce the amount of drugs a patient uses during their time at a hospital.

CPOE and Meaningful Use

In order for eligible providers and hospitals to qualify for federal stimulus dollars, they must use certified electronic health technology in a meaningful way. [3] Sometimes organizations struggle to achieve meaningful use. [4] [[5] Computer physician order entry is one of the meaningful use measures that looks at all orders for a patient and how many were entered electronically by a licensed healthcare professional.


There are studies emerging that indicate that CPOE may actually increase medical errors especially if not implemented correctly [6] [7] [8]. There is evidence that the current CCHIT-certified EHR technology is challenging to use for physicians and hospitals and takes years of training. The CCHIT certification model is mandates hundreds of required features and functions, often which are non user-friendly. [9]

An interesting study was performed by a team of authors that set out to study the myth associated with eHealth initiatives implementation that this lead to substantial gains in quality and patient safety and concluded that evidence they found using qualitative methods is not that compelling but they leave great room for improvements.[8]

However, it is clear that the federal government is doing everything in its power to get various health care systems certified and working together and willing to commit funds and oversight and where necessary, impose penalties to make it happen.

Pediatric Use

Due to the medical needs of children varying from that of adults, the use of a CPOE without pediatric CPOE capabilities will actually increase medical errors.

Implementation Strategies

Some organizations hire computer scribes who follow and enter orders for physicians. This allows reluctant physicians to also comply with CPOE.

Big Bang vs. Incremental Roll-out

In the 1990s, one site used a gradual implementation with the old TDS system. First, very useful things to physicians were introduced, such as x-ray reports, labs results, and rounding lists. This allowed everyone to get accustomed to the user interface. Then, the CPOE introduced electornic ordering with the least dangerous medications. By the time the pharmacy was also using CPOE, everyone in the hospital was accustomed to the interface. In fact, most saw the benefit of doing things online instead of the paper system. The entire process took about a year and a half to get to full CPOE (93% of all orders by physicians). Paper orders were a fall back, however, with great pressure not to use them. There is also a psychological benefit to a paper fall-back system. Physicians get angry when they are in a hurry and can't order because they can't navigate the system.

Whether, when, and how to remove paper from the process?

Whether, when, and how to remove paper from the process?

Can Utilizing a Computer Provider Order Entry (CPOE) System Prevent Hospital Medical Errors and Adverse Drug Events?

This is a review of an article by Charles et al 2014. Can utilizing a Computer Provider Order Entry (CPOE) System Prevent Hospital Medical Errors and Adverse Drug Events?

Unintended Consequences of Implementing CPOE

Factors contributing to an increase in duplicate medication order errors after CPOE implementation

Successful CPOE implementation at teaching hospital

An Observational Study of the Impact of a Computerized Physician Order Entry System on the Rate of Medication Errors in an Orthopaedic Surgery Unit

Medication Errors

Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems

Reviews

References

  1. HIMSS dictionary of healthcare information technology terms, acronyms and organizations. (2010). Chicago, IL: Healthcare Information and Management Systems Society.
  2. Kuperman & Gibson 2003. http://www.annals.org/content/139/1/31.abstract>
  3. Love, J.S., Wright, A., Simon, S.R., Jenter, C.A., Soran, C.S., Volk, L.A., Bates, D.W., and Poon, E.G. (2012). Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use? Journal of American Medical Informatics Association, 19(4), 610-614. DOI 10.1136/amiajnl-2011-000544 http://www.ncbi.nlm.nih.gov/pubmed/22199017
  4. 4.0 4.1 Osheroff JA, Pifer EA, Teich JM, Sittig DF, Jenders RA. Improving Outcomes with Clinical Decision Support. http://ebooks.himss.org/product/improving-outcomes-clinical-decision-support
  5. McDonald,J.M. Improving Outcomes with Clinical Decision Support. The Regenstrief Medical Record System:a quarter century experience. http://www.ncbi.nlm.nih.gov/pubmed/10405881
  6. Salmon JW, Jiang R. E-prescribing: history, issues, and potentials. Online J Public Health Inform. 2012;4(3). http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pmc/articles/PMC3615836/
  7. Payne TH and G Graham. Managing the Life Cycle of Electronic Clinical Documents. J Am Med Inform Assoc. 2006 Jul-Aug; 13(4): 438–445. http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pmc/articles/PMC1513669//
  8. http://clinfowiki.org/wiki/index.php/The_Impact_of_eHealth_on_the_Quality_and_Safety_of_Health_Care:_A_Systematic_Overview#Approach

Related Links

http://clinfowiki.org/wiki/index.php/The_Influence_that_Electronic_Prescribing_has_on_Medication_Errors_and_Preventable_Adverse_Drug_Events:_an_Interrupted_Time-Series_Study#Internal_Outgoing_Links

Addition of electronic prescription transmission to computerized prescriber order entry: Effect on dispensing errors in community pharmacies.

Computerized physician order entry: promise, perils, and experience