Computerized physician order entry: promise, perils, and experience
This is a review of literature by Raman Khanna, and Tony Yen. (2014) in The Neurohospitalist, entitled “Computerized physician order entry: promise, perils, and experience.” 
The paper is a narrative literature review about computerized physician order entry (CPOE). The authors described a neurohospitalist’s perspective about CPOE, defined terms CPOE and meaningful use, compared it to the present standard of care, CPOE in association with clinical decision support systems (CDSS), its potential drawbacks, qualitative approaches, and implementation factors. The studies were drawn from PubMed and other non-medical peer reviewed journals.
CPOE and Meaningful Use
The essential features of CPOE are to provide patient safety, improve quality of care and cost-effectiveness. The Centers for Medicare and Medicaid Services (CMS) defined CPOE as “…the provider’s use of computer assistance to directly enter medication orders from a computer or mobile device. The order is also documented or captured in a digital, structured, and computable format for use in improving safety and organization.”  According to one of CMS’s criteria, to achieve meaning use, CPOE must be implemented and actively incorporated into patient care and workflow.
Computerized vs. Paper-Based
In one singular trial, the computerized discharge summary and medication reconciliation were compared to the traditional paper-based routine discharge procedures. The results demonstrated patient’s readiness for discharge in the CPOE group. The results from other non-randomized studies showed a 10-fold decrease in prescription errors with CPOE use. Another showed a reduction in adverse drug events in the hospital. An increase in the ordering of tests was seen in one study. Another study showed physician dissatisfaction from disempowerment. A reduction of mortality was noticed in a pediatric hospital after CPOE implementation. However, several studies proved no significant difference between CPOE and pre-CPOE practice.
CPOE with CDSS
One randomized study showed that the use of order sets lowered cognitive burden in physicians. Two other randomized controlled trials demonstrated that CDSS enhanced renal function-based medication dosing. Another trial found improved insulin dosing, scheduling, and hyperglycemia in hospitalized patients and also decreased the duration of stay with use of larger order sets. One study confirmed improved medication dosing and user satisfaction and reduced miscalculation and prescription errors in pediatric patients. Likewise, accurate medication dosing and adherence to transfusion guidelines was noted in elderly patients in another study. Timely administration of clot busters was noted in stroke patients in the emergency department. Overall, several studies confirmed benefits of CPOE with CDSS.
Unintended consequences of CPOE
In one study at a children’s hospital, negative effects of CPOE showed increased mortality occurring from errors such as wrong dosing and duplication of orders. Alert fatigue was another barrier to EHR adoption. Also, some studies proved no benefit from CPOE use.
Experience from implementing CPOE
The common challenges encountered by the physicians ranged from workflow interruption to recall issues. However, several benefits were noted, such as efficiency in STAT orders and orders requiring pharmacy verification in inpatient settings. In general, all providers accepted CPOE’s role in clinical effectiveness. Nurses recognized its legibility; pharmacists recognized its processing and scheduling of complex regimens; and even physicians appreciated how CDSS modules enabled evidence-based decision making.
CPOE has been proved to be beneficial, especially in the inpatient setting. Meaningful use incentives are driving CPOE adoption. Together with CDSS, CPOE has potential to enhance patient safety, quality and cost-effectiveness. Routine use of CPOE has reduced cognitive burden and its potential benefits led to its acceptance among the users.
This paper is a comprehensive review about CPOE. Several benefits, comparison, and challenges were described by analyzing numerous studies. In addition, greater insight was given through personal experience with CPOE implementation. I chose this paper because of its unique and thorough presentation.
- Computer physician order entry: benefits, costs, and issues.
- Principles for a Successful Computerized Physician Order Entry Implementation.
- Duplicate orders: an unintended consequence of computerized provider/physician order entry (CPOE) implementation: analysis and mitigation strategies
- Implementation of a clinical decision support system for computerized drug prescription entries in a large tertiary care hospital
- Khanna & Yen. (2014). Computerized physician order entry: promise, perils, and experience. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3869307/.
- CMS. (2010). CPOE for medication orders; 2010. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/down-loads/1_CPOE_for_Medication_Orders.pdf .