Effect of computerized prescriber order entry on pharmacy: experience of one health system
This is a review article by McMullen et al., about the experience of transformation brought by the implementation of CPOE focusing mainly on pharmacists perspective in a large non profit Health System in Michigan-Spectra Health System. 
The purpose of this article was to study the consequences of the implementation of computerized prescriber order entry (CPOE) on pharmacist’s workflow and order verification in a nonprofit Hospital System -Spectrum Health, Michigan in three of the largest branches Blodgett Hospital, Helen DeVos Children's Hospital and Butterworth Hospital.
Much research is documented on the impact on physicians, physician assistants, nurse practitioners and medical residents of CPOE implementation but not in view of other staff such as pharmacists and laboratory staff. Spectrum Health adopted the Cerner Millennium electronic health record (EHR) in 2010. Prior to the initiation of CPOE, pharmacists with other stakeholders (physicians, nurses, and operational staff) were involved in designing standardized order sets which included appropriate therapy and formulary choices to choose from for prescribers. The pharmacists were given training to face challenging order processes and a competency test to evaluate their order entry and verification abilities.After the CPOE went live, there was a command center available in order to solve the technological and workflow related problems. 
Methods used in evaluation
McMullen et.al. used three mixed-method approach , a triangulation research design to investigate how CPOE affected pharmacists through
- Quantitative approach: Online circulated Web-based Clinical Information System Implementation Evaluation Scale (CISIES) survey to quantitate pharmacists' self-reported perceptions prior and after implementation. This survey had 37 questions about CPOE system expectations and experiences and was evaluated by the 15-item Clinical Information System Questionnaire (CISQ-15) and an elaborated, 36-item version (the CISQ-36).All the survey data were analyzed with Stata Statistical Software, release 12.
- Qualitative approach: Combined data from ethnographic data from site visits post implementation and personal interviews with pharmacists and other stakeholders and pharmacy focus groups were all themed and analyzed using standard theme analysis
- Observational approach: Systematic structured quantitative observations noted the frequency and duration of pharmacists' work hours spent on clarifying orders prior and post CPOE implementation.
- CISIES survey results: The ratio of participation of Pharmacists prior to post implementation was 9/7 (54/42). It showed that the mean pre-CPOE pharmacist score was 1.04 while that of post CPOE was 1.25 compared to mean score of 0.04 for providers with a further decrease to -0.46.
- Qualitative Ethnographic data analyzed showed that pharmacists actually had appreciated benefits with respect to prioritization of orders, increased mobility for pharmacists across various places in hospital through any computer terminal and legible orders with a single click verification for clarifying orders. But they had to face new noticeable challenges elaborated in detail.
- Structured observational data highlighted the fewer and faster times for the available pharmacist shifts post implementation of CPOE that before CPOE. The clarification of medication orders were measured at shift level and event level calculated for pre- and post –CPOE implementation. Also various reasons was other than drugs with 12.9% and 38.7% respectively and the corresponding number and rate for clarification for contraindicated orders were 38.2% and 68% respectively for pre- and post CPOE.
Pharmacists had considerable acceptance rates prior and after implementation compared to other hospital staff. Also they have realized the benefits it had on the workflow and as these were evidenced by McMullen et al., survey data and ethnographic data were faster order verification, better prioritization of orders, increased accessibility for pharmacists throughout the hospital, and fewer orders requiring clarification. These findings were strengthened by structured observation of medication orders and the ethnographic results. Also Color-coding of orders and visual cues focusing for priority levels and need for urgency were of great help to pharmacists. But they expressed dissatisfaction over reliability, impact on patient care, and technical support for resolving problems and responding to user input about the system. Challenges of CPOE caused system "lockouts" with issues with alerts, timing of medication orders, and medication reconciliation, with prescriber-pharmacist lost or miscommunication as the features are different for both and train physicians so that the pharmacists need not bear the burden of as informal trainers in addition to duplicate orders. These challenges can easily be faced by pharmacy vigilance and well trained pharmacists.
The pre and post CPOE implementation evaluation, involvement of particularly pharmacists early on in the implementation in the development of order sets and with the prescribers or other areas as per demand with benefits of prioritization of workload, order clarifications and also enlightening to focus on potential challenges to increase the successful and maximize meaningful use of the CPOE.
Short study period could have changed results and resolved few challenges if studied for a longer period. As the conclusions were confined to single electronic health record ( EHR) hospital system they cannot be generalized. Also quantitative assessment was on only medication clarification events. McMullen et al., study findings were comparable to other studies in respect to multiple methods and data types.
McMullen et al., from Spectrum Health's case exposed unique concept of direct guidance for prescribers on CPOE medication ordering by pharmacists which could sometimes compromise the important areas to focus for pharmacists as trainers. Further studies on this aspect will be interesting.Also further studies involvement of pharmacists in order validation and solving technical problems post CPOE implementation.
McMullen et al., Study was an eye opener and unique in many aspects. They focused on their study purpose and it brought to light new points in perspective of pharmacists as they also play a major role in the patient safety, accurately carrying out medication orders and outcomes.
- McMullen,C.K., Macey,T. A., Pope, J., Gugerty, B., Slot, M., Lundeen, P., Ash, J., and Carlson,N. (Jan 2015). Effect of computerized prescriber order entry on pharmacy: experience of one health system. American Journal of Health-System Pharmacy.72.2 133-142. http://dx.doi.org.ezproxyhost.library.tmc.edu/10.2146/ajhp140106