Difference between revisions of "CPOE"
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Physicians’ responses towards CPOE are often mixed. Many don’t want to spend that much time sitting in front of a computer entering data, the “power of being a doctor” feels reduced when they must spend part of their day entering data. The design and implementation of many CPOE systems often results in more negative views; if physicians are not inputting data fully – or correctly – then the information is misinterpreted by nurses and other staff and errors still occur, or rise. <ref name="khajouei 2010">Khajouei R, Jaspers MW. (2010). The impact of CPOE medication systems’ design aspects on usability, workflow and medication orders. Methods of Information in Medicine, 49(1), 3-19. DOI 10.3414/ME0630 http://www.ncbi.nlm.nih.gov/pubmed/19582333</ref> | Physicians’ responses towards CPOE are often mixed. Many don’t want to spend that much time sitting in front of a computer entering data, the “power of being a doctor” feels reduced when they must spend part of their day entering data. The design and implementation of many CPOE systems often results in more negative views; if physicians are not inputting data fully – or correctly – then the information is misinterpreted by nurses and other staff and errors still occur, or rise. <ref name="khajouei 2010">Khajouei R, Jaspers MW. (2010). The impact of CPOE medication systems’ design aspects on usability, workflow and medication orders. Methods of Information in Medicine, 49(1), 3-19. DOI 10.3414/ME0630 http://www.ncbi.nlm.nih.gov/pubmed/19582333</ref> | ||
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| + | * [[Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit]] | ||
Revision as of 05:38, 24 January 2015
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]
Contents
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]
Security configuration
The security system should be configured correctly.
- Passwords should be secure yet easy to remember. [1]
- Co-signatures allows for multiple levels of function and security (eg, an RN can place an order but only with a signature from a physician)
- Time-out settings prevent accidental unauthorized access.
- Clinical staff are sometimes reluctant to switch from paper to electronics. Active encouragement, additional training, and a deadline to fully integrate into CPOE increases compliance.
Dealing with Patient Transfers
Dealing with Patient Transfers
Pre-Admission Order Policies
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.
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
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. [2] Sometimes organizations struggle to achieve meaningful use. [3] [[4] 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 [5] [6] [7]. 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. [8]
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?
Users, Settings, and Roles
Nursing and CPOE
Emergency Department Setting
Monitoring and Evaluation
Routine Methods
Leapfrog CPOE Standard
Unintended Consequences
Unintended consequences fall into two main categories: [9]
- increased mortality
- Error in entering and retrieving information
- Communication and coordination
- Increased Resource Utilization
Emotional Reactions
Prescribers’ Responses to Alerts During Medication Ordering in the Long Term Care Setting
Prescribers’ Responses to Alerts During Medication Ordering in the Long Term Care Setting
Project Governance
Readiness Assessment
- Readiness Assessment
- Computerized physician order entry with clinical decision support in the long-term care setting
Setting up the Project Team
Negatives of Computer Provider Entry System
Despite resulting in medication and other errors, CPOE still faces many negative views from physicians and other providers. “The increased time required by physicians to enter data into CPOE products will result in increased personnel costs for direct patient care;” also more time spent entering data resulted in less face-time with patients and reduction in profit[6]
Another negative of CPOE is cost. On top of additional personnel costs to cover longer work hours, estimated costs of a computer provider entry system can be 1.6-2 million annually – this cost is after initial implementation and regular maintenance and support. [6]
Physicians’ responses towards CPOE are often mixed. Many don’t want to spend that much time sitting in front of a computer entering data, the “power of being a doctor” feels reduced when they must spend part of their day entering data. The design and implementation of many CPOE systems often results in more negative views; if physicians are not inputting data fully – or correctly – then the information is misinterpreted by nurses and other staff and errors still occur, or rise. [7]
Reviews
References
- ↑ HIMSS dictionary of healthcare information technology terms, acronyms and organizations. (2010). Chicago, IL: Healthcare Information and Management Systems Society.
- ↑ Kuperman & Gibson 2003. http://www.annals.org/content/139/1/31.abstract>
- ↑ 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
- ↑ 4.0 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
- ↑ 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
- ↑ 6.0 6.1 Berger, R. G., & Kichak, J. P. (2004). Computerized physician order entry: helpful or harmful? Journal of American Medical Informatics Association, 11(2), 100-103. DOI 10.1197/jamia.M1411 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC353014/
- ↑ Khajouei R, Jaspers MW. (2010). The impact of CPOE medication systems’ design aspects on usability, workflow and medication orders. Methods of Information in Medicine, 49(1), 3-19. DOI 10.3414/ME0630 http://www.ncbi.nlm.nih.gov/pubmed/19582333
