Unit 4: Computerized Provider Order Entry (CPOE)

Lecture A defines CPOE, states the purpose of CPOE, lists attributes and functions of CPOE, and explains how CPOE is currently being used in health care. Lecture B describes the major value to adopting CPOE applications, identifies the common barriers to adoption, and summarizes the potential impact CPOE has on patient care safety, quality and efficiency, and patient outcomes.

Lectures

Lecture A Notes

Slide 1

Welcome to Health Management Information Systems: Computerized Provider Order Entry.  This is Lecture a.

The component, Health Management Information Systems, is a “theory” component that provides an introduction to health care applications and the systems that use them, health information technology standards, health-related data structures, and enterprise architecture in health care organizations.

Lecture a will define CPOE, state the purpose of CPOE, list attributes and functions of CPOE, and explain how CPOE is currently being used in health care.

Slide 2

The Objectives for Computerized Provider Order Entry are:

  • Describe the purpose, attributes and functions of CPOE;
  • Explain ways in which CPOE is currently being used in health care;

Slide 3

Additional Objectives for this unit, Computerized Provider Order Entry, are to:

  • Discuss the major value to CPOE adoption;
  • Identify common barriers to CPOE adoption;
  • and Identify how CPOE can affect patient care safety, quality and efficiency, as well as patient outcomes.

Slide 4

Interventions in patient care, such as performing diagnostic tests, administering medications, and drawing blood, are initiated by provider’s orders. The more traditional methods of placing provider orders are written (paper), verbal (in person or via telephone), and fax. A computer application known as computerized provider order entry is now being used in place of these traditional methods.

According to HIMSS, Computerized Practitioner Order Entry or CPOE is “An order entry application specifically designed to assist clinical practitioners in creating and managing medical orders for patient services and medications” (HIMSS Dictionary, 2010, p. 28).

The Centers for Medicare & Medicaid Services (CMS) defined CPOE as “entailing the provider’s use of computer assistance to directly enter medical orders (for example, medications, consultations with other providers, laboratory services, imaging studies, and other auxiliary services) 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” (CMS, 2010, pp. 1854-1855).

CPOE is often depicted in the literature and referred to in the healthcare community as computerized practitioner order entry, or computerized physician order entry. For this unit, the term computerized provider order entry will be used.

Slide 5

Care delivery and clinical documentation systems are systems that support the delivery of the care and documentation of that care. An example would be clinical information systems. A clinical information system (CIS)  “The components of a health care information system designed to support the delivery of patient care, including order communications, results reporting, care planning, and clinical documentation” (Shortliffe & Cimino, 2006, p. 924). Computerized provider order entry is typically a module of an integrated clinical information system.

CPOE is a computer application that enables a provider to place patient orders via the computer for further processing. It is much more than a replacement of paper orders with electronic ones. CPOE is also not just an electronic prescribing system. It may or may not include the electronic transmittal of that order to another department, such as the pharmacy, laboratory, or diagnostic imaging center.

Coupled with a clinical decision support system, CPOE has the capability of applying rules-based logic to assist the provider with making optimal ordering decisions. Later on in this unit the relationship between CPOE and CDS is further explored.

Slide 6

The next several slides will explain the purpose of computerized provider order entry. The overall purpose of CPOE is to automate the ordering process in order to manage patient care more effectively and efficiently, and as a result improve patient safety and outcomes. CPOE is a far-reaching technology, as it affects everyone in the organization from administration to providers to patients.

Slide 7

As was previously explained, CPOE’s purpose is to automate the patient ordering process. This in turn helps to manage patient care more effectively and efficiently and as a result, improve patient safety and outcomes. Given this overarching purpose, the four main reasons healthcare providers implement CPOE are to:

- Prevent, reduce, or eliminate medical errors and adverse drug events

- Improve patient safety,

- Reduce unnecessary variation in health care, and

- Improve efficiency of health care delivery.

Each will be explored more in detail on the next few slides.

Slide 8

The first main reason health care organizations and providers implement CPOE is to prevent, reduce, or eliminate medical errors and adverse drug events or ADEs. Two well known reports from the Institute of Medicine, To err is human: Building a safer health system and Crossing the quality chasm: A new health system for the 21st century, provided an impetus to health care organizations and physician practices to consider CPOE. These IOM reports stated 98,000 patients die each year in U.S. hospitals due to medical errors (Kohn, Corrigan, & Donaldson, 2000) and advised rapid adoption of electronic medication ordering to support clinical decisions (Committee on Quality of Health Care in America, 2001).

While the automation of the patient ordering process is recognized as not a small or easy task, CPOE’s potential to prevent, reduce, or eliminate medical errors and adverse drug events is a major motivation for health care organizations and physician practices to adopt this application.

Slide 9

The second main reason health care organizations and providers implement CPOE is to improve patient safety. According to The Leapfrog Group (2011), the IOM report mentioned in the previous slide supplied the Leapfrog founders an initial focus, that is, the reduction of preventable medical mistakes.

The Leapfrog Group is a consortium of major companies and other large private and public healthcare purchasers. Their mission is “To trigger giant leaps forward in the safety, quality and affordability of health care by: supporting informed healthcare decisions by those who use and pay for health care; and, promoting high-value health care through incentives and rewards” (The Leapfrog Group, 2011, para. 1).

A “leap” is a recommended hospital quality and safety practice. The Leapfrog Group identified CPOE deployment by hospitals as one of its “leaps,” or key patient safety standards. The progress in implementing CPOE systems is monitored through The Leapfrog Hospital Survey. In June 2010, the Leapfrog Group published a report on the results from a test of hospitals’ computerized physician order entry systems on their ability to detect common medication errors. According to the report, “The CPOE systems on average missed one half of the routine medication orders and a third of the potentially fatal orders. Nearly all of the hospitals improved their performance after adjusting their systems and protocols, and running the simulation a second time” (The Leapfrog Group, 2010, p. 1).

Slide 10

The third main reason health care organizations and providers implement CPOE is to reduce unnecessary variation in health care. CPOE helps the physician make optimal ordering decisions and improve adherence to evidence-based practice. For example, a specific diagnosis may have a set of orders associated with it. The CPOE application provides the use of the pre-programmed, provider or institution-reviewed and approved orders to facilitate the process and guide the provider to follow accepted protocols for the diagnosis.

However, a CPOE system requires orders and order sets be configured for this goal to be achieved. This is discussed in lecture 4b.

Slide 11

The fourth main reason health care organizations and providers implement CPOE is to improve the efficiency of health care delivery. CPOE applications accept orders into the system which are then communicated to the department and personnel to execute. Notification of the status is sent back. Thus a reduction in the time from placement of the order to its completion is realized. CPOE also saves a step as there is no need to re-enter data into an ancillary computer system so the time it takes for the ancillary department to complete the order is less (First Consulting Group, 2003, p. 6).

Slide 12

Having covered the reasons why health care organizations and providers are adopting CPOE, attributes will be covered next.

First, computerized provider order entry is typically a module of an integrated clinical information system which in turn is part of a larger integrated information technology infrastructure.

Second, interfaces with existing information systems such as registration, pharmacy, laboratory, and electronic medical record systems are needed for CPOE to be most effective (Dixon & Zafar, 2009). In addition, coupling CPOE with a clinical decision support system provides the capability of applying rules-based logic to assist the provider with making optimal ordering decisions which is key to enhancing patient safety and provider efficiencies.

A third attribute is the capability for the provider to place patient orders via the computer or mobile device for further processing thereby automating the communication of orders from the ordering practitioner to the location where the order is processed. Through the use of pre-programmed, provider or institution-reviewed and approved orders and order sets that facilitate the process and guide the provider to follow accepted protocols for the diagnosis, this attribute helps the physician make optimal ordering decisions and improve adherence to evidence-based practice.

Slide 13

Other attributes include order processing and documentation. The application is able to assist clinical practitioners in creating and managing medical orders for patient services. Specific features document or capture orders in a digital, structured, and computable format and accept them into the system which are then communicated to the department and personnel to execute. Notification of the status is sent back. Regulatory compliance related to order documentation, such as the creation of a permanent, signed order, and security controls, for example, secure access, are important attributes but these may not be included in every CPOE application.

Additional CPOE attributes are system responsiveness and system response time. Positive provider experiences are linked to application responsiveness. Providers expect CPOE to not leave them hanging and to provide them with a quick response during their ordering sessions. Response time is the time interval between an executed event and some response, e.g., acknowledgment of receipt, an estimated completion time, or a progress bar. Providers may find variable response times almost as frustrating as a CPOE application that is all-around slow.

Slide 14

CPOE also needs to be reliable. The U.S. Food and Drug Administration’s glossary (as cited in Booth, 1993) includes the following definition of software reliability:

“(1) the probability that software will not cause the failure of a system for a specified time under specified conditions. The probability is a function of the inputs to and use of the system in the software. The inputs to the system determine whether existing faults, if any, are encountered. (2) The ability of a program to perform its required functions accurately and reproducibly under stated conditions for a specified period of time” (Booth, 1993).

Providers expect CPOE to perform without interruption due to system shutdowns from crashes, or even routine maintenance to facilitate the critical ordering process.

Slide 15

Moving on, the next topic that will be discussed is CPOE functionality. CPOE applications may encompass only basic functionality or expand to more complex functionality where clinical decision support is used.

For basic functionality, the focus is on the capture and transmission of the order or order communication. There may or may not be minimal access to knowledge resources and simple bi-directional communication.

Many CPOE applications accept the physician’s orders for diagnostic and treatment services, transmit the order to the appropriate location, return the status of the order, and return the results of the order execution

Slide 16

The more advanced CPOE applications have some form of clinical decision support. However, when it comes to clinical decision support and CPOE applications, there are different levels of sophistication. An elementary level is simple, clinical decision support where, for example, the capability to perform drug-drug interaction checks is possible. An example of a complex level is when an alert is generated from an identified drug and a lab value. This interactive decision support goes a long way towards improvements in patient safety and quality. According to Dixon & Zafar (2009), limited benefit may result from implementing an order entry system without coupling clinical decision support with it during the order-entry process.

CPOE and clinical decision support are explored further in the next several slides.

Slide 17

According to HIMSS, “Clinical decision support system is an application that uses pre-established rules and guidelines that can be created and edited by the healthcare organization, and integrates clinical data from several sources to generate alerts and treatment suggestions” (HIMSS Dictionary, 2010, p. 21).

Slide 18

CPOE can be much more than the replacement of paper orders with electronic ones. United with a clinical decision support system, CPOE has the ability to provide access to evidence-based guidelines, give prompts, reminders, or alerts regarding the order entered thereby enhancing patient safety and provider efficiencies.

The clinical decision support system use of rules-based logic assists the provider with making optimal and safe ordering decisions by supplying clinical advice at the time of order entry about a wide-range of diagnostic and treatment-related information. Advice such as patient allergies, possible drug reactions and interactions, and calculations of medication dosages based on patient weight and age is possible when the CPOE application is coupled with clinical decision support. 

For example, once the medication order is entered into the computer the CPOE application could then trigger a warning of a drug allergy along with a suggested alternative medication.

As numerous studies show, CPOE needs to include clinical decision support to reach its full value. A CPOE system employing CDSS elements provides clinicians with access to evidence-based guidelines, prompts, and alerts at the point of care delivery. 

Slide 19

There is not one single approach to integrating CDSS into CPOE. According to HIMSS, questions information technology specialists should be asking with regards to the clinical decision support available to the CPOE application are:

 “What kind and how much clinical support?

“What about medication alerts, allergies, routine preventive diagnostics?

“How many alerts will users tolerate before ignoring them?

“How difficult should it be for the practitioners to override the alerts?” (HIMSS, 2003, para. 2)

Joining a clinical decision support system with CPOE has been shown to unlock the patient safety and provider efficiency benefits such as the ability to provide access to evidence-based guidelines and give prompts, reminders, or alerts regarding the order entered.

Slide 20

CPOE is a broad-ranging application with a multitude of users including but not limited to those who enter the orders and those who process the orders. CPOE users include physicians, nurses, physician assistants, nurse practitioners, ancillary staff such as pharmacists, therapists, laboratory and radiology personnel, dieticians and others.

Slide 21

CPOE also is far-reaching from the sense of where it is used, and the order types involved. CPOE use is not limited to the inpatient environment. It is useful to any health care setting where clinical processes, tests, procedures, and medications are ordered, performed, or administered. The most common settings are inpatient or ambulatory settings.

CPOE is also not limited to medication orders. Order types, such as those for tests, procedures, and other clinical processes fall under the umbrella of CPOE.

Thus, CPOE is currently being used in health care as a replacement for the more traditional methods of placing a variety of order types, including written (paper prescriptions), verbal (in person or via telephone), and fax, in any health care settings where tests and medications are ordered, performed, or administered.

Slide 22

This concludes Lecture a of Computerized Provider Order Entry.  This lecture defined computerized provider order entry and described the purpose, attributes and functions of CPOE. It also explained ways in which CPOE is currently being used in health care.

Lecture B Notes

Slide 1

Welcome to Health Management Information Systems, Computerized Provider Order Entry. This is Lecture b.

The component, Health Management Information Systems, is a “theory” component that provides an introduction to health care applications and the systems that use them, health information technology standards, health-related data structures, and enterprise architecture in health care organizations.

Lecture b will describe the major value to adopting CPOE applications, identify the common barriers to adoption, and summarize the potential impact CPOE has on patient care safety, quality and efficiency, and patient outcomes.

Slide 2

The Objectives for Computerized Provider Order Entry are:
• Describe the purpose, attributes and functions of CPOE;
• Explain ways in which CPOE is currently being used in health care;

Slide 3

Additional Objectives for this unit, Computerized Provider Order Entry, are to:
• Discuss the major value to CPOE adoption;
• Identify common barriers to CPOE adoption;
• and Identify how CPOE can affect patient care safety, quality and efficiency, as well as patient outcomes.

Slide 4

CPOE is a valuable tool and has many advantages when compared with paper-based systems.

As cited in Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors by Koppel, et al. (2005), the following advantages were identified:

• Handwriting identification problems no longer exist
• The order reaches the pharmacy quicker
• Errors associated with similar drug names are not as likely to occur
• Easier to interface with electronic health records and decision support systems

Slide 5

Four more advantages as several studies cited in Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors by Koppel, et al. (2005) described are:
• Errors caused by use of apothecary measures not as likely to occur
• Easy connection to drug-drug interaction warnings
• Probability of recognizing the prescribing physician
• Connection to adverse drug event reporting systems made possible

Slide 6

Additional advantages of CPOE when compared with paper-based systems that were cited in various studies noted by Koppel, et al. (2005) are:
• Immediate data analysis made possible
• Economic savings may occur
• Via online prompts
- Join CPOE with algorithms to underscore cost-effective medications
- Decrease underprescribing and overprescribing
- Lessen incorrect drug choices

Slide 7

With all these advantages, the value of CPOE is apparent.

According to an HIMSS CPOE Fact Sheet, CPOE value extends to the organization beyond having an electronic record, rather than a paper one in the following ways:

• “Enhanced patient safety—medication errors are reported to be the largest cause of adverse hospital events. CPOE eliminates transcription error and clinical alerts can warn of allergies and drug/drug interaction.
• CPOE can reduce costs—Studies have found that adverse drug events can increase hospital stays significantly. Additional cost savings can be realized with clinical decision support that directs practitioners to lower doses or alternate medications.
• CPOE is a powerful tool in guiding practitioners in reducing unnecessary variation in care by encouraging best practices” (HIMSS, 2003, para. 5).

One of the NQF-endorsed safe practices (2010) that has been demonstrated to be effective in reducing the occurrence of adverse healthcare events and improving health care safety is CPOE.

Adverse drug events can increase hospital stays significantly so any technology such as CPOE, which can reduce ADEs, can also reduce costs.

Slide 8

Even with the recognition that CPOE is valuable, barriers to adoption and implementation do exist.

They include:

• The belief that physicians will not use computerized ordering,
• Physicians who are used to the paper method may resist switching to the computerized system and adapting to it, and

• The time to switch from a paper to an electronic system will take time that providers do not want to allow for.

CPOE is complex. It requires the cooperation of many individuals and implementation involves representatives from many areas of operations.

For example, CPOE requires a number of interfaces with other existing systems such as the electronic health record. Orders and order sets need to be configured. Even if the health care organization starts the order set development process with a standard, baseline collection format provided by a vendor, it is a time-consuming process requiring the participation of numerous and disparate clinical departments (Dixon & Zafar, 2009).

CPOE impacts workflow and process of all caregivers and ancillary personnel. It is “a disruptive technology that fundamentally changes the processes used to place, review, authorize, and carry out orders” (Dixon & Zafar, 2009, p. 7).

CPOE involves risk. Poorly-designed user interfaces and unacceptable processing speeds can increase the odds of errors, and therefore increase patient safety risks. A delay in order entry delays treatment and could result in mistakes.

CPOE is costly to implement and maintain. The New England Healthcare Institute (2008) estimated acquisition cost for a hospital CPOE system to be about $2.1 million and annual operating expenses of about $450,000 a year. Costs may differ depending on hospital size and level of existing IT infrastructure. An example of a cost is the continuous, frequent training and retraining needed as users adapt to CPOE. Another example are vendor support costs including day-to-day costs of having staff to support the users. Organizational staff is also needed to provide testing for upgrades and enhancements.

Slide 9

In addition to the barriers previously identified, there is the issue of e-iatrogenesis. Although CPOE systems are designed to decrease errors, they can be a source of errors if not designed correctly. Thus, CPOE can have a potential negative affect on patient care safety, quality and efficiency, as well as patient outcomes.

E-iatrogenesis is “Patient harm caused at least in part by the application of health information technology” (Weiner, Kfuri, Chan, & Fowles, 2007, p. 387).

Actual or potential e-iatrogenic events related to CPOE errors have been discussed in published research. The results of one such study are found in the article, Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. A total of 22 situations were identified where CPOE increased the probability of medication errors (Koppel, et al., 2005). These are summarized on the next slide.

Slide 10

The 22 situations where CPOE increased the probability of medication errors were categorized into the following two groups:

“…(1) Information errors generated by fragmentation of data and failure to integrate the hospital’s several computer and information systems and (2) human-machine interface flaws reflecting machine rules that do not correspond to work organization or usual behaviors” (Koppel, et al., 2005, p. 1199).

Examples of information errors are:

• Medication discontinuation failures;
• Immediate order and give-as-needed medication discontinuation faults;
• Antibiotic renewal failure;
• Conflicting or duplicative medications. (Koppel, et al., 2005)

Slide 11

Examples of human-machine interface flaws are:

• Wrong medication selection
• Loss of data, time, and focus when CPOE is nonfunctional
• Sending medications to wrong rooms when the computer system has shut down
• Late-in-day orders lost for 24 hours
• Role of charting difficulties in inaccurate and delayed medication administration
• Inflexible ordering screens, incorrect medications (Koppel, et al., 2005)

Slide 12

While CPOE has been a major initiative of US hospitals for over a decade, the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act and specifically Section 3001(b) calls for the Office of the National Coordinator for Health Information Technology (ONC) to develop “a nationwide health information technology infrastructure that allows for the electronic use and exchange of information and that…ensures that each patient’s health information is secure and protected, in accordance with applicable improvements in health care quality, reduces medical errors, reduces health disparities, and advances the delivery of patient centered medical care” among other goals.

In support of the HITECH Act, to help meet the statutory requirements in the Medicare and Medicaid Programs of the Electronic Health Record Incentive Program Final Rule, the meaningful use core set of measures was expanded to include the use of CPOE in the fundamental elements with the goal to improve patient care.

Slide 13

CPOE is considered to be a foundational element to many of the other objectives of meaningful use including the exchange of information and clinical decision support. The Electronic Health Record Incentive Program Final Rule states for Stage 1 CPOE is included in the core set of measures. The meaningful use core measure for eligible professionals, eligible hospitals, and critical access hospitals is ‘‘Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines” (CMS, 2010, p. 44370).

Only medication orders are included. More than 30% of all unique patients, with at least one medication in their medication list seen by the eligible professional or admitted to the eligible hospital’s or critical care hospital’s inpatient or emergency department during the EHR reporting period, have at least one medication order entered using CPOE. The threshold for Stage 2 is 60%. In addition, for Stage 1 the transmission of the order is not included in the objective or the associated measure.

The Final Rule also clarified which healthcare professional can enter orders using CPOE, as any licensed healthcare professional per state, local and professional guidelines (CMS, 2010)..

Slide 14

CPOE can also have a potential positive affect on patient care safety, quality and efficiency, as well as patient outcomes.

Citing several studies, Dixon & Zafar noted “When implemented together, CPOE systems and CDS can improve medication safety and quality of care and reduce costs of care. They can also improve compliance with provider guidelines, as well as the efficiency of hospital workflow” (Dixon & Zafar, 2009, p. 2).

However, as mentioned previously, use of CPOE should not be executed by itself as limited benefit may result from implementing an order entry system without coupling clinical decision support with it during the order-entry process (Dixon & Zafar (2009).

Slide 15

CPOE can also have a positive impact on efficiency. Any reduction in the time it takes to render patient care can potentially reduce the amount of time in the hospital. CPOE is a powerful tool in guiding practitioners in reducing unnecessary variation in care by encouraging evidenced-based practices. However, in order to optimize impact on efficiency, CPOE should be an integrated component of the clinical information system which in turn is part of a larger integrated information technology infrastructure.

Positive and negative effects of CPOE on patient care safety, quality and efficiency, as well as patient outcomes, have been documented in the literature. However, both patient safety and health care cost pressures, along with the Federal incentives tied to meaningful use, present a clear imperative to proceed with the implementation of CPOE.

Slide 16

As pointed out by the California HealthCare Foundation. “…CPOE is not a technology implementation, but a redesign of a complex clinical process, which integrates technology at key points to optimize ordering decisions… CPOE is an organizational change initiative, not an IT project” (California HealthCare Foundation, 2000, p. 2)

Slide 17

This concludes Computerized Provider Order Entry.

Lecture a defined computerized provider order entry and described the purpose, attributes and functions of CPOE. It also explained ways in which CPOE is currently being used in health care.

Lecture b described the major value to adopting CPOE applications, identified the common barriers to adoption, and summarized the potential impact CPOE has on patient care safety, quality and efficiency, and patient outcomes.

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Comments

  • I found CPOE is very important programme for medical persons.
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