Computerized Provider Order Entry (CPOE)
Computerized Provider Order Entry (CPOE) is to replace a hospital’s paper-based ordering system. It allows users to electronically write the full range of orders. It also helps to maintain an online medication administration record, and review changes made to an order by successive personnel. In addition the system also offers safety alerts, when an unsafe order (such as for a duplicate test or therapy) is entered. Even further guides caregivers to less expensive alternatives or to choices that better fit established hospital protocols. Medical Orders Entry System can, increase efficiency and improve patient safety and patient care.
Interventions in patient care, such as performing diagnostic tests, administering medications, and drawing blood, are initiated by the provider’s orders. A computer application known as Computerized Provider Order Entry (CPOE) is now being used in place of the traditional methods. CPOE is much more than a replacement of paper orders with electronic ones. It 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.
What is a CPOE system
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”.
Medical orders directly enter from a computer or mobile device are medications, consultations with other providers, laboratory services, imaging studies, and other auxiliary services. The order is also in a digital, structured, and computable format for use in improving safety and organization.
The purpose of CPOE
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 main 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. In addition, through the use of 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.
CPOE is a far-reaching technology
An order entry system is a far-reaching technology, as it affects everyone in the organization from administration to providers to patients. CPOE coupled with a clinical decision support system, (CDSS) has the capability of applying rules-based logic to assist the provider with making optimal ordering decisions. 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 and efficiency of health care delivery
- Reduce unnecessary variation in health care
- Improve efficiency
1. Reduce or eliminate medical errors
The first main reason health care organizations and providers implement CPOE is to prevent, reduce, or eliminate medical errors and adverse drug events. While the automation of the patient ordering process is not a small or easy task, CPOE’s potential to prevent, reduce, or eliminate medical errors and adverse drug events is a major motivation.
2. Improve Patient safety
The second main reason health care organizations and providers implement Computerized Provider Order Entry, is to improve patient safety. 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 miss 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”.
3. Reduce unnecessary variations in health care
The third main reason health care organizations and providers implement Computerized Provider Order Entry, 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 to facilitates the process and guides the provider to follow protocols for the diagnosis.
However, a CPOE system requires a proper configuration of orders and order sets to achieve this goal.
4. Improve efficiency of health care delivery
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 communicates these orders 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.
Order processing and documentation
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 format and accept them into the system. Notification of the status is sent back. Regulatory compliance such as the creation of a permanent, signed order, and security controls, for example, secure access, are important attributes.
Additional CPOE attributes are system responsiveness and system response time. 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, completion time, or a progress bar.
Reliability is the ability of a program to perform its required functions accurately and reproducibly under stated conditions for a specified period of time. Providers expect CPOE to perform without interruption due to system shutdowns from crashes, or even routine maintenance to facilitate the critical ordering process.
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. There is 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
Clinical Decision Support System (CDSS)
Clinical decision support system is an application that uses rules and guidelines and integrates clinical data from several sources to generate alerts and treatment suggestions.
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.
Rules based logic
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. 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 a clinical decision support system.
The system 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 enhances patient safety and provider efficiencies. 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.
Approaching integration of CDSS into CPOE
There is not one single approach to integrating CDSS into CPOE. Joining a clinical decision support system with CPOE unlocks 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.
A broad-ranging application
CPOE is a broad-ranging application with a multitude of users including those who enter the orders and those who process the orders. Users include physicians, nurses, physician assistants, nurse practitioners, ancillary staff such as pharmacists, therapists, laboratory and radiology personnel, dieticians and others.
Not limited to Inpatients environment
The use of CPOE is not limited to the inpatient environment. It is useful to any health care setting where orders take place including clinical processes, tests, procedures, and medications. The most common settings are inpatient or ambulatory settings.
Not limited to medication orders.
Order types, such as those for tests, procedures, and other clinical processes fall under the umbrella of CPOE.
Thus, Computerized Provider Order Entry is in use 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.
Major value to adopting CPOE applications
This section describes the major value of adopting CPOE applications, identifying the common barriers to adoption, and summarizes the potential impact CPOE has on patient care safety, quality and efficiency, and patient outcomes.
The Objectives for Computerized Provider Order Entry
- Describe the purpose, attributes, and functions of CPOE;
- Explain ways in which CPOE is currently in use in health care;
- Discuss the major value to CPOE adoption;
- Identify common barriers to CPOE adoption;
- Identify how CPOE can affect patient care safety, quality, and efficiency, as well as patient outcomes.
CPOE is a valuable tool and has many advantages when compared with paper-based systems. Advantages are:
- Handwriting identification problems no longer exist
- The order reaches the target department quicker
- Errors associated with similar names are not as likely to occur
- Easier to interface with electronic health records and decision support systems
- Errors caused by the use of apothecary measures not as likely to occur
- Easy connection to drug-drug interaction warnings
- The Probability of recognizing the prescribing physician
- Connection to adverse drug event reporting systems made possible
Additional advantages of CPOE when compared with paper-based systems that were cited in various studies, are:
- Immediate data analysis made possible
- Economic savings may occur.
- Join CPOE with algorithms to underscore cost-effective medications
- Decrease underprescribing and overprescribing
- Lessen incorrect test choices
With all these advantages, the value of CPOE is apparent. It extends to the organization beyond having an electronic record, rather than a paper one in the following ways:
It is a powerfull tool
- enhances patient safety—medication errors is the largest cause of adverse hospital events. CPOE eliminates transcription error and clinical alerts can warn of allergies and drug/drug interaction.
- reduces costs. Adverse drug events can increase hospital stays significantly. Clinical decision support that directs practitioners to lower doses or alternate medications. produces additional cost savings.
- is a powerful tool in guiding practitioners in reducing unnecessary variation in care.
CPOE barriers to adoption and implementation
Even with the recognition that CPOE is valuable, barriers to adoption and implementation do exist.
- 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,
- 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 configuration. Even if the health care organization starts the order set development process with a standard, baseline collection format, it is a time-consuming process requiring the participation of numerous and disparate clinical departments.
- impacts the workflow and process of all caregivers and ancillary personnel.
- involves risk. Poorly-designed user interfaces and unacceptable processing speeds can increase the odds of errors and therefore increase patient safety risks.
- it is costly to implement and maintain.
Decrease the probability of medication errors
To decrease the probability of medication errors must be aware of:
- Information errors by fragmentation of data
- failure to integrate the hospital’s several computer and information systems
- human-machine interface flaws reflecting machine rules that do not correspond to work organization or usual behaviors
Examples of information errors are:
- Medication discontinuation failures
- Immediate order and give-as-needed medication discontinuation faults
- Antibiotic renewal failure
- Conflicting or duplicative medications
- 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
CPOE usage ensures that:
- Each patient’s health information is secure, in accordance with applicable improvements in health care quality
- Reduces medical errors and health disparities
- Advances the delivery of patient-centered medical care.
The meaningful use core set of measures must include the use of CPOE in the fundamental elements with the goal to improve patient care.
Computerized Provider Order Entry (CPOE) is a foundational element to many of the other objectives of meaningful use including the exchange of information and clinical decision support. The meaningful use core measure for eligible professionals, eligible hospitals, and critical access hospitals are :
Medication orders are directly entered by any licensed healthcare professional into the medical record.
CPOE is a powerful tool in guiding practitioners in reducing unnecessary variation in care by encouraging evidenced-based practices. It is not just a technology implementation, but a redesign of a complex clinical process, which integrates technology at key points to optimize ordering decisions. Finally CPOE is an organizational change initiative, not an IT project.
Read about ‘MediLab LIS’ the Laboratory Information System that supports the orders entry procedure.