Laboratory Order Entry System CPOE – CDSS
Laboratory Order Entry System is to replace a hospital’s paper-based ordering system. It allows users to electronically write the full range of orders, maintain an online medication administration record, and review changes made to an order by successive personnel.
It also offers safety alerts that are triggered when an unsafe order (such as for a duplicate test or therapy) is entered, as well as clinical decision support to guide caregivers to less expensive alternatives or to choices that better fit established hospital protocols. Medical Orders Entry System can, markedly 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. 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 (CPOE) is now being used in place of these traditional methods.
CPOE 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.
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 documented or captured in a digital, structured, and computable format for use in improving safety and organization.
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. 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.
CPOE 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.
CPOE, to be effective, needs interfaces with existing information systems such as registration, pharmacy, laboratory, and electronic medical record systems (Dixon & Zafar, 2009). In addition, coupling CPOE with a clinical decision support system (CDSS) 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.
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.
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 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).
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.
2. Improve Patient safety
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).
3. Reduce unnecessary variations in health care
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.
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 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).
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, structured, and computable format and accept them into the system which is 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.
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.
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.
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
Clinical Decision Support System (CDSS)
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).
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), a limited benefit may result from implementing an order entry system without coupling clinical decision support with it during the order-entry process.
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 a clinical decision support system.
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.
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. According to HIMSS, questions 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?”
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.
CPOE is a broad-ranging application
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.
CPOE is not limited to Inpatients environment
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.
Major value to adopting CPOE applications
This section describes the major value of 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.
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;
• 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.
As cited in the 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 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 noted by Koppel, 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 test choices
With all these advantages, the value of CPOE is apparent.
According to a 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.
One of the NQF-endorsed safe practices (2010) that have been demonstrated to be effective in reducing the occurrence of adverse healthcare events and improving health care safety is CPOE.
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 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 the 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 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 is vendor support costs including day-to-day costs of having the staff to support the users. Organizational staff is also needed to provide testing for upgrades and enhancements.
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 potentially negative effect 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.
Decrease the probability of medication errors
To decrease the probability of medication errors must be aware of:
• Information errors generated 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 and protected, in accordance with applicable improvements in health care quality
• Reduces medical errors
• Reduces health disparities
• Advances the delivery of patient-centered medical care.
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.
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 meaningful use core measure for eligible professionals, eligible hospitals, and critical access hospitals are ‘Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record’.
CPOE is a powerful tool in guiding practitioners in reducing unnecessary variation in care by encouraging evidenced-based practices.
CPOE is not just 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