Difference between revisions of "CPOE"

Revision as of 18:48, 6 February 2012

Computerized physician order entry (CPOE) is an electronic medical record technology that allows physicians to enter orders, medications, or procedures directly into the computer instead of handwriting them. [1] [2] The system transmits the order to the appropriate department or individual so the order can be carried out. [3] 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].

History of CPOE

Main article: History of computerized physician order entry

Security configuration

The security system should be configured correctly.

• Passwords should be secure yet easy to remember. [5]
• 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

Pre-Admission Order Policies

Creating Order Sets

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

Success Factors

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. [6] Sometimes organizations struggle to achieve meaningful use. [7] [[8]

There are studies emerging that indicate that CPOE may actually increase medical errors especially if not implemented correctly [9] [10] [11]. 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. [12]

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

Nursing and CPOE

Emergency Department Setting

Emergency Department Setting

Monitoring and Evaluation

Monitoring and Evaluation

Routine Methods

Routine Methods

Leapfrog CPOE Standard

Leapfrog

Unintended Consequences

Unintended consequences fall into two main categories: [13]

1. Error in entering and retrieving information
2. Communication and coordination

Increased Resource Utilization

Increased Resource Utilization

Emotional Reactions

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

Project Governance

Readiness Assessment

Readiness Assessment

Setting up the Project Team

• Setting up the Project Team
• Lessons Learned from a Seasoned Novice

References

Osheroff JA, Pifer EA, Teich JM, Sittig DF, Jenders RA. Improving Outcomes with Clinical Decision Suppport: An Implementer's Guide, Health Information Management and Systems Society, 2005.