CPOE
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 (Osheroff, 2005).
Contents
CPOE History
- In 1971, Lockheed Martin developed the first CPOE system in the El Camino hospital in Mountain View, California. The system was rudimentary, with almost no clinical decision support, but it did allow physicians to quickly order medications with a few simple clicks. Despite the reported success of the medical information system in El Camino Hospital[5], others were slow to follow.
- In 1984, the Regenstrief Institute implement a CPOE at Wishard Memorial Hospital. This system required keyboard input, but had more decision support than the El Camino system. It allowed automatic reordering and alerts for known adverse interactions.
- In 1988, the LDS Hospital in Salt Lake came out with Health Evaluation through Logical Programming (HELP), a blood-product-specific CPOE system that added an additional "standing orders" feature, which automatically placed orders for specific procedures that were added over time. [4]
- From 1994 to 2004, commercial CPOE grew quickly. Cerner Millennium came out with Millenium, Eclipsys changed their E7000 line into SCM, Siemens launched InVision, Meditech announced Magic, Epic Systems released Epic, McKesson developed Horizon, and GE was just finishing Centricity. [5]
- However, as of 2009, less than 10% of the hospitals in the US had fully operational CPOE systems. [6]
System Configuration
The system should be configured correctly for ease of use and security.
- Passwords should be secure yet easy to remember. [7]
- 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 computerized physician order entry (CPOE) pilot on one unit an organization discovered, or rediscovered, just how much people communicate with those yellow sticky notes. For example, they found notes that said “Oxygen is up for renewal.” “Telemetry is up for renewal.” “You’ve got a narcotic that’s going to expire in twenty-four hours.”
And it seemed that 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. For example, many physician's login from home, and just placeing their morning orders. They are not looking at that paper chart with those sticky notes on it.
So one way of deciding which alerts and rules to put in place first is to try and replace the world of sticky notes. So the organization developed alerts that said, “Okay, your twenty-four hours are up with oxygen. Do you want the patient to continue?” “Telemetry’s up for renewal.” So they started with basic alerts that helped with communication and work flow. These alerts were really nonthreatening. 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 are a essential. There are many, including Logical Observation Identifiers Names and Codes (LOINC), the Unified Medical Language System (UMLS), Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT), RxNorm, International Statistical Classification of Diseases (ICD).
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
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. [8] Sometimes organizations struggle to achieve meaningful use. [9] [[10]
There are studies emerging that indicate that CPOE may actually increase medical errors especially if not implemented correctly [11] [12] [13]. 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. [14]
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?
Physical Computing Environment
From a large systematic review of all articles published between 1980 and 1997, the following conclusions were reached.
- Computer use during consultations lengthened the consultation.
- Reminder systems for preventive tasks and disease management improved process rates, although some returned to preintervention levels when reminders were stopped.
- Use of computers for issuing prescriptions increased prescribing of generic drugs, and use of computers for test ordering led to cost savings and fewer unnecessary tests.
- There were no negative effects on those patient outcomes evaluated.
- Doctors and patients were generally positive about use of computers, but issues of concern included their impact on privacy, the doctor-patient relationship, cost, time, and training needs.
Wall Mounted Computers
Mobile Computers
Laptop Computers
Laptops allow access to both the CPOE and the electronic medical record.
Some issues are the weight, battery life, screen display, and durability. There is typically a tradeoff between battery life, screen size, and weight; lightweight laptops suffer from inadequate battery life. In addition, larger screens, although they offer more space for CPOE and electronic charting, are heavier.
Several different approaches have been utilized in implementing laptop use:
- Rolling carts
- Hand held and
- Combinations of wall mounting and classic desktop configurations
Rolling carts take up significant space, are heavier and are less mobile. In addition, the battery charge is still limited. Chargers incorporated into the cart and multiple battery packs increase the time to next charge. [16]
Finally there is the real issue of security of data using hand held laptops and there have been numerous examples of loss of laptops containing patient information [17]. At a minimum, laptops that contain protected health information (PHI) should be required to be password protected. Additional security such as data encryption, the use of biometrics and technology such as smart cards should be strongly considered.
Tablet Computers
Handheld Computers
While handheld computers are good replacements for small reference books and interactive guides, they are unlikely to be significantly used in an integrated clinical record system. The interface is small and difficult to enter data into, security is more easily compromised, and wireless connections are slower than their Ethernet counterparts. [18]
Infection Control Concerns
There is considerable evidence and discussion of the keyboard as a source of pathogens; particularly the antibiotic resistant Methcillin Resistant Staph Aureus (MRSA) and Vancomycin Resistant Enterococcus (VRE). [19] MRSA may reside on medical surfaces for days to weeks. [20] Multiple precautions can be take to reduce transmission of infection. Physicians and nurses should be educated to the risks posed by the keyboard. Housekeeping staff should have keyboard cleaning techniques added the daily cleaning rounds. Standard housekeeping operating procedure should include cleaning keyboard surfaces every shift (every 8 hours) or at least every 12 hours.
Emergency Department Setting
Mobile Computers
Monitoring and Evaluation
Routine Methods
Leapfrog CPOE Standard
Unintended Consequences
Unintended errors fall into two main categories: [21]
- Error in entering and retrieving information
- Communication and coordination
Increased Resource Utilization
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
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.
