View source for Evaluation and Certification of Computerized Provider Order Entry Systems


Classen, D.C., Avery, A.JK., Bates, D. W., Evaluation and Certification of Computerized Provider Order Entry System, J Am Med Informatics Assoc, 2007; 14:48-55.DOI 10.1197/jamia.M2248.

This was a viewpoint paper from authors from the University of Utah School of Medicine (DCC), Division of Primary Care, Nottingham, United Kingdom, (AJA) and Brigham and Women’s Hospital, and Harvard Medical School (D. W. Bates). CPOE is utilized in about 15% of U. S. Hospitals, and about 15% in ambulatory clinic settings. The majority of early studies of the benefits of CPOE were reported from four exemplar institutions that had homegrown systems (LDS Hospital, Partners/Brigham and Women’s, Regenstreif Institute, and Vanderbilt). The outcomes of these studies focused on the effects of CPOE on costs of care, medication safety and quality. These sites contributed the bulk of the research on CPOE and utilization of the EHR. While these contributions have been valuable, the authors noted some drawbacks. The systems possessed limitations in generalizability for the following reasons: their CPOE systems were home grown and not available commercially; they were all developed in academic teaching hospitals with little/no experience with community hospitals; and they all used different approaches for evaluation of their CPOE system implementations. 

Several studies looked at the costs and potential benefits of HIT systems including CPOE. The authors recommended that it would seem wise for an organization implementing CPOE to consider the following measures: 1) easily available metrics; 2) performance on any quality measure targeted by CPOE; 4). Numbers of alerts and warnings that occur, and how they are managed by providers.  
 Vendor began funding their own studies of the benefits their EHRs. A typical strategy for these vendor studies was to collect data from their customers involved in early implementation. They listed 14 EHR vendor database benefit measures including overall ROI, increased revenues, costs saving, provider productivity enhancements and reduction in medical errors.
Professional associations formed a certification process for vendors on recommendation of the National Coordinator of HIT. AHIMA, HIMSS and The Alliance joined forces to launch the Certification Commission for Health Information Technology (CCHIT). CCHIT received over 7.5 million over 3 years by the Department of Health and Human Services. CCHIT adopted the EHR Draft Standard for Trial Use (DSTU) from HL7 as the basic framework. CCHIT piloted ambulatory EHRs in March-April 2006 and launched actual certification May 2006. The first group of certifications was announced July 18, 2006. The next goal was to develop, pilot test and assess certification of inpatient settings by September 2007, and do the same to identify the infrastructure for interoperability by September 2008.
The Leapfrog Group was formed in 2000 by a coalition of health care purchasers. Their target was EHR implementation, and safety/quality of health care in the US. The Leagfrog Vendor CPOE Certification differs from the CCHIT in that it certifies CPOE as an implemented safe practice in individual hospitals or health care organizations. The Leapfrog inpatient standard included a requirement that the CPOE system alerts providers at least 50 percent of the time fore medication administration. The Leapfrog CPOE evaluation included a simulation of different clinical scenarios to evaluate how a hospital system responds to unsafe medication orders. 

The authors concluded that the Leapfrog CPOE evaluation methodology can compliment the efforts of CCHIT.  They also called for more research on the use of commercially available systems in use in clinics and community hospitals, especially in respect to safety, effectiveness and implementation. In addition, they stated that all the efforts were supported by a large federal effort to certify EHR and CPOE systems as well as pay for performance initiates that are developing their own certification approaches for HER and CPOE. . All organizations will need to perform ongoing evaluations of their CPOE applications and their EHRs, if the benefits of the technologies are to be realized. 
Comment: This was a comprehensive overview of current efforts and future strategy for certification of CPOE and EHR applications. The bulk of research thus far contributed by the four exemplars is very valuable and will continue to contribute value. I agree with the call for more research on the safety, effectiveness and implementation of CPOE and HER systems in community clinics and community hospitals. I believe this is very necessary if we are to realize the value of EHRs and CPOE’s contributions to decreases in med errors, increased primary/secondary prevention and overall contributions to effectiveness in clinical practice as well as increases in quality of care.
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