Computer physician order entry

Computerized physician order entry (CPOE), is a process of electronic entry of physician instructions for the treatment of patients (particularly hospitalized patients) under his or her care. These orders are communicated over a computer network to the medical staff (nurses, therapists or other physicians) or to the departments (pharmacy, laboratory or radiology) responsible for fulfilling the order. CPOE decreases delay in order completion, reduces errors related to handwriting or transcription, allows order entry at point-of-care or off-site, provides error-checking for duplicate or incorrect doses or tests, and simplifies inventory and posting of charges.

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Terminology related to order entry

Filler

The application responding to, i.e., performing, a request for services (orders) or producing an observation. The filler can also originate requests for services (new orders), add additional services to existing orders, replace existing orders, put an order on hold, discontinue an order, release a held order, or cancel existing orders.

Order

A request for a service from one application to a second application. The second application may in some cases be the same; i.e., an application is allowed to place orders with itself.

Order detail segment

One of several segments that can carry order information. Future ancillary specific segments may be defined in subsequent releases of the Standard if they become necessary.

Placer

The application or individual originating a request for services (order).

Placer order group

A list of associated orders coming from a single location regarding a single patient.

Features of CPOE systems

Features of the ideal computerized physician order entry system (CPOE) include:

Ordering 

Physician orders are standardized across the organization, yet may be individualized for each doctor or specialty by using order sets. Orders are communicated to all departments and involved caregivers, improving response time and avoiding scheduling problems and conflict with existing orders.

Patient-centered decision support 

The ordering process includes a display of the patient's medical history and current results and evidence-based clinical guidelines to support treatment decisions. Often uses medical logic module and/or Arden syntax to facilitate fully integrated Clinical Decision Support Systems (CDSS).

Patient safety features 

The CPOE system allows real-time patient identification, drug dose recommendations, adverse drug reaction reviews, and checks on allergies and test or treatment conflicts. Physicians and nurses can review orders immediately for confirmation.

Intuitive Human interface 

The order entry workflow corresponds to familiar "paper-based" ordering to allow efficient use by new or infrequent users.

Regulatory compliance and security 

Access is secure, and a permanent record is created, with electronic signature.

Portability 

The system accepts and manages orders for all departments at the point-of-care, from any location in the health system (physician's office, hospital or home) through a variety of devices, including wireless PCs and tablet computers.

Management 

The system delivers statistical reports online so that managers can analyze patient census and make changes in staffing, replace inventory and audit utilization and productivity throughout the organization. Data is collected for training, planning, and root cause analysis for patient safety events.

Billing 

Documentation is improved by linking diagnoses (ICD-9-CM codes) to orders at the time of order entry to support appropriate charges.

Patient safety benefits of CPOE

In the past, physicians have traditionally hand-written or verbally communicated orders for patient care, which are then transcribed by various individuals (such as unit clerks, nurses, and ancillary staff) before being carried out. Handwritten reports or notes, manual order entry, non-standard abbreviations and poor legibility lead to errors and injuries to patients, according to a 1999 Institute of Medicine (IOM) report.^[1] A follow up IOM report in 2001 advised use of electronic medication ordering, with computer- and internet-based information systems to support clinical decisions.^[2] Prescribing errors are the largest identified source of preventable hospital medical error. A 2006 report by the Institute of Medicine estimated that a hospitalized patient is exposed to a medication error each day of his or her stay.^[3] Computerized physician order entry (CPOE) reduces the medication error rate by 80%, and by 55% for errors with serious potential patient harm.^[4] CPOE systems can provide automatic dosing alerts (for example, letting the user know that the dose is too high and thus dangerous) and interaction checking (for example, telling the user that 2 medicines ordered taken together can cause health problems).

Risks of CPOE

CPOE presents several possible dangers by introducing new types of errors.^[5][6] Prescriber and staff inexperience may cause slower entry of orders at first, use more staff time, and is slower than person-to-person communication in an emergency situation. Physician to nurse communication can worsen if each group works alone at their workstations. Automation causes a false sense of security, a misconception that when technology suggests a course of action, errors are avoided. These factors contributed to an increased mortality rate in the Children's Hospital of Pittsburgh's Pediatric ICU when a CPOE systems was introduced.^[7] In other settings, shortcut or default selections can override non-standard medication regimens for elderly or underweight patients, resulting in toxic doses. Frequent alerts and warnings can interrupt work flow, causing these messages to be ignored or overridden. CPOE and automated drug dispensing was identified as a cause of error by 84% of over 500 health care facilities participating in a surveillance system by the United States Pharmacopoeia.^[8] Introducing CPOE to a complex medical environment requires ongoing changes in design to cope with unique patients and care settings, close supervision of overrides caused by automatic systems, and training, testing and re-training all users.

Implementation

CPOE systems can take years to install and configure. Despite ample evidence of the potential to reduce medication errors, adoption of this technology by doctors and hospitals in the United States has been slowed by resistance to changes in physician's practice patterns, costs and training time involved, and concern with interoperability and compliance with future national standards.^[9] According to a study by RAND Health, the US healthcare system could save more than 81 billion dollars annually, reduce adverse medical events and improve the quality of care if it were to widely adopt CPOE and other health information technology.^[10] As more hospitals become aware of the financial benefits of CPOE, and more physicians with a familiarity with computers enter practice, increased use of CPOE is predicted. A 2004 survey by Leapfrog found that 16% of US clinics, hospitals and medical practices are expected to be utilizing CPOE within 2 years.^[11] Several high profile failures of CPOE implementation have occurred,^[12] so a major effort must be focused on change management, including restructuring workflows, dealing with physicians' resistance to change, and creating a collaborative environment.

An early success with CPOE by the United States Department of Veterans Affairs (VA) is the Veterans Health Information Systems and Technology Architecture or VistA. A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient’s record at any computer in the VA's over 1,000 healthcare facilities. CPRS includes the ability to place orders by CPOE, including medications, special procedures, x-rays, patient care nursing orders, diets, and laboratory tests.

As of 2005, one of the largest projects for a national EHR is by the National Health Service (NHS) in the United Kingdom. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practices in England access to the National Programme for IT (NPfIT). The NHS component, known as the "Connecting for Health Programme",^[13] includes office-based CPOE for medication prescribing and test ordering and retrieval, although some concerns have been raised about patient safety features.^[14]

See also

• Continuity of Care Record
• Electronic health record
• Electronic medical record
• Health informatics
• Veterans Health Information Systems and Technology Architecture (VistA)

Notes