Computerized physician order entry
Computerized physician order entry (CPOE), sometimes referred to as computerized provider order entry or computerized provider order management (CPOM), is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care.
The entered orders are communicated over a computer network to the medical staff or to the departments (pharmacy, laboratory, or radiology) responsible for fulfilling the order. CPOE reduces the time it takes to distribute and complete orders, while increasing efficiency by reducing transcription errors including preventing duplicate order entry, while simplifying inventory management and billing.
CPOE is a form of patient management software.[1]
Required data
In a graphical representation of an order sequence, specific data should be presented to CPOE system staff in cleartext, including:
- identity of the patient
- role of required member of staff
- resources, materials and medication applied
- procedures to be performed
- operational sequence to be obeyed
- feedback to be noted
- case specific documentation to build
Some textual data can be reduced to simple graphics.
CPOE systems use terminology familiar to medical and nursing staff, but there are different terms used to classify and concatenate orders. The following items are examples of additional terminology that a CPOE system programmer might need to know:
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. In some cases 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.
Order Set
A grouping of orders used to standardize and expedite the ordering process for a common clinical scenario. (Typically, these orders are started, modified, and stopped by a licensed physician.)
Protocol
A grouping of orders used to standardize and automate a clinical process on behalf of a physician. (Typically, these orders are started, modified, and stopped by a nurse, pharmacist, or other licensed health professional.)
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 or ICD-10-CMcodes) to orders at the time of order entry to support appropriate charges.
Patient safety benefits
In the past, physicians have traditionally hand-written or verbally communicated orders for patient care, which are then
Advantages
Generally, CPOE is advantageous, as it leaves the trails of just better formatting retrospective information, similarly to traditional hospital information systems designs. The key advantage of providing information from the physician in charge of treatment for a single patient to the different roles involved in processing he treatise itself is widely innovative. This makes CPOE the primary tool for information transfer to the performing staff and lesser the tool for collecting action items for the accounting staff. However, the needs of proper accounting get served automatically upon feedback on completion of orders.
CPOE is generally not suitable without reasonable training and tutoring respectively. As with other technical means, the system based communicating of information may be inaccessible or inoperable due to failures. That is not different from making use of an ordinary telephone or with conventional hospital information systems. Beyond, the information conveyed may be faulty or erratic. A concatenated validating of orders must be well organized. Errors lead to liability cases as with all professional treatment of patients.
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.
But, in general, the options to reuse order sets anew with new patients lays the basic for substantial enhancement of the processing of services to the patients in the complex distribution of work amongst the roles involved. The basic concepts are defined with the clinical pathway approach. However, success does not occur by itself. The preparatory work has to be budgeted from the very beginning and has to be maintained all the time. Patterns of proper management from other service industry and from production industry may apply. However, the medical methodologies and nursing procedures do not get affected by the management approaches.
Risks
CPOE presents several possible dangers by introducing new types of errors.
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.[13] 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.[14] 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. Several high-profile failures of CPOE implementation have occurred,[15] 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.
The world's first successful implementation of a CPOE system was at El Camino Hospital in Mountain View, California in the early 1970s. The Medical Information System (MIS) was originally developed by a software and hardware team at Lockheed in Sunnyvale, California, which became the TMIS group at Technicon Instruments Corporation. The MIS system used a light pen to allow physicians and nurses to quickly point and click items to be ordered.
As of 2005[update], one of the largest projects for a national EHR is by the
In 2008, the Massachusetts Technology Collaborative and the
In addition, the study[20] also concludes that it would cost approximately $2.1 million to implement a CPOE system, and a cost of $435,000 to maintain it in the state of Massachusetts while it saves annually about $2.7 million per hospital. The hospitals will still see payback within 26 months through reducing hospitalizations generated by error. Despite the advantages and cost savings, the CPOE is still not well adapted by many hospitals in the US.
The
See also
- Continuity of Care Record
- Electronic health record
- Electronic medical record
- Electronic prescribing
- Health informatics
- Pharmacy informatics
- VistA – Veterans Health Information Systems and Technology Architecture
References
- ^ Agency for Healthcare Research and Quality (2009). http://healthit.ahrq.gov/images/jan09cpoereport/cpoe_issue_paper.htm
- ^ Institute of Medicine (1999). "To Err Is Human: Building a Safer Health System (1999)". The National Academies Press. Archived from the original on 2013-09-09. Retrieved 2012-12-08.
- ^ Institute of Medicine (2001). "Crossing the Quality Chasm: A New Health System for the 21st Century". The National Academies Press. Retrieved 2006-06-29.
- ISBN 9780309101479. Retrieved 2006-07-21.
- PMID 12892029.
- PMID 9794308.
- ^ "Study shows for first time decrease in mortality associated with physician order entry system".
- ^ "Study: CPOE Systems Improve Prophylactic Antibacterial Use in Surgical Patients".
- PMID 15755942.
- ^ Lohr, Steve (2005-03-09). "Doctors' Journal Says Computing Is No Panacea". The New York Times. Retrieved 2006-07-15.
- S2CID 24233742.
- ^ Santell, John P (2004). "Computer Related Errors: What Every Pharmacist Should Know" (PDF). United States Pharmacopia. Archived from the original (PDF) on 2008-11-20. Retrieved 2006-06-20.
- ^ Kaufman, Marc (2005-07-21). "Medication Errors Harming Millions, Report Says. Extensive National Study Finds Widespread, Costly Mistakes in Giving and Taking Medicine". The Washington Post. pp. A08. Retrieved 2006-07-21.
- ^ RAND Healthcare: Health Information Technology: Can HIT Lower Costs and Improve Quality? Retrieved on July 8, 2006
- ^ Connolly, Ceci (2005-03-21). "Cedars-Sinai Doctors Cling to Pen and Paper". The Washington Post. Retrieved 2006-08-03.
- ^ NHS Connecting for Health: Delivering the National Programme for IT Archived 2006-08-10 at the Wayback Machine Retrieved August 4, 2006
- PMID 15933310.
- ^ "High error rate creates new urgency for CPOE". July 2008.
- ^ Massachusetts Hospitals Must Have CPOE By 2012 And CCHIT-Certified EHRS By 2015: [1] Retrieved April 11, 2012
- ^ Dolan, Pamela L. (2008). "Insurer finds EMRs won't pay off for its doctors". American Medical News. Retrieved 2009-10-13.
- ^ "Leapfrog Hospital Survey Results" (PDF). The Leapfrog Group. 2008. Archived from the original (PDF) on 2011-09-29. Retrieved 2009-10-13.