COMPUTERIZED PROVIDER ORDER ENTRY CPOE This work is

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DEFINITION OF CPOE • Computerized provider order entry (CPOE) • – Order entry application • • Assists practitioners with the creation and management of orders for services and medications • HIMSS Dictionary of Healthcare Information Technology Terms, Acronyms and Organizations

CPOE • Is part of an integrated clinical information system • • Is a computer application • • Not just an electronic prescribing system • • Use of computer assistance by a provider to directly enter medical orders from a computer or mobile device for further processing

CPOE • Coupled with clinical decision support systems • –Applies rules-based logic • –Supplies real-time feedback • –Example • • Alert of a drug allergy with a suggested alternative medication

PURPOSE OF CPOE • Automate the patient ordering process in order to manage patient care more effectively and efficiently and as a result improve patient safety and outcomes • Prevent, reduce, or eliminate medical errors and adverse drug events (ADEs) • • Improve patient safety • • Reduce unnecessary variation in health care • • Improve efficiency of health care delivery

PREVENT, REDUCE, OR ELIMINATE MEDICAL ERRORS AND ADES • IOM reports • – 98, 000 patients die each year in U. S. hospitals due to medical errors • –Advised rapid adoption of electronic medication ordering to support clinical decisions • • CPOE seen as a solution

IMPROVE PATIENT SAFETY • Leapfrog Group • –Consortium of major companies and other large private and public healthcare purchasers • –One of its key patient safety standards • • CPOE seen as a way to “leap” forward • –“leap” is a recommended hospital quality and safety practice

REDUCE UNNECESSARY VARIATION IN HEALTH CARE • Help the physician make optimal ordering decisions and improve adherence to evidence-based practice • • Requires configuration of orders and order sets

IMPROVE EFFICIENCY OF HEALTH CARE DELIVERY • Reduction in order verification and processing times • –Electronic communication both directions • • Order entered electronically • • Order sent electronically • • Order received electronically • • Status returned electronically • • Requires interfaces with existing information systems

ATTRIBUTES OF CPOE • Patient ordering • • Patient-centered decision support • • Patient safety features • • Optimally the human computer interface is intuitive • Regulatory compliance and security • • Portability • • Management

ATTRIBUTES OF CPOE • Billing • Responsiveness -users are not left hanging • • Response time –prompt response to input • • Reliable –probability of failure-free operation

FUNCTIONS OF CPOE • Basic: Electronic order communication • Advanced: includes clinical decision support • –Accepts/captures the provider’s orders for services • –Simple: drug-drug interaction checks, medication dose calculators • –Transmits the order to the appropriate location • –Returns status of order • –Returns results of order execution • –Complex: Alert of a drug allergy along with an alternative medication

CPOE AND CLINICAL DECISION SUPPORT SYSTEM(CDSS) • Clinical Decision Support System (CDSS) • –Uses pre-established rules and guidelines • –Integrates clinical data form several sources • –Generates alerts and treatment suggestions • HIMSS Dictionary of Healthcare Information Technology Terms, Acronyms and Organizations, 2010 • • CPOE needs clinical decision support to reach its full value

CPOE AND CLINICAL DECISION SUPPORT SYSTEM(CDSS) • Three parts to CDSS • –Knowledge base, aka the “rules-engine” • –Inference engine • –Mechanism to communicate

CPOE AND CLINICAL DECISION SUPPORT SYSTEM(CDSS) • No single approach to integration • • Questions to ask • –“What kind and how much clinical support? ” • –“What about medication alerts, allergies, routine preventive diagnostics? ” • –“How many alerts will users tolerate before ignoring them? ” • –“How difficult should it be for the practitioners to override the alerts? ”

CPOE USERS • Physicians • • Nurses • • Physician assistants • • Nurse practitioners • • Therapists • • Pharmacists • • Others

CPOE USES • Applies to both the inpatient and ambulatory setting • • Order types • –Medications • –Tests, e. g. , laboratory • –Procedures • –Other clinical processes such as admissions, referrals

ADVANTAGES OF CPOE OVER PAPERBASED SYSTEMS • Free of handwriting identification problems • • Faster to reach pharmacy • • Less subject to error associated with similar drug names • • More easily integrated into medical records and decision-support systems • Koppel, R. , et al Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors , http: //jama. ama- assn. org/cgi/content/full/293/10/1197? ijkey=83 e 2 c 4349737 ab 8 b 717 ca 9 f 12 ccdca 4 a 1 de 9 f 26 a

ADVANTAGES OF CPOE OVER PAPERBASED SYSTEMS • Less subject to errors caused by use of apothecary measures • • Easily linked to drug-drug interaction warnings • • More likely to identify the prescribing physician • • Able to link to ADE reporting systems • Koppel, R. , et al Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors , http: //jama. ama- assn. org/cgi/content/full/293/10/1197? ijkey=83 e 2 c 4349737 ab 8 b 717 ca 9 f 12 ccdca 4 a 1 de 9 f 26 a

ADVANTAGES OF CPOE OVER PAPERBASED SYSTEMS • Able to avoid specification errors • • Available and appropriate for training and education • • Available for immediate data analysis • • Claimed to generate significant economic savings • Koppel, R. , et al Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors , http: //jama. ama- assn. org/cgi/content/full/293/10/1197? ijkey=83 e 2 c 4349737 ab 8 b 717 ca 9 f 12 ccdca 4 a 1 de 9 f 26 a

ADVANTAGES OF CPOE OVER PAPERBASED SYSTEMS • With online prompts, CPOE systems can • –Link to algorithms to emphasize cost-effective medications • –Reduce underprescribing and overprescribing • –Reduce incorrect drug choices • Koppel, R. , et al Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors , http: //jama. ama- assn. org/cgi/content/full/293/10/1197? ijkey=83 e 2 c 4349737 ab 8 b 717 ca 9 f 12 ccdca 4 a 1 de 9 f 26 a

MAJOR VALUE OF CPOE • Enhanced patient safety • • Reduced costs • • Reduced variations in care by encouraging best practices

MAJOR BARRIERS • Belief that physicians will not use computerized ordering • • Not a small or easy task • • Impact on workflow • • Risk • • Cost

E-IATROGENESIS • • “Patient harm caused at least in part by the application of health information technology” • • Probability of medication errors increases • Weiner, J. et al. “e-Iatrogenesis”: The Most Critical Unintended Consequence of CPOE and other HIT http: //www. ncbi. nlm. nih. gov/pmc/articles/PMC 2244888

MEDICATION ERROR RISKS • Information errors • –Medication discontinuation failures • –Procedure-linked medication discontinuation faults • –Immediate order and give-as-needed medication discontinuation faults • –Antibiotic renewal failure • –Diluent options and errors • –Allergy information delay • Koppel, R. , et al Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors , http: //jama. amaassn. org/cgi/content/full/293/10/1197? ijkey=83 e 2 c 4349737 ab 8 b 717 ca 9 f 12 ccdca 4 a 1 de 9 f 26 a

MEDICATION ERROR RISKS HUMAN-MACHINE INTERFACE FLAWS Patient selection Loss of data, time, and focus when CPOE is nonfunctional Wrong medication Late-in-day orders lost for 24 hours selection Unclear Failure to provide medications after surgery logon/log off Sending medications to wrong rooms when the computer system has shut down Role of charting difficulties in inaccurate and delayed medication administration Post-surgery“suspended” medications Inflexible ordering screens, incorrect medications

MAJOR SUPPORT FOR CPOE ADOPTION • HITECH Act • –Use of health information technology in • • Improving the quality of health care • • Reducing medical errors • • Reducing health disparities • • Increasing prevention • • Improving the continuity of care among health care settings

ELECTRONIC HEALTH RECORD INCENTIVE PROGRAM FINAL RULE • Stage 1 • –CPOE included in the core set of measures • –Only medication orders • • 30% threshold (60% for Stage 2) • –Transmission of the order is not included in the objective or the associated measure • • Any licensed healthcare professional can enter orders into the medical record per state, local and professional guidelines

CPOE’S IMPACT • CPOE can with Clinical Decision Support (CDS) • –Improve medication safety and quality of care • –Reduce costs of care • –Improve compliance with provider guidelines • –Improve the efficiency of hospital workflow • Inpatient Computerized Provider Order Entry (CPOE): Findings from the AHRQ Health IT Portfolio. http: //healthit. ahrq. gov/portal/server. pt/gateway/PTARGS_0_1248_846328_0_0_18/09 -0031 - EF_cpoe. pdf

CPOE’S IMPACT • Improve the efficiency • • Improve compliance with evidence-base practices • Inpatient Computerized Provider Order Entry (CPOE): Findings from the AHRQ Health IT Portfolio. http: //healthit. ahrq. gov/portal/server. pt/gateway/PTARGS_0_1248_846328_0_0_18/09 -0031 - EF_cpoe. pdf