Computerized physician order entry
Computerized physician order entry (CPOE) — sometimes referred to as computerized provider order entry — is a portable electronic system typically implemented in hospitals that allows a medical practitioner to directly enter testing and treatment orders for a patient, afterward electronically transmitting the orders to the correct department(s) for fulfillment. Orders may be entered from mobile devices or dedicated computers and may include requests for medications, laboratory tests, and patient care assessments. In many cases the CPOE is integrated into a network of other computer systems, including clinical decision support systems.
CPOE is reported to improve staff communication, decrease delays in order completion, reduce errors related to handwriting or transcription, allow order entry at the point of care as well as off-site, offer an error checking mechanism for duplicate or incorrect tests/doses, and simplify inventory and billing management.
Some people consider the first predecessor to CPOE to be a hospital information system (HIS) implemented in the early 1970s. The idea of implementing a computerized information-handling system in the hospital sphere was first conceived in 1965, when Lockheed Martin conducted an information gathering project on the feasibility of such a system. Lockheed built a prototype hospital information system called "MIS" or "Medical Information System," and El Camino Hospital agreed to pilot it incrementally. In 1971 Lockheed was forced to sell its HIS research division to Technicon Data Systems; however, El Camino ultimately decided to fully implement it in 1972. The system had features such as laboratory test scheduling, IV ordering, and pharmacy management.
Though the HIS would progress in sophistication into the 1990s, its primary focus wasn't necessarily on integrated information and order entry. The need for such a system became more apparent at the end of the century, with the major turning point being the 1999 Institute of Medicine publication of To Err Is Human: Building a Safer Health System. Noting that 44,000 to 98,000 people were dying each year in the hospital from adverse events, a public debate ensued on what methods and tools could be implemented to improve patient safety in the hospital. A follow-up report by the Institute in 2001 gave more specific advice, recommending the use of electronic medication ordering with computer- and internet-based information systems to support clinical decision making. Yet despite Institute recommendations and advances in health informatics, by 2002 only an estimated five to 10 percent of hospitals were utilizing CPOE. A 2004 paper by Poon et al. attempted to address some of the reasons for the slow adoption of CPOE, citing "physician and organizational resistance," exorbitant costs, underdeveloped offerings, and few vendors with quality track records. The situation wasn't much better in 2008, when Ford et al. published their finding on CPOE adoption, noting "[u]nder current conditions, CPOE adoption in urban hospitals will not reach 80% penetration until 2029." The group concluded:
[T]he CPOE products available as of 2006 represent only a 'second generation technology', characterized by many limitations. Without increased external and internal pressures, such CPOE systems are unlikely to achieve full diffusion in US hospitals in a timely manner.
The passage of the Health Information Technology for Economic and Clinical Health Act (HITECH Act) in 2009 set meaningful use of interoperable electronic health record (EHR) adoption in the U.S. health care system as a critical national goal and incentivized EHR adoption. The three-stage Meaningful Use program that grew out of that incorporated the CPOE, forcing CPOE utilization rates of at least 30 percent with eligible patients during the first stage. That percentage was scaled up to 80 percent utilization of all eligible patients by the Stage Three effective date of January 1, 2018.
With the HITECH Act and first two Meaningful Use stages enacted, CPOE adoption in the U.S. has since increased, though more slowly than some have anticipated. Data from the Leapfrog Group, a coalition of healthcare and informatics entities and researchers, released in 2014 found that the number of hospitals that met the group's CPOE adoption standards increased from 31 percent in 2012 to 43 percent in 2013. (To meet Leapfrog's standard, all inpatient units at a hospital must order at least 75 percent of their medications through CPOE.) The American Medical Association and 41 other medical societies raised concerns in 2015 about whether EHR and CPOE adoption can be realized by the previously revised 2017 deadline, particularly due to changes in reformed Medical payment systems that didn't take Stage Three into account. In October 2015, the Centers for Medicare and Medicaid Services (CMS) released their proposed Stage Three rules with a January 2018 deadline.
Features of CPOE systems
Features common to a CPOE system include:
- Order entry: The order entry component allows physicians to enter testing and treatment orders for a patient, which are then electronically transmitted to the correct department(s) for fulfillment. The physician is able to choose from order sets — a grouping of orders specific to a disease or procedure — preloaded in the system or create custom orders which can, if desired, be integrated into other order sets based on hospital policy.
- Clinical decision support: This functionality may be part of the CPOE, or the CPOE may be interconnected with a clinical decision support system (CDSS) that provides that functionality. However implemented, clinical decision support tools further clinical advice for patient care based on multiple pieces of patient data. That data may come in the form of currently prescribed medications, patient weight and age, renal function, current immunities and allergies, and even genomics.
- Medication analysis and other patient safety features: This portion of the system "checks for potential problems such as drug-drug interactions, duplicate orders, drug allergies and hypersensitivities, and dosage miscalculations." Co-morbidities, drug-lab interaction, and cost efficiency checks may also be made in more advanced medication analysis modules. Additional patient safety features include real-time patient identification and adverse event reviews.
- Intuitive user interface: The order entry workflow corresponds to familiar paper-based ordering to allow efficient use by new or infrequent users.
- Data management and assessment: This portion of the system offers statistical reporting so that managers can analyze patient results 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.
Potential benefits and risks of CPOE
CPOE systems are arguably among some of the most studied health information technologies in the United States. That research has found many benefits, though not without risks.
Early studies of computerized physician order entry (CPOE) suggested medication error rates could be reduced by as much as 80 percent, and errors that have potential for serious harm or death for patients could be reduced by 55 percent. Research by Gray and Felkey in 2004 greatly expanded upon the potential benefits, listed below:
Quality improvements and error reductions
- Reducing or eliminating lost orders
- Producing more consistent and thorough documentation
- Automating outcome analysis and reporting
- Reducing dosage errors
- Preventing medication errors through system checks
- Eliminating illegible orders
- Verifying administration of medications
- Providing immediate access to online databases and reference material
Process improvements and cost reductions
- Reducing order verification, processing, and execution times
- Providing remote access to systems
- Reducing or eliminating duplicate orders
- Improving charge capture
- Reducing average length of stay and cost per admission
- Minimizing data entry needs
- Decreasing malpractice exposure
- Suggesting alternative medications
Research published in 2010 also showed, for the first time, "that a significant decrease in hospital-wide mortality rates can be associated with implementation of a computerized physician order entry system."
Research in the mid-2000s found that CPOE implementations pose some risks by introducing new types of errors and contributing to some adverse events. Additionally, the automated aspects of the system can cause a false sense of security as well as 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. And in 2004, CPOE and automated drug dispensing was identified as a cause of error by 84 percent of over 500 health care facilities participating in a surveillance program by the United States Pharmacopoeia.
Frequent alerts and warnings also cause problems such as interruptions in work flow, inevitably creating "alert fatigue" and causing these messages to be ignored or overridden.
CPOE outside the United States
A 2009 study of seven Western countries — Australia, France, Germany, Netherlands, Switzerland, United Kingdom, and United States — revealed that CPOE adoption at that time was limited at best. The Netherlands saw 20 percent of its hospitals containing CPOEs up to that point, with the U.K. at two percent and the other countries with a handful or no CPOEs hospital-wide.
In a 2012 study of CPOE use at the National Guard Health Affairs in Saudi Arabia, the authors spoke of health information technology and CPOE adoption in Saudi Arabia in general, stating "implementation of health information systems including CPOE has been especially challenging for Saudi hospitals because of high implementation costs, technical complexity, lack of information and communication technology (ICT) infrastructure, and lack of well-trained employees and non-compliance."
This article reuses a few elements from the Wikipedia article.
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