Computer physician order entry
Encyclopedia
Computerized physician order entry (CPOE) (also sometimes referred to as Computerized Provider Order Entry) is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospital
ized patients) under his or her care. These 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 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. Although manufacturers use the term Computerized Physician Order Entry, a more accurate term would be Computerized Prescriber Order Entry or Computerized Pharmacist Order Entry. Order Entry is in the domain of the pharmacist because it is the pharmacist's responsibility to verify any entry into the system concerning the use of medications within the hospital or health care system. Order clarification requests will be enhanced by improved communication and collaboration amongst the health care team. CPOE is a form of patient management software.
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 computer
s.
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-CM codes) to orders at the time of order entry to support appropriate charges.
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. A follow up IOM report in 2001 advised use of electronic medication ordering, with computer- and internet-based information systems to support clinical decisions. 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. Studies of computerized physician order entry (CPOE) has yielded evidence that suggests the medication error rate can be reduced by 80%, and errors that have potential for serious harm or death for patients can be reduced by 55%, and other studies have also suggested benefits. Further, in 2005, CMS and CDC released a report that showed only 41 percent of prophylactic antibacterials were correctly stopped within 24 hours of completed surgery. The researchers conducted an analysis over an eight-month period, implementing a CPOE system designed to stop the administration of prophylactic antibacterials. Results showed CPOE significantly improved timely discontinuation of antibacterials from 38.8 percent of surgeries to 55.7 percent in the intervention hospital. CPOE/e-Prescribing 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). In this way, specialists in pharmacy informatics work with the medical and nursing staffs at hospitals to improve the safety and effectiveness of medication use by utilizing CPOE systems.
's Pediatric ICU
when a CPOE systems was introduced. 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 due to alert fatigue. 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. 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.
. As more hospitals become aware of the financial benefits of CPOE, and more physicians with a familiarity with computer
s 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. Several high profile failures of CPOE implementation have occurred, 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.
, 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", includes office-based CPOE for medication prescribing and test ordering and retrieval, although some concerns have been raised about patient safety
features.
In 2008, the Massachusetts Technology Collaborative and the New England Healthcare Institute
(NEHI) published research showing that 1 in 10 patients admitted to a Massachusetts
community hospital suffered a preventable medication error. The study argued that Massachusetts hospitals could prevent 55,000 adverse drug events per year and save $170 million annually if they fully implemented CPOE. The findings prompted the Commonwealth of Massachusetts to enact legislation requiring all hospitals to implement CPOE by 2012 as a condition of licensure.
In addition, the study 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. And 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 Leapfrog’s 2008 Survey showed that most hospitals are still not complying with having a fully implemented, effective CPOE system. The CPOE requirement became more challenging to meet in 2008 because the Leapfrog introduced a new requirement: Hospitals must test their CPOE systems with Leapfrog’s CPOE Evaluation Tool. So the number of hospitals in the survey considered to be fully meeting the standard dropped to 7% in 2008 from 11% the previous year. Though the adoption rate seems very low in 2008, it is still an improvement from 2002 when only 2% of hospitals met this Leapfrog standard.
Hospital
A hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....
ized patients) under his or her care. These orders are communicated over a computer network
Computer network
A computer network, often simply referred to as a network, is a collection of hardware components and computers interconnected by communication channels that allow sharing of resources and information....
to the medical staff or to the departments (pharmacy
Pharmacy
Pharmacy is the health profession that links the health sciences with the chemical sciences and it is charged with ensuring the safe and effective use of pharmaceutical drugs...
, laboratory, or radiology
Radiology
Radiology is a medical specialty that employs the use of imaging to both diagnose and treat disease visualized within the human body. Radiologists use an array of imaging technologies to diagnose or treat diseases...
) responsible for fulfilling the order. CPOE decreases delay in order completion, reduces errors related to handwriting or transcription
Transcription (linguistics)
Transcription in the linguistic sense is the systematic representation of language in written form. The source can either be utterances or preexisting text in another writing system, although some linguists only consider the former as transcription.Transcription should not be confused with...
, 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. Although manufacturers use the term Computerized Physician Order Entry, a more accurate term would be Computerized Prescriber Order Entry or Computerized Pharmacist Order Entry. Order Entry is in the domain of the pharmacist because it is the pharmacist's responsibility to verify any entry into the system concerning the use of medications within the hospital or health care system. Order clarification requests will be enhanced by improved communication and collaboration amongst the health care team. CPOE is a form of patient management software.
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 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
Guideline (medical)
A medical guideline is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare...
to support treatment decisions. Often uses medical logic module
Medical Logic Module
A medical logic module is an independent unit in a healthcare knowledge base that represents the knowledge published on a requirement for treating a patient according to a single medical decision....
and/or Arden syntax
Arden Syntax
The Arden syntax is an artificial intelligence frame-based grammar for representing and processing medical conditions and recommendations as "Medical Logic Modules ", used in Medical algorithms....
to facilitate fully integrated Clinical Decision Support Systems (CDSS)
Clinical decision support system
Clinical decision support system is an interactive decision support system Computer Software, which is designed to assist physicians and other health professionals with decision making tasks, as determining diagnosis of patient data. A working definition has been proposed by Dr...
.
Patient safety
Patient safety
Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. The frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported...
features : The CPOE system allows real-time patient identification, drug dose recommendations, adverse drug reaction
Adverse drug reaction
An adverse drug reaction is an expression that describes harm associated with the use of given medications at a normal dosage. ADRs may occur following a single dose or prolonged administration of a drug or result from the combination of two or more drugs...
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
Electronic signature
An electronic signature, or e-signature, is any electronic means that indicates either that a person adopts the contents of an electronic message, or more broadly that the person who claims to have written a message is the one who wrote it . By comparison, a signature is a stylized script...
.
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
Computer
A computer is a programmable machine designed to sequentially and automatically carry out a sequence of arithmetic or logical operations. The particular sequence of operations can be changed readily, allowing the computer to solve more than one kind of problem...
and tablet computer
Tablet computer
A tablet computer, or simply tablet, is a complete mobile computer, larger than a mobile phone or personal digital assistant, integrated into a flat touch screen and primarily operated by touching the screen...
s.
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
Root cause analysis
Root cause analysis is a class of problem solving methods aimed at identifying the root causes of problems or events.Root Cause Analysis is any structured approach to identifying the factors that resulted in the nature, the magnitude, the location, and the timing of the harmful outcomes of one...
for patient safety
Patient safety
Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. The frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported...
events.
Billing :Documentation is improved by linking diagnoses (ICD-9-CM or ICD-10-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 transcribedTranscription (linguistics)
Transcription in the linguistic sense is the systematic representation of language in written form. The source can either be utterances or preexisting text in another writing system, although some linguists only consider the former as transcription.Transcription should not be confused with...
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. A follow up IOM report in 2001 advised use of electronic medication ordering, with computer- and internet-based information systems to support clinical decisions. 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. Studies of computerized physician order entry (CPOE) has yielded evidence that suggests the medication error rate can be reduced by 80%, and errors that have potential for serious harm or death for patients can be reduced by 55%, and other studies have also suggested benefits. Further, in 2005, CMS and CDC released a report that showed only 41 percent of prophylactic antibacterials were correctly stopped within 24 hours of completed surgery. The researchers conducted an analysis over an eight-month period, implementing a CPOE system designed to stop the administration of prophylactic antibacterials. Results showed CPOE significantly improved timely discontinuation of antibacterials from 38.8 percent of surgeries to 55.7 percent in the intervention hospital. CPOE/e-Prescribing 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). In this way, specialists in pharmacy informatics work with the medical and nursing staffs at hospitals to improve the safety and effectiveness of medication use by utilizing CPOE systems.
Risks of CPOE
CPOE presents several possible dangers by introducing new types of errors. 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 PittsburghPittsburgh, Pennsylvania
Pittsburgh is the second-largest city in the US Commonwealth of Pennsylvania and the county seat of Allegheny County. Regionally, it anchors the largest urban area of Appalachia and the Ohio River Valley, and nationally, it is the 22nd-largest urban area in the United States...
's Pediatric ICU
Intensive Care Unit
thumb|220px|ICU roomAn intensive-care unit , critical-care unit , intensive-therapy unit/intensive-treatment unit is a specialized department in a hospital that provides intensive-care medicine...
when a CPOE systems was introduced. 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 due to alert fatigue. 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. 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. 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 technologyHealth informatics
.Health informatics is a discipline at the intersection of information science, computer science, and health care...
. As more hospitals become aware of the financial benefits of CPOE, and more physicians with a familiarity with computer
Computer
A computer is a programmable machine designed to sequentially and automatically carry out a sequence of arithmetic or logical operations. The particular sequence of operations can be changed readily, allowing the computer to solve more than one kind of problem...
s 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. Several high profile failures of CPOE implementation have occurred, so a major effort must be focused on change management
Change management
Change management is a structured approach to shifting/transitioning individuals, teams, and organizations from a current state to a desired future state. It is an organizational process aimed at helping employees to accept and embrace changes in their current business environment....
, 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
United States Department of Veterans Affairs
The United States Department of Veterans Affairs is a government-run military veteran benefit system with Cabinet-level status. It is the United States government’s second largest department, after the United States Department of Defense...
(VA) is the Veterans Health Information Systems and Technology Architecture or VistA
VistA
The Veterans Health Information Systems and Technology Architecture is an enterprise-wide information system built around an Electronic Health Record , used throughout the United States Department of Veterans Affairs medical system, known as the Veterans Health Administration .It's a collection...
. A graphical user interface
Graphical user interface
In computing, a graphical user interface is a type of user interface that allows users to interact with electronic devices with images rather than text commands. GUIs can be used in computers, hand-held devices such as MP3 players, portable media players or gaming devices, household appliances and...
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
El Camino Hospital
El Camino Hospital is a 395-bed hospital based in Mountain View, California.Located on a campus in the heart of Silicon Valley, El Camino Hospital serves residents in the El Camino Hospital District — Mountain View, Los Altos, Los Altos Hills, and portions of Sunnyvale and Palo Alto — as...
in Mountain View, California in the early 1970s. The Medical Information System (MIS) was originally developed by a software and hardware team at Lockheed
Lockheed Corporation
The Lockheed Corporation was an American aerospace company. Lockheed was founded in 1912 and later merged with Martin Marietta to form Lockheed Martin in 1995.-Origins:...
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.
, one of the largest projects for a national EHR is by the National Health Service
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...
(NHS) in the United Kingdom
United Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...
. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record
Electronic Health Record
An electronic health record is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations...
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", includes office-based CPOE for medication prescribing and test ordering and retrieval, although some concerns have been raised about patient safety
Patient safety
Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. The frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported...
features.
In 2008, the Massachusetts Technology Collaborative and the New England Healthcare Institute
New England Healthcare Institute
NEHI is an independent, nonprofit national network and research organization focused on enabling innovation to improve health care quality and lower health care costs. In partnership with members from all across the health care system, NEHI conducts evidence-based research and stimulates policy...
(NEHI) published research showing that 1 in 10 patients admitted to a Massachusetts
Massachusetts
The Commonwealth of Massachusetts is a state in the New England region of the northeastern United States of America. It is bordered by Rhode Island and Connecticut to the south, New York to the west, and Vermont and New Hampshire to the north; at its east lies the Atlantic Ocean. As of the 2010...
community hospital suffered a preventable medication error. The study argued that Massachusetts hospitals could prevent 55,000 adverse drug events per year and save $170 million annually if they fully implemented CPOE. The findings prompted the Commonwealth of Massachusetts to enact legislation requiring all hospitals to implement CPOE by 2012 as a condition of licensure.
In addition, the study 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. And 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 Leapfrog’s 2008 Survey showed that most hospitals are still not complying with having a fully implemented, effective CPOE system. The CPOE requirement became more challenging to meet in 2008 because the Leapfrog introduced a new requirement: Hospitals must test their CPOE systems with Leapfrog’s CPOE Evaluation Tool. So the number of hospitals in the survey considered to be fully meeting the standard dropped to 7% in 2008 from 11% the previous year. Though the adoption rate seems very low in 2008, it is still an improvement from 2002 when only 2% of hospitals met this Leapfrog standard.
See also
- Electronic prescribingElectronic prescribingElectronic prescribing or e-prescribing is the ability to send error-free, accurate, and understandable prescriptions electronically from the healthcare provider to the pharmacy. E-prescribing is meant to reduce the risks associated with traditional prescription script writing. It is also one of...
- Continuity of Care RecordContinuity of Care RecordContinuity of Care Record is a health record standard specification developed jointly by ASTM International, the Massachusetts Medical Society , the Healthcare Information and Management Systems Society , the American Academy of Family Physicians , the American Academy of Pediatrics , and other...
- Electronic health recordElectronic Health RecordAn electronic health record is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations...
- Electronic medical recordElectronic medical recordAn electronic medical record is a computerized medical record created in an organization that delivers care, such as a hospital or physician's office...
- Health informaticsHealth informatics.Health informatics is a discipline at the intersection of information science, computer science, and health care...
- Pharmacy informatics
- VistAVistAThe Veterans Health Information Systems and Technology Architecture is an enterprise-wide information system built around an Electronic Health Record , used throughout the United States Department of Veterans Affairs medical system, known as the Veterans Health Administration .It's a collection...
- Veterans Health Information Systems and Technology Architecture