Computerized Physician Order Entry: Way Forward

Fig. above shows that the computer systems in hospitals are evolving from stand-alone data collection mode to an integrated healthcare enterprise (IHE). Once the systems are integrated the stage is set to institutionalize CRM (consumer relationship management), evidence based medicine and the topmost layer of patient safety-- CPOE.

Introduction and Background:

44,000 - 98,000 people die in the USA hospitals each year as a result of medical errors that could have been prevented.1 These facts were cited in the Institute of Medicine’s report of 1999, which was based on estimates from two major studies in the USA. Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS. As a result of the IOM report, Fortune 500 employers in the USA found that though a lot of healthcare standards were being put in place, but patient safety still remained an area where focus was needed to reduce errors and thereby control the spiralling medical costs and premiums. This led to the formation of The Leapfrog Group with the aim of improving patient safety. Developing Computerized Physician Order Entry (CPOE) standards is one of the many initiatives from The Leapfrog Group to improve patient safety.

It has been found that lot of deaths happen due to human error at the physician’s order entry stage itself. CPOE is aimed at alerting the physician about potentially dangerous/erroneous orders before the orders are really executed, thereby facilitating a solution for this long-standing issue in medical set up. The testimony to the benefits of CPOE is that more than 10% of U.S. hospitals now have CPOE.

The CPOE concept has existed for a long time and now The Leapfrog Group is laying down the standards to give it a proper direction. Large Healthcare-IT vendors are already putting efforts to make their clinical systems CPOE compliant. However the obstacle is that many clinical systems from different vendors still do not talk to each other. The Computer systems in hospital environment have to evolve a lot before the true benefits of CPOE can be realized. Large Healthcare-IT vendors have to play a responsible role in integrating the Health delivery industry, and thereby move towards a greater patient safety.

What is CPOE?

The Leapfrog Group includes the following language in their CPOE Fact sheet. “In order to fully meet Leapfrog’s CPOE Standard, hospitals must:

1. Assure that physicians enter at least 75% of medication orders via a computer system that includes prescribing-error prevention software;
2. Demonstrate that their in-patient CPOE system can alert physicians of at least 50% of common, serious prescribing errors, using a testing protocol now under development by First Consulting Group and the Institute for Safe Medication Practices;
3. Require that physicians electronically document a reason for overriding an interception prior to doing so.’’

CPOE Evolution:

Decentralized and fragmented nature of healthcare delivery system has been the oft-cited problem that has contributed to medical errors. When patients see multiple providers in different settings, none of whom have access to complete information, it becomes easier for things to go wrong.1 Fully integrated Hospital IT infrastructure, EMR, and computer based data capture and data storage are pre-requisites for institutionalizing CPOE standards.

Computer systems have evolved in the hospital environment over a period of time. The early computer systems in the hospitals were essentially stand-alone islands of patient data that could not communicate with other systems in the same department, let alone the other systems in the hospital.

Nowadays, most hospitals are investing time and effort for integrating various stand-alone systems across departments to reduce errors during double entry of patient data and enable physician order execution in near real-time.

Today all of the large clinical systems vendors are making sincere efforts to make their own products CPOE compliant. However the reality is that the hospital can have islands of computer systems installed/ built at various periods of time by different product vendors. Large Healthcare-IT vendors have to come out of business silos and move to open standards to help Health delivery industry for integrating the stand-alone systems and tiding over the chasm. Only then, true CPOE can be implemented enterprise wide.

CPOE Alerts:

CPOE standards recommend that alerts be given to the Physician for basic to expert level warnings. The range of alerts varies from the drug allergy and drug overdose (basic alert) to contraindication based on individual’s laboratory studies (expert alert).

Basic level alerts are simple alerts for allergy to penicillin and overdose of antihistamine. Whereas alerts for unusual drop in blood clotting time and prothrombin laboratory values in patient’s charts due to increasing dose of anti-coagulant like warfarin is an expert level alert.

Alerts need a huge enterprise-wide knowledge base to operate in the backend. Some of the medical knowledge is readily available whereas some of it is still state, region and hospital specific. Expert/ Advance level alerts e.g. drug-lab-document alert will need data from across different hospital systems. These systems need to be integrated to yield full benefits of CPOE.

Flip Side of CPOE:

Physicians and medical staff need real time access to data that is relevant to the case at hand. They need to be able to record a maximum amount of information in a minimum amount of time and in such a way that it is most useful to other health care professionals involved in the handling of this patient. It is totally unacceptable if the alerts do not appear real time and increases the physician’s time per patient.

Decision support systems also suffer from the problem of an overdose of reminders, alerts, or warning messages. This delay can be dangerous in emergency situations. CPOE compliant systems are infamous for “…causing cognitive overload by overemphasizing structured and ‘Complete’ information entry”.

There is a rather large grey zone of informal management, which can be entirely rational given the everyday organization and exigencies of health care work. In emergency and some other special situations, orders may be entered after the order execution. For example, while transferring a patient between the emergency department and ward, orders could not be transferred or new orders could not be entered in the system because the patient was not yet ‘‘in the system”.

In the case of urgent medication orders, nurses can give a medication before the physician formally activates the order. During nightly routine medication administration, nurses can initiate distribution without waking up the junior doctor who is formally responsible for signing the order. Within this same grey zone, there could lay many practices that would contribute to unsafe medication routines such as doctors actively discouraging nurses to call them for medication requests or nurses taking too many liberties with dosing.5 All of these practices exist within the current paper medication systems, but many CPOE systems do not leave room for such practices.

Inexperienced computer users can face issues like a slip of the mouse on a data entry form leading to an order for the right medication for the wrong patient. Such errors due to inexperience lead to arguments that pen and paper are simpler and better. However expert level alerts in CPOE systems are expected to take care of such issues to some extent.

Conclusion:

The Institute of Medicine’s report has had its desired effect. Formation of The Leapfrog Group and coming out with the CPOE standards is a right step towards patient safety.

CPOE systems can reduce unnecessary repetitive orders and also significantly cut down the delays between writing and completing orders. They can also cut staff costs directly by reducing the time spent by nursing, pharmacy, and other ancillary services on callbacks to clarify orders and by eliminating the personnel time of transcribing orders. So, health care institutions have much to gain in efficiency and cost savings from CPOE systems.

In the late 1980s and 1990s, some people criticized that no one else used or ever would use CPOE. Whereas more than 13% of U.S. hospitals have CPOE today.6

To derive the true benefits of CPOE the challenge is to create user-friendly, seamless systems that integrate all critical disparate systems throughout the enterprise- including patient records, order entry, pharmacy, radiology and Lab.

To completely replace legacy clinical systems with a single-vendor, monolithic solution would be expensive and cumbersome. As an alternative, taking the application integration approach to meet CPOE requirements will typically cost less in terms of time and material.

Large Healthcare-IT vendors should focus on larger benefits by integrating the health delivery industry rather than competing with each other for the same piece of the pie.

Source: Dr Pankaj Gupta. CPOE: Way Forward, paper presentation, Indian Conference on Medical Informatics and Telemedicine, ICMIT 2005, IIT Kharagpur, India