Computerized Provider Order Entry (CPOE) and Its Impact on Patient Safety
Computerized Provider Order Entry (CPOE) is a critical component of healthcare technology that automates the patient ordering process to enhance efficiency, reduce medical errors, and improve patient safety outcomes. Integrated with clinical decision support systems, CPOE applies rules-based logic to offer real-time feedback, such as alerting healthcare providers of potential drug interactions. Rapid adoption of electronic medication ordering, supported by CPOE, is seen as a solution to prevent, reduce, or eliminate medical errors leading to adverse drug events. The ultimate goal is to manage patient care effectively while enhancing healthcare delivery efficiency.
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COMPUTERIZED PROVIDER ORDER ENTRY (CPOE) This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Based on a work at https://www.healthit.gov/. This workforce product was funded by a grant awarded by the U.S. Department of Labor's Employment and Training Administration. The product was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including, but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership.
DEFINITION OF CPOE Computerized provider order entry (CPOE) Order entry application Assists practitioners with the creation and management of ordersfor services and medications HIMSS Dictionary of Healthcare Information Technology Terms, Acronyms and Organizations
CPOE Is part of an integrated clinical informationsystem Is a computer application Not just an electronic prescribing system Use of computer assistance by a provider to directly enter medicalorders 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 safetyand 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 ANDADES IOM reports 98,000 patients die each year in U.S. hospitals due to medical errors Advised rapid adoption of electronic medication ordering tosupport clinical decisions CPOE seen as a solution
IMPROVE PATIENTSAFETY 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 safetypractice
REDUCE UNNECESSARY VARIATIONIN 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 HEALTHCARE DELIVERY Reduction in order verification and processingtimes Electronic communication both directions Order entered electronically Order sent electronically Order received electronically Status returned electronically Requires interfaces with existing informationsystems
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-freeoperation
FUNCTIONS OF CPOE Basic: Electronicorder communication Advanced: includesclinical 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 Complex: Alert of a drugallergy along with an alternative medication Returns status of order Returns results of order execution
CPOE AND CLINICAL DECISIONSUPPORT SYSTEM(CDSS) Clinical Decision Support System (CDSS) Uses pre-established rules and guidelines Integrates clinical data form severalsources Generates alerts and treatment suggestions HIMSS Dictionary of Healthcare Information TechnologyTerms, Acronyms and Organizations, 2010 CPOE needs clinical decision support to reach its fullvalue
CPOE AND CLINICAL DECISIONSUPPORT SYSTEM(CDSS) Three parts to CDSS Knowledge base, aka the rules-engine Inference engine Mechanism to communicate
CPOE AND CLINICAL DECISIONSUPPORT SYSTEM(CDSS) No single approach to integration Questions to ask What kind and how much clinical support? What about medication alerts, allergies, routine preventivediagnostics? 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 PAPER- BASED 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-supportsystems 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=83e2c4349737ab8b717ca9f12ccdca4a1de9f26a
ADVANTAGES OF CPOE OVER PAPER- BASED SYSTEMS Less subject to errors caused by use of apothecary measures Easily linked to drug-drug interaction warnings More likely to identify the prescribingphysician Able to link to ADE reportingsystems 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=83e2c4349737ab8b717ca9f12ccdca4a1de9f26a
ADVANTAGES OF CPOE OVER PAPER- BASED SYSTEMS Able to avoid specification errors Available and appropriate for training and education Available for immediate data analysis Claimed to generate significant economicsavings 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=83e2c4349737ab8b717ca9f12ccdca4a1de9f26a
ADVANTAGES OF CPOE OVER PAPER- BASED 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=83e2c4349737ab8b717ca9f12ccdca4a1de9f26a
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 ofhealth 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/PMC2244888
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.ama- assn.org/cgi/content/full/293/10/1197?ijkey=83e2c4349737ab8b717ca9f12ccdca4a1de9f26a
MEDICATION ERROR RISKS HUMAN-MACHINE INTERFACE FLAWS Patient selection Loss of data,time,and focus when CPOE is nonfunctional Wrong medication selection Late-in-day orders lost for 24 hours Unclear logon/log off Failure to provide medications after surgery Role of charting difficulties in inaccurate and delayed medication administration Sending medications to wrong rooms when the computer system has shut down Post-surgery suspended medications Inflexible ordering screens, incorrect medications
MAJOR SUPPORT FOR CPOEADOPTION HITECHAct 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 FINALRULE 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 orthe associated measure Any licensed healthcare professional can enter orders into themedical record per state, local and professional guidelines
CPOES IMPACT CPOE can with Clinical Decision Support (CDS) Improve medication safety and quality of care Reduce costs of care Improve compliance with providerguidelines 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
CPOES 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
