Computerized Provider Order Entry (CPOE) and Its Impact on Patient Safety
This work is licensed under a
. Based on a work at
.https://www.healthit.gov/Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License
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.
COMPUTERIZED PROVIDER ORDER
ENTRY
(CPOE)
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
•
–Accepts/captures
the
provider’s
orders
for
services
•
–Transmits
the order to
the
appropriate
location
•
–Returns
status
of
order
•
–Returns
results
of
order
execution
•
Advanced: includes
clinical
decision
support
•
–Simple:
drug-drug
interaction
checks,
medication
dose
calculators
•
–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
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-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=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 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=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 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=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
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/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
Wrong
medication selection
Unclear logon/log
off
Role
of charting
difficulties in inaccurate
and
delayed
medication
administration
Post-surgery“suspended”
medications
Loss
of
data,
time,
and
focus
when
CPOE
is
nonfunctional
Late-in-day orders
lost for
24
hours
Failure
to
provide
medications after
surgery
Sending medications to
wrong rooms
when the
computer system has shut
down
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
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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Presentation Transcript
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
