Computer Physician Order Entry: To Implement or Not?
Primary Psychiatry. 2006;13(3):19-21
Dr. Luo is assistant clinical professor in the Department of Psychiatry and Biobehavioral Sciences at the University of California in Los Angeles; past president of the American Association for Technology in Psychiatry (AATP) in New York City; and Gores Informatics Advocacy chair at the AATP.
An Institute of Medicine report1 in 2000 cited two large studies indicating an average of 3% medical error incidences in New York, Utah, and Colorado. In Utah and Colorado, 6.6% of these adverse events led to death, compared to 13.6% of adverse events in New York. The economics of preventable medical errors is staggering, ranging from $17–$29 billion due to loss of income and household production, disability, and healthcare costs. The Leapfrog Group,2 which includes organizations that leverage their healthcare purchasing power to encourage patient safety, quality, and customer value, uses computer physician order entry (CPOE) as an important measure toward patient safety in hospitals. Given that illegible handwriting might be open to misinterpretation, hospital systems see CPOE as a viable solution to reduce errors in prescriptions and medical orders. However, implementation of CPOE is not necessarily quick or easy. Cedars Sinai Hospital in Los Angeles abandoned their CPOE program in January 2003 when 400 physicians complained that it was difficult, time-consuming, and posed risks to patient safety. The hospital has no plans to try to implement a new CPOE program until sometime after 2006.3 CPOE is a conceptually good idea, but it is difficult to implement. A more than cursory assessment of CPOE will clarify whether your organization is ready.
What is CPOE?
CPOE is difficult to implement. Although most healthcare systems utilize computerized medication or laboratory orders in some form, the goal of using physicians for order entry is not to add to their administrative burden, nor is it to reduce costs by decreasing the number of inpatient ward clerks. Basic CPOE ensures standardized, legible, and complete orders by only accepting typed orders in a standard format. CPOE systems are implemented with varying degrees of an integrated clinical decision support system (CDSS) that alerts the physician of a medication dosing error or potential drug interaction.4 Basic clinical decision support may include suggestions or default values for drug doses, routes, and frequencies. A more sophisticated CDSS can perform drug allergy checks, drug-laboratory value checks, and drug-drug interaction checks, and can provide reminders about corollary orders such as prompting the user to order lithium levels after ordering lithium.5 Traditional inpatient wards also utilize nursing staff who often scrutinize medication and laboratory orders for clarification when their clinical judgment and experience tells them that something appears amiss. In teaching hospitals, this role to check and validate orders is often crucial when resident physicians are clinically inexperienced with medication dosing strategies.
Benefits and Limitations of CPOE
CPOE systems are challenging to implement, but the projected benefits are real. CPOE has been demonstrably effective in improving both efficiency and accuracy of orders.6
Bates and colleagues,7 and Cullen and colleagues,8 in their reviews of CPOE and CDSS on medication errors, established that these systems can reduce serious medication errors by 55%. Additionally, there was a 17% decrease in adverse drug events, and as the study progressed, the frequency decreased. Jha and colleagues,9 in 1998 reported that CPOE identified more adverse drug events, but not at a statistically significant difference. Ozdas and colleagues10 demonstrated that CPOE-based initial order sets which implement standardized acute coronary syndrome recommendations for acute myocardial infraction significantly increased the number of patients who received aspirin.
In contrast to the popular opinion that CPOE has benefits for reduction of adverse drug events, Berger and Kichak11 challenge the Institute of Medicine1 report on rates of adverse events, as well as the conclusions of the Bates studies.6,7 The authors11 indicate that the rates of adverse events based on studies in the 1980s was flawed due to lack of control groups, and that there were other methodologic flaws. King and colleagues12 demonstrated that CPOE generated a 40% decrease in medication error rates, but no actual difference in morbidity or mortality was shown. Berger and Kichak11 also highlighted conflict of interest in the Leapfrog Group, where 10% of the companies are involved in sales of software or hardware to healthcare organizations. In a review of the literature in 2003, Oren and colleagues13 noted that despite the published evidence on the effects of CPOE and other technologies such as automated dispensing machines, bar coding, and computerized medication administration records, the literature supporting the impact of these technologies in the reduction of medication errors and adverse drug events was limited because many of these systems could not be generalized to other systems. King and colleagues,12 in a cohort retrospective study of CPOE use on a pediatric inpatient ward, found a 40% reduction in medication error rate, but not in improved adverse drug events.
Implementation of a CPOE system evokes strong emotion, as identified in a qualitative study by Sittig and colleagues.14 In this study, a secondary analysis was done on previously collected qualitative data sets from interviews and observations of individuals where CPOE was implemented. The authors note that negative emotional responses were the most prevalent of the observations, and the number of positive emotions was quite small. An interesting conclusion from this study was that most of the negative emotions were based on how the system provided negative feedback, such as a failure to complete a task or erroneous actions. The authors surmise that a positive feedback system, which provides education and congratulatory messages, may help physicians react differently to the system by recognizing how CPOE helps them to achieve their own objectives of quality care. In a survey of 143 Johns Hopkins School of Medicine students, Knight and colleagues15 demonstrated that 95% of medical students thought that CPOE would help them learn what types of tests and treatments their patients needed. However, limitations were due to housestaff and faculty not wanting students to enter orders, because it would require extra time spent training and reviewing the orders.
A more distressing issue is how new errors arise with information technology in healthcare. Based on qualitative study of CPOE in four hospital systems, Ash and colleagues16 highlight two types of errors—those which occur in the process of entering and retrieving information, and errors in the communication and coordination process. The authors note that many computer systems are not well designed. Thus, providers are required to direct and isolate their attention in order to avoid juxtaposition errors. Such errors are often due to choosing a selection on the screen that is close to the correct, desired selection. In addition, the highly structured data needs of CPOE systems do not fit into the “flow” of human thinking, which is geared more toward free text. Therefore, such shifts to check all of the boxes on the screen may create a loss of perspective on the patient and fragment the focus on care. In terms of communication and coordination, some problems are inherent in the way that a CPOE system is often inflexible, forcing physicians to work in a linear and structured fashion. Urgency in such a structured system could prevent nurses from executing stat orders to be charted later. Feedback via communication with other healthcare professionals is often critical, and a CPOE may falsely limit the discussion among professionals because it was assumed that everyone saw it in the system. These new errors are not the result of poor computer programming, but are rather due to poor design or poor implementation of a CPOE system (Table).
The decision to implement a CPOE system is not simply a matter of deciding that it is a good idea for improving quality of care and patient safety. Ash and colleagues,17 members of the Oregon Health & Science University’s Physician Order Entry Team, interviewed thirteen experts from around the globe for the purpose of developing recommendations for CPOE implementation.
Clearly, successful implementation requires more than administration approval, as evidenced by Cedar Sinai’s experience of CPOE termination without physician buy-in. Multiple factors, including workflow, cost, change-management principles, vendor readiness, long-term support, continued evaluation and education, and integration into work flow must be addressed and constantly monitored.18
CPOE, using computers to enter orders directly, appears to be a simple solution for reducing errors. However, converting from paper to computer is not a simple matter. An underlying system of checks and balances exists with other care providers such as nursing and pharmacists who play a significant role in the oversight process. Clinical decision support systems are necessary to make CPOE more successful in catching errors and changing behavior to implement guidelines. Addressing human factors and emotional response to change are crucial in the successful adoption of the CPOE system. Seamless integration into the workflow process is necessary to reduce resistance. CPOE at the present time appears to be a great idea, but it is a complex process. With improved mobile computer technology, secure wireless communication, and standardized information exchange between various healthcare computer systems, CPOE may find its way into medical practice on a standard basis. PP
1. Corrigan JM, Kohn LT, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.
2. The Leapfrog Group. Available at: http://www.leapfroggroup.org. Accessed February 9, 2006.
3. Morrissey J. Harmonic divergence. Cedars-Sinai joins others in holding off on CPOE. Mod Healthc. 2004;34(8):16.
4. Osheroff JA, Pifer EA, Teich JM, Sittig DF, Jenders RA. Improving Outcomes with Clinical Decision Support: An Implementer’s Guide. Chicago, IL: Health Information Management and Systems Society; 2005.
5. Kaushal R, Bates DW. Computerized physician order entry (CPOE) with clinical decision support systems (CDSSs). In: Wachter RM. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment no. 43l. Agency for Healthcare Research and Quality. Contract No. 290-97-0013; 2001. Available at: http://www.ahrq.gov/clinic/ptsafety/chap6.htm. Accessed February 9, 2006.
6. Bates DW, Leape LL, Cullen DJ, et al. Effect of a computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280(15):1311-1316.
7. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274(1):29-34.
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11. Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc. 2004;11(2):100-103.
12. King WJ, Paice N, Rangrej J, Forestell GJ, Swartz R. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;112(3 Pt 1):506-509.
13. Oren E, Shaffer ER, Guglielmo BJ. Impact of emerging technologies on medication errors and adverse drug events. Am J Health Syst Pharm. 2003;60(14):1447-1458.
14. Sittig DF, Krall M, Kaalaas-Sittig J, Ash JS. Emotional aspects of computer-based provider order entry: a qualitative study. J Am Med Inform Assoc. 2005;12(5):561-567.
15. Knight AM, Kravet SJ, Harper GM, Leff B. The effect of computerized provider order entry on medical student clerkship experiences. J Am Med Inform Assoc. 2005;12(5):554-560.
16. Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11(2):104-112.
17. Computerized Physician/Provider Order Entry Team. Available at: http://www.ohsu.edu/dmice/research/cpoe/index.shtml. Accessed February 9, 2006.
18. Ash J. Considerations concerning computerized physician order entry implementation: The 2001 menucha conference list. Available at: http://www.ohsu.edu/dmice/research/cpoe/research/menucha_2001.pdf. Accessed February 9, 2006.