Computerized physician order entry

From Self-sufficiency
Jump to: navigation, search

Computerized physician order entry (CPOE), is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized 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 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 of collaboration amoungst the health care team.

Terminology related to order entry

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. The second application may in some cases be the same; i.e., 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

The application or individual originating a request for services (order).

Placer order group

A list of associated orders coming from a single location regarding a single patient.

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 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 computers.
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.

Patient safety benefits of CPOE

In the past, physicians have traditionally hand-written or verbally communicated orders for patient care, which are then transcribed 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.[1] A follow up IOM report in 2001 advised use of electronic medication ordering, with computer- and internet-based information systems to support clinical decisions.[2] 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.[3] Computerized physician order entry (CPOE) has been estimated to reduce the medication error rate by 80%, and by 55% for errors with serious potential patient harm,[4] and other studies have also suggested benefits.[5] 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.[6][7] 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 Pittsburgh's Pediatric ICU when a CPOE systems was introduced.[8] 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.[9] 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.[10] 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 technology.[11] As more hospitals become aware of the financial benefits of CPOE, and more physicians with a familiarity with computers 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.[12] Several high profile failures of CPOE implementation have occurred,[13] 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.

As of 2005, 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",[14] includes office-based CPOE for medication prescribing and test ordering and retrieval, although some concerns have been raised about patient safety features.[15]

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.[16]

In addition, the study [17]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[18] 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

External links

Notes

Cite error: Invalid <references> tag; parameter "group" is allowed only.

Use <references />, or <references group="..." />
de:Computerized Physician Order Entry
  1. ↑ Institute of Medicine (1999). "To Err Is Human: Building a Safer Health System (1999)". The National Academies Press. Retrieved 2006-06-20. 
  2. ↑ Institute of Medicine (2001). "Crossing the Quality Chasm: A New Health System for the 21st Century". The National Academies Press. Retrieved 2006-06-29. 
  3. ↑ The Institute of Medicine (2006). "Preventing Medication Errors". The National Academies Press. Retrieved 2006-07-21. 
  4. ↑ David W. Bates, MD; et al. (1998). "Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors" (abstract). JAMA. 280 (15): 1311–1316. doi:10.1001/jama.280.15.1311. PMID 9794308. Retrieved 2006-06-20. 
  5. ↑ http://www.eurekalert.org/pub_releases/2010-05/sumc-ssf042710.php
  6. ↑ Ross Koppel, PhD; et al. (2005). "Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors" (abstract). JAMA. 293 (10): 1197–1203. doi:10.1001/jama.293.10.1197. PMID 15755942. Retrieved 2006-06-28. 
  7. ↑ Lohr, Steve (2005-03-09). "Doctors' Journal Says Computing Is No Panacea". The New York Times. Retrieved 2006-07-15. 
  8. ↑ Yong Y. Han, Joseph A. Carcillo, Shekhar T. Venkataraman, Robert S.B. Clark, R. Scott Watson, Trung C. Nguyen, Hülya Bayir, and Richard A. Orr (2005). "Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System". Pediatrics. 116 (6): 1506–1512. doi:10.1542/peds.2005-1287. PMID 16322178. Retrieved 2006-07-30. 
  9. ↑ Santell, John P (2004). "Computer Related Errors: What Every Pharmacist Should Know" (PDF). United States Pharmacopia. Retrieved 2006-06-20. 
  10. ↑ Kaufman, Marc (2005-07-21). "Medication Errors Harming Millions, Report Says. Extensive National Study Finds Widespread, Costly Mistakes in Giving and Taking Medicine". The Washington Post. pp. A08. Retrieved 2006-07-21. 
  11. ↑ RAND Healthcare: Health Information Technology: Can HIT Lower Costs and Improve Quality? Retrieved on July 8, 2006
  12. ↑ "Hospital Quality & Safety Survey" (PDF). The Leapfrog Group. 2004. Retrieved 2006-07-08. 
  13. ↑ Connolly, Ceci (2005-03-21). "Cedars-Sinai Doctors Cling to Pen and Paper". The Washington Post. Retrieved 2006-08-03. 
  14. ↑ NHS Connecting for Health: Delivering the National Programme for IT Retrieved August 4, 2006
  15. ↑ C J Morris, B S P Savelyich, A J Avery, J A Cantrill and A Sheikh (2005). "Patient safety features of clinical computer systems: questionnaire survey of GP views". Quality and Safety in Health Care. 14 (3): 164–168. doi:10.1136/qshc.2004.011866. PMC 1744017 Freely accessible. PMID 15933310. Retrieved 2006-07-08. 
  16. ↑ http://www.todayshospitalist.com/index.php?b=articles_read&cnt=614
  17. ↑ Dolan, Pamela L. (2008). "Insurer finds EMRs won't pay off for its doctors". American Medical News. Retrieved 2009-10-13. 
  18. ↑ "Leapfrog Hospital Survey Results" (PDF). The Leapfrog Group. 2008. Retrieved 2009-10-13. 
Retrieved from "http://ssf.f15ijp.com/wiki/index.php?title=Computerized_physician_order_entry&oldid=37491"