Computerized physician order entry (CPOE) Systems- An introduction

Transcription

1 Review Article ISSN: Patel Minesh et al. / Journal of Pharmacy Research 2012,5(10), Available online through Computerized physician order entry (CPOE) Systems- An introduction Patel Minesh a,1*, Patel Isha b,c,2*, Chang Jongwha d,**, Rarus Rachel b,3, Srivastava Jatin e,4, Ahmad Akram f,5, Balkrishnan Rajesh b,c,g,6 a Department of Healthcare and Public Administration, Long Island University, 720 rthern Boulevard Brookville, NY b Clinical, Social and Administrative Sciences, College of Pharmacy, University of Michigan at Ann Arbor, 428 Church Street, Ann Arbor, MI , USA c Center for Global Health, The University of Michigan, 428 Church Street, Ann Arbor, MI , USA d Department of Public Health Sciences, Penn State College of Medicine, The Pennsylvania State University, 500 University Drive, Hershey, PA-17033, USA e E.W. Scripps School of Journalism, Ohio University, 220 Scripps Hall, Athens,OH, , USA f Department of Pharmacy Practice, Annamalai University, Annamalai Nagar , Tamil Nadu, India g Department of Health Management and Policy, The University of Michigan, 428 Church Street, Ann Arbor, MI , USA *Both the authors have contributed equally to the project INTRODUCTION Computerized Physician Order Entry (CPOE) systems are a specific type of health information technology, which is the application of science and technology to healthcare. Health information technology systems provide real-time access to medical information to coordinate patient medical care and also help to ensure the completeness of medical information entry. Figure 1 illustrates the wide range of health information technology utilized in clinical practice and changes over time in their prevalence of use. 1 As one example of health information technology, electronic medical record (EMR) systems are employed to improve the efficiency and management of patients medical records, including clinical and administrative data. Similar to EMR systems, CPOE systems are a readily accessible technological system and facilitate the completeness of medical documentation. CPOE systems, however, focus specifically on improving the safety and completeness in the ordering step of the medication use process. 2 Received on: ; Revised on: ; Accepted on: ABSTRACT Computerized Physician Order Entry (CPOE) systems are a type of health information technology that facilitate the process of ordering medications, tests, and procedures and can reduce the rate of medical errors and enhance patient safety. CPOE systems integrate basic patient medical information, current medication orders, and recent clinical treatment guidelines to alert clinicians of orders that may result in adverse effects and patient harm. Currently, implementation of CPOE systems in the United States is limited due to a variety of substantial barriers, although it is anticipated that adoption of CPOE systems will be more widespread in the future. In this introduction to CPOE systems, we describe the purpose and set up of CPOE systems. Moreover, we briefly review the CPOE systems available from different vendors and the various methods of integrating CPOE systems with pharmacy information systems. Finally, we explore several key features and potential benefits of CPOE systems on improving medication prescribing, reducing medication errors, promoting patient safety, and decreasing healthcare costs. Key words: CPOE, health information technology, pharmacy information systems, patient safety **Corresponding author. Chang Jongwha Department of Public Health Sciences, Penn State College of Medicine, The Pennsylvania State University, 500 University Drive, Hershey, P A-17033, USA jchang@phs.psu.edu Figure 1. Trends showing the barriers in implementing different types of Health Information Technology: Figure 1 mentions about the different barriers that were faced by healthcare systems and healthcare providers in implementing different types of health information technology.

2 Patel Minesh et al. / Journal of Pharmacy Research 2012,5(10), The medication use process in the inpatient setting consists of four main steps: ordering, transcribing, dispensing, and administration. In the ordering step, the clinician chooses the appropriate drug, dose, frequency and route of administration, quantity to be dispensed, and directions of use for the patient. In the transcribing step, the order is verbally or electronically transmitted to the pharmacist. Next, in the dispensing step, the pharmacist checks for drug interactions and patient allergies and for the purity and accuracy of the medication order. Finally, in the administration step, the nurse receives the medication and provides it to the patient. 3 CPOE systems provide clinical and technological support to optimize the process of healthcare providers ordering of medications, laboratory tests, and other medical procedures. 4 CPOE systems incorporate basic patient information such as drug allergies, and the medical technology system including electronic patient records, laboratory reports, pharmacy prescription, and pertinent information from other sources. Furthermore, CPOE systems enhance patient safety by generating alerts for contraindicated medications, inappropriate drug or route of drug administration, or duplicated orders. These alerts are based on rules and programs that are included in the system. By including and synthesizing all of these sources of information, CPOE systems help prescribers develop and transmit an effective, accurate, and safe order. See Figure 2 for a depiction of how CPOE systems interface with clinicians, interrelate with other health information technology systems, and work in the ordering process. 5 Figure 2. CPOE flowchart 5 Figure 2. This diagram illustrates the role of CPOE systems in the medication order system processing and the importance of alerts in the CPOE process. First, an order is inputted by the clinician via a user interface, such as a computer or personal device. Clinicians can consult a clinical database of medical information that is provided with the CPOE system when placing the order, as illustrated in box 1. Next, when the order is placed, alerts may be generated for allergies, potential dosing errors, or safety considerations based on lab values. When the order is ready to be filled and processed, additional alerts may be generated to ensure the safety of the order, as shown in box 3. Alerts and notifications are created based on rules engines, shown in box 4. This information provides a recurring cycle of feedback that can inform the users of the CPOE system and help guide clinical decision making, which is reflected in box 2. From all of this, CPOE systems help provide optimal patient outcomes at the point of care. The overarching goal of CPOE systems is to increase patient safety by reducing errors in the order process. 6-7 Therefore, the effectiveness and utility of CPOE systems can be assessed as a reduction in the number of medical errors or the number of adverse events. It is important to distinguish between medical errors and adverse events in order to accurately assess the effectiveness of CPOE systems. 7 A medical error is defined as a prescription or treatment that does not comply with current clinical guidelines or the administration of treatment different from what was prescribed. Some examples of medication errors include: administrating the wrong drug, drug over or underdosing, and overlooking drug interactions and patient allergies. Most medical errors are due to medication errors associated with the medication use process. One study of medication errors found that about 90 percent of errors occurred at either the ordering or transcribing step of the medication use process. Therefore, since CPOE systems primarily act at the ordering stage, they have great potential to reduce medication errors. 3 Many serious medication errors result in preventable adverse drug events, approximately 20 percent of which are life-threatening. 8 An adverse event is defined as an actual injury to a patient that is due to medical treatment. Many times, medical errors do not lead to adverse events. Adverse events may be further classified as either preventable or not preventable. Additionally, not all adverse events are due to medical errors that were preventable. An error is only preventable if there was existing information that could have prevented the error from occurring. For example, if a physician prescribed a medication that a patient had an allergic reaction to, but no one, including the patient, had any knowledge of the allergy, this could lead to an adverse event. In this case, however, the adverse event was not preventable. 9 Although not all medical errors lead to adverse events and not all adverse events are preventable, the Institute of Medicine (IOM) indicated in its report in 1999, that between 44,000 and 98,000 Americans die each year due to preventable medical errors. One of the IOM s recommended strategies for improving care and reducing errors is to invest in an information infrastructure to support the processes of care delivery, quality measurement and improvement, health services research, and clinical education. 10 CPOE systems are one important strategy to reduce preventable medical errors in several different ways. CPOE systems provide physicians with standardized lists and templates for entering orders, and thus reduce the likelihood that a physician will prescribe an order that is inappropriate for the patient or that the physician will provide incomplete information. In this sense, CPOE systems reduce potential delays to the processing of the medication order and adverse drug events. The use of standardized lists in a computerized system also reduces the necessity of other providers to interpret handwritten orders, which may be difficult to read or contain inappropriate abbreviations. Furthermore, CPOE systems provide clinical decision support features to help physicians input appropriate, safe orders CPOE systems vary widely in their functional components and capabilities, depending on how the systems have been designed and integrated into the hospital and pharmacy information system and what software applications and information resources populate the CPOE system. 12 In this introduction, we first discuss the current state of CPOE systems in the United States and analyze substantial barriers to successful implementation. Then, we provide an overview of current CPOE vendors and the different ways of integrating CPOE systems with pharmacy information systems. Next, we explore in more detail CPOE systems key features of order selection and specification and clinical decision support that help to prevent medication errors. Finally, we investigate some of the evidence-

3 based benefits of CPOE systems in promoting patient care and reducing healthcare expenditures. COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE) IN THE UNITED STATES Several important surveys have been conducted to measure the prevalence of implementation of CPOE systems in health care systems. The Leapfrog group, a consumer organization focused on patient safety, conducted a survey in 2005 regarding CPOE system use in hospitals in the United States. According to this survey, out of the thousand hospitals that participated in the survey, four percent had fully implemented CPOE systems and only 16 percent planned to implement by Another study conducted in the Commonwealth of Massachusetts indicated that out of the 67 acute care hospitals surveyed, only seven had successfully implemented CPOE systems. 11,13 Thus, the rate of implementation of CPOE systems in the United States remains low due to a variety of factors, such as the costs and effort associated with incorporating CPOE systems and training clinicians how to properly utilize CPOE systems. Fortunately, however, the number of hospitals implementing CPOE systems has increased overall, as indicated by Figure 1 referenced earlier in this paper. Figure 3 below illustrates major significant barriers to implementation of health information technology and the shifts in these barriers over time. 1 Figure 3. Trends showing the application of different types of Health Information Technology: Figure 3. Health information technology is a collective term that encompasses many uses of technology that impact clinical practice. Over time, utilization of health information technology has increased. Computerized practitioner order entry (CPOE) systems are one type of health information technology. Despite the relatively low use of CPOE systems in the United States, implementation of CPOE systems is increasing. This bar graph shows that use of computerized practitioner order entry (CPOE) peaked in 2003, and then has steadily increased from 2004 to Patel Minesh et al. / Journal of Pharmacy Research 2012,5(10), CPOE Vendors Currently, there are a variety of health information vendors marketing CPOE systems. A few examples include Horizon Clinicals by McKesson, Enterprise Medical Record by MEDITECH, and the Healthcare Centricity Enterprise system by General Electric. Each CPOE system has its own unique advantages and disadvantages that need to be evaluated by institutions seeking to purchase and implement CPOE systems. For example, some CPOE systems also include electronic medical information systems that have other health information technology applications such as clinical analytical tools for evaluating outcomes, coordinated with barcode medication administration technology, and financial and billing. Other major technological differences between CPOE systems are the applications, cost, and compatibility with systems from other vendors. All CPOE systems are designed to help coordinate patient care across the continuum of the healthcare system, from inpatient, ambulatory care, and to long-term care facilities, laboratories, and other medical centers. CPOE systems also enable multiple users to access patient medical records at the same time and some systems even automatically update data as well. 14 Integrating CPOE Systems With Pharmacy Information Systems In order to be successfully incorporated in the medication use process, CPOE systems must be integrated with pre-existing pharmacy information systems. Once orders are submitted electronically, the pharmacy department has several different methods of integrating the orders between the pharmacy computer database system and CPOE system. There are three different types of integration: complete, bidirectional, and unidirectional. Alternatively, the systems can also be separate and not integrated. Understanding the distinctions between these integrations is important because the type of connection impacts the degree of functionality and efficiency of the CPOE system. 15 Fully integrated systems employ a single database for storing and managing information and share all data between the CPOE and pharmacy information systems. The major disadvantage to completely integrated systems is that they have fewer applications and functional programs. Unidirectional interface systems utilize transmit orders electronically one-way and are less complex than bidirectional interfaces, but they do require additional work by clinicians to re-enter orders in the CPOE system when changes are needed. Bidirectional connections communicate across different interfaces and automatically update changes made on one system with all others. Thus, this type of interface can reduce the amount of time spent to re-enter incorrect orders into the CPOE system. Finally, an option for CPOE and pharmacy information systems is to not use an interface at all. This type of set-up means that clinicians have to manually enter information into the computer system based on printed copies of the order. With this approach, less time can be spent on entering orders because the information can be automatically populated into various systems as long as they mapped correctly. However, all components in the technological link must be completely connected; any breaks in the system may affect all of the other systems. 15 KEY FEATURES OF COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE) SYSTEMS Order Selection and Specification One of the most important functions of CPOE systems are to assist in order selection and specification. In a paper-based ordering system, most orders are written individually on a blank form of a prescription pad, in an order book, or in a patient chart. Once an order is written, many healthcare professionals are involved with interpreting and carrying out the order. On the other hand, users of CPOE systems follow a standard step-by-step process to select and specify orders. For most CPOE systems, selecting an order requires the user to search or choose the medication from a menu. Then, once the order is selected, the CPOE system prompts the user to enter all of the components of the order completely, such as the strength, dose, formulation, route of administration, quantity, and directions of use of the ordered medication. Another advantage of CPOE systems over handwritten orders is the avoiding errors that may occur if a physician s intent is misinterpreted or a handwritten order cannot be read. Furthermore, CPOE systems are beneficial in reducing the use of error-prone abbreviations in orders. 3,16-17 Finally, when CPOE systems are integrated with electronic medical record

4 Patel Minesh et al. / Journal of Pharmacy Research 2012,5(10), systems, physicians have access to relevant patient information such as demographic data, past visits, current medications, problem lists, and test results at the time an order is entered. Integration of CPOE systems with electronic medical record systems further enhances the functionality of the CPOE system, mainly its ability to check for drug interactions and contraindications. Clinical Decision Support In addition to improving the selection and specification process of transmitting orders, most CPOE systems are equipped with some degree of clinical decision support. Clinical decision support systems provide computerized information helpful to physicians, such as clinical practice guidelines, patient allergies, potential drug duplications, and drug interactions. Clinical decision support is provided in a variety of forms. For instance, pop up alerts may be generated about a potentially harmful drug interaction that requires the user to take action before proceeding or links to drug information resources and clinical treatment guidelines may be provided. In summary, clinical decision support provide useful point-of-care references and relevant patient information to assist in medical decision-making. 18 In the current literature on CPOE systems, clinical decision support systems have been classified as either positive or negative. Positive clinical decision support refers to the provision of the relevant recommendation or information aimed at guiding or improving patient care decisions. Clinical decision support tailors information based on the specific order being placed at the time of entry. As one example, clinical decision support systems automatically show pertinent patient data in medical decision-making, such as recent laboratory values that impact drug dosing and available drug dosage forms. Moreover, CPOE systems also provide templates and default order choices based on hospital s specific formularies, thereby assisting physicians in following evidence-based recommendations for cost-effective treatment. Clinical decision support systems also aid physicians in making complete orders by listing predefined orders that can be either manually selected or are automatically displayed in conjunction with related orders. Finally, another feature of clinical decision support systems are dose calculators to assist clinicians in computing the correct dose for a patient based on current health status Negative clinical decision support refers to a suggestion to discontinue or change the current order because it may result in an adverse event or medical error. For example, clinical decision support systems can check a drug order against all existing drugs that the patient is taking and alert the physician of potential drug interactions. 20 Table 1: Currently Available Computerized Physician Order Entry (CPOE) Systems in the United States 21 Product by Company Advertised Features of CPOE system Need for pharmacists to re-enter orders done by physicians which can increase the rate of errors and delay the order process i.e. CPOE and PIS are not interconnected Cerner Millennium by Cerner Corporation Eclipsys Knowledge-Based CPOE by Eclipsys Corporation EpicCare Enterprise Clinical System by Epic Systems Corporation Centricity Enterprise-CPOE by General Electric Healthcare Horizon Expert Orders by McKesson Physician Care Manager (PCM) by MEDITECH Misys computerized Patient record (CPR) by Misys Healthcare Systems Computerized Physician Order Entry by QuadraMed Soarian Clinicals by Siemens Medical Solutions Designed by clinicians For both acute and ambulatory care settings Includes clinical database of information, data, documentation, and ordering capabilities Clinical decision support tools that alert clinicians about changes in patients clinical status System can be readily adapted for any care setting, including specialty medical services Clinical capabilities include automated order recommendations based on diagnosis and other pertinent patient information, order sets with links to references, alerts, customization of specialty order Preference Lists, electronic prescribing Connectivity with other prescription information networks is possible, System is completely integrated with other Epic Systems Corporation products such as inpatient pharmacy EpicRx system and electronic medication administration records applications Designed to meet the needs of both inpatient and ambulatory care settings Structured order sets and order pad, dosing calculators Order checking capabilities and alerts for potential drug interactions, patient allergies, therapeutic duplications, under or dosing Clinical database support from First Databank, a third-party online pharmaceutical reference database, linked to the patient record More focused on clinical decision-making support than just order entry Clinical decision support: checking for appropriateness of dose and drug, therapeutic duplications,patient allergies, pertinent patient clinical information, evidence-based order sets, dose calculator Drug information linked to hospital formulary services and Medication Administration Records Comprehensive system that includes integrated system including: CPR, CPOE, integrated pharmacy systems, radiology and laboratory results, clinical information, nursing documentation, medication administration Information based on patient diagnosis and clinical conditions System is highly customizable based on physician preference Integrated applications with order sets, electronic signature capabilities for transmitting and transcribing orders Designed for acute inpatient care Task lists, clinical documentation, CPOE, operational and analytical reporting, work flow designs Bidirectional interface with Siemens Pharmacy operating system facilitates pharmacy access to orders entered Customizable for patient populations and clinical departments Yes Yes

5 BENEFITS OF COMPUTERIZED PRESCRIBER ORDER ENTRY (CPOE) SYSTEMS Current research suggests that CPOE systems have powerful capabilities to assist in reducing medical errors, promoting evidence-based standards of care, and decreasing costs. The following sections provide examples of how CPOE can be applied to clinical care processes to improve patient safety and quality of care. CPOE systems impact all areas of patient care, from prescribing of appropriate, evidence-based medications to promotion of the utilization of cost-effective drugs. Improved medication prescribing, reduced medication errors, and better patient safety According to a survey conducted by the LeapFrog group, more than one million serious medication errors occur every year in hospitals in the United States. 11 As discussed previously in this paper, medication errors may occur due to many reasons, such as illegible handwritten prescriptions and improperly written prescriptions that could be misinterpreted. CPOE systems help to reduce errors by providing very drug-specific information that can clarify potential confusion due to drug names that sound and look alike. 8 CPOE systems that have positive clinical decision support features further ensure appropriate drug prescribing by guiding appropriate choices and providing alerts and recommendations when the drug orders are entered. For example, the system may present a menu of appropriate drug doses and frequencies from which to choose, thus preventing excessive or incorrect doses of drugs. Moreover, by improving and streamlining the medication ordering process and healthcare workflow, CPOE systems decrease the time until patients receive care. 21 In general, employment of health information technology has dramatically impacted patient care by improving quality of care outcomes, reducing medication errors, and improving patient satisfaction. Figure 4 demonstrates the impact of health information technology on improved patient care. 1 Patel Minesh et al. / Journal of Pharmacy Research 2012,5(10), Figure 4. Health information technology positively influences patient health outcomes, quality of care, and degree of satisfaction with care. These trends change over time, depending on the year. Studies demonstrate that CPOE systems can be very effective in reducing the rate of serious medication errors. Dr. David Bates, Chief of General Medicine at Boston s Brigham and Woman s hospital, demonstrated that CPOE reduced error rates by 55 percent 10.7 to 4.9 per 1000 patient-days. Rates of serious medication error dramatically decreased by 88 percent in a follow up study of the same group. 22 Dr. John Birkmeyer, professor of surgery and a health services researcher at University of Michigan Medical School, estimates that implementation of CPOE systems at all non-rural U.S. hospitals could prevent between 570,000 and 907,000 serious medication errors each year. 23 Promotion of Standard of Medical Care Practice CPOE systems can promote adherence to evidence-based standards of care. For example, clinical guidelines indicate that beta-blockers and aspirin should be prescribed for most patients who suffer an acute myocardial infarction. One study found that beta-blocker use for acute myocardial infarction in 16,869 Medicare patients was only 45 percent in A CPOE system could be equipped to suggest orders for beta-blockers and aspirin early during the course of patients hospitalization for an acute myocardial infarction in order to improve clinical outcomes. Clinical decision support networks provide current treatment guidelines that help to keep physicians up to date with changes in clinical practice and the introduction of new drugs to market. 19 Therefore, CPOE systems can be utilized to narrow the gap between clinical guidelines and actual medical care. Reduced Costs and Improved Efficiency of Care CPOE systems promote cost-effective medication utilization in several ways, such as by suggesting substitution to a less expensive and therapeutically equivalent drug and promoting use of a lower dose or frequency of a medication without loss of effectiveness. Moreover, CPOE systems can alert healthcare providers that a test is potentially unnecessary because it was recently performed. One of the fundamental ways that a CPOE system can reduce drug cost is by encouraging physicians to use hospital formulary medications and to adhere to recommended frequencies of administration. In addition to encouraging cost-effective medical care, CPOE systems may potentially reduce overall healthcare expenditures by improving the efficiency of the delivery of healthcare services and the medication use process. 25 This literature review has emphasized how CPOE systems improve the flow of the medication use process and reduce the time to process and fill orders. Thus, a well-designed CPOE system can decrease the delay in implementing care interventions. A CPOE system also can improve communication of patient-specific information by reducing the potential for errors in the interpretation and transcription processes and by allowing all members of the care team rapid, real time access to patient data. When integrated with electronic medical records, CPOE systems can share and transmit this patient specific data. Therefore, implementation of CPOE systems can enhance communication and help coordinate care in all settings and among all members of the healthcare team Figure 4. Trends showing impact of Health Information Technology on improved patient care: CONCLUSION In this introduction to CPOE systems, we have provided an overview of the purpose of CPOE systems and their place in the medication process, their current state in the United States healthcare system, and key features that aim to reduce medical errors. In summary, the goal of CPOE systems is to

6 Patel Minesh et al. / Journal of Pharmacy Research 2012,5(10), provide the safest, most therapeutically effective treatment to patients by preventing medical errors and adverse events by providing clinical information and alerts based on synthesis of medical and patient information. In the following literature review of CPOE systems, we specifically focus on current evidence-based articles and studies that illustrate how implementation of CPOE systems can reduce medication errors and enhance patient safety. REFERENCES Healthcare Information and Management Systems Society Leadership Survey. Healthcare Information Management and Systems Society. Available at: < healthcarecio_home.asp>.2011 Accessed May 10, Holdford DA, Huffiness SK, Rosenbloom ST. Electronic Data Management: Electronic Health Record Systems and Computerized Provider Order Entry Systems. Introduction to Hospital and Health-System Pharmacy Practice. 1 st Edition. 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Bathesda, MD: American Society of Health-System Pharmacists;2010: Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Google books. Available at: books?id=zzyqdmsq1vac&pg=ra11-pt21&lpg=ra11- PT21&dq= CAMH+2004&source=bl&ots=puZPSMqGZy&sig= xvc9o1lzm3dg0ry9ru0a QtQljy4&hl=en&sa=X&ei=ug6T_SIHLDo2gX9x5GnCg&sqi=2&ved=0CB4Q6 AEwAA#v= onepage&q= CAMH%202004&f=false Accessed May 10, Sengstack PP, Gugerty B. CPOE systems: success factors and implementation issues. J Healthc Inf Manag Winter;18(1):36-45.Available at: focus_success.pdf. Accessed May 10, Bates DW, Kaushal R, Shojania KG. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med. June 2003;163(12): Avery AJ, Bobb A, Burns G et al. Medication-related clinical decision support in computerized provider order entry systems: a review. J Am Med Inform Assoc. Jan-Feb 2007;14(1): Patient Safety. Soma Access Systems. 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