Computerized Provider Order Entry (CPOE)

This unit defines CPOE, states the purpose of CPOE, lists attributes and functions of CPOE, and explains how CPOE is currently being used in health care.

Unit Objectives

Definition of CPOE

Interventions in patient care, such as performing diagnostic tests, administering medications, drawing blood, are initiated by provider’s orders. The more traditional methods of placing provider orders are written (paper), verbal (in person or via telephone), and fax. A computer application known as computerized practitioner order entry is now being used in place of these traditional methods.

The Healthcare Information and Management Systems Society’s (HIMSS) Dictionary of Healthcare Information Technology Terms, Acronyms and Organizations provides this definition of CPOE: “CPOE or Computerized Practitioner Order Entry, is an order entry application specifically designed to assist clinical practitioners in creating and managing medical orders for patient services and medications.”

CPOE is often depicted in the literature and referred to in the healthcare community as computerized provider order entry or computerized physician order entry. For this unit, the term computerized provider order entry will be used.

CPOE

Care delivery and clinical documentation systems are systems that support the delivery of the care and documentation of that care. An example would be clinical information systems. The textbook Biomedical informatics: computer applications in health care and biomedicine, defines clinical information system as “The components of a health care information system designed to support the delivery of patient care, including order communications, results reporting, care planning, and clinical documentation.” Computerized provider order entry is typically a module of an integrated clinical information system.

CPOE is a computer application that enables a provider to place patient orders via the computer for further processing. It is much more than a replacement of paper orders with electronic ones. CPOE is also not just an electronic prescribing system.

The provider’s use of computer assistance to directly enter medical orders (for example, medications, consultations with other providers, laboratory services, imaging studies, and other auxiliary services) from a computer or mobile device. The order is also documented or captured in a digital, structured, and computable format for use in improving safety and organization. It may or may not include the electronic transmittal of that order to another department such as the pharmacy, laboratory, or diagnostic imaging center.

Coupled with a clinical decision support system, CPOE has the capability of applying rules-based logic to assist the provider with making optimal ordering decisions.

As was mentioned previously, CPOE is much more than an the replacement of paper orders with electronic ones. United with a clinical decision support system, CPOE has the ability to provide access to evidence-based guidelines, give prompts, reminders, or alerts regarding the order entered thereby enhancing patient safety and provider efficiencies.

The clinical decision support system use of rules-based logic assists the provider with making optimal and safe ordering decisions by supplying clinical advice at the time of order entry about a wide-range of diagnostic and treatment-related information. Advice such as patient allergies, possible drug reactions and interactions, and calculations of medication dosages based on patient weight and age is possible when the CPOE application is coupled with clinical decision support.

For example, once the order is entered into the computer the CPOE application could then trigger a warning of a drug allergy along with a suggested alternative medication.

Additional information on CPOE and clinical decision support systems is provided later in this unit.

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

The overall all purpose of CPOE is to automate the patient ordering process in order to manage patient care more effectively and efficiently and as a result improve patient safety and outcomes. CPOE is a far reaching technology as it affects everyone in the organization from administration to providers to patients.

As previously explained, taken as a whole CPOE’s purpose is to automate the patient ordering process which in turn helps to manage patient care more effectively and efficiently and as a result improve patient safety and outcomes. Given this overarching purpose, the four main reasons healthcare providers implement CPOE are to:

  • 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

1. 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

The first main reason health care organizations and providers implement CPOE is to prevent, reduce, or eliminate medical errors and adverse drug events or ADEs. Two well known reports from the Institute of Medicine, To err is human: Building a safer health system, published in 2000 and Crossing the quality chasm: A new health system for the 21st century published in 2001, provided an impetus to health care organizations and physician practices to consider CPOE. The first IMO report stated 98,000 patients die each year in U.S. hospitals due to medical errors and the second report advised rapid adoption of electronic medication ordering to support clinical decisions.

While the automation of the patient ordering process is recognized as not a small or easy task, CPOE’s potential to prevent, reduce, or eliminate medical errors and adverse drug events or ADEs is a major motive for health care organizations and physician practices to adopt this application.

2. 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

The second main reason health care organizations and providers implement CPOE is to improve patient safety. According to the Leapfrog Group’s web site, the IMO report mentioned in the previous slide supplied the Leapfrog founders an initial focus that is the reduction of preventable medical mistakes. The Leapfrog Group is a consortium of major companies and other large private and public healthcare purchasers. The Web site states Leapfrog’s mission is “to trigger giant leaps forward in the safety, quality and affordability of health care by supporting informed healthcare decisions by those who use and pay for health care and promoting high-value health care through incentives and rewards.”

A “leap” is a recommended hospital quality and safety practice. The Leapfrog Group identified CPOE deployment by hospitals as one of its “leaps” or key patient safety standards. The progress in implementing CPOE systems is monitored through the Leapfrog Hospital Survey. In June 2010, the Leapfrog Group published a report on the results from a test of hospitals’ computerized physician order entry systems on their ability to detect common medication errors. According to the report, Leapfrog Group Report on CPOE Evaluation Tool Results, “The CPOE systems on average missed one half of the routine medication orders and a third of the potentially fatal orders. Nearly all of the hospitals improved their performance after adjusting their systems and protocols, and running the simulation a second time.”
(http://www.leapfroggroup.org/media/file/NewCPOEEvaluationToolResultsReport.pdf)

3. 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

The third main reason health care organizations and providers implement CPOE is to reduce unnecessary variation in health care. CPOE helps the physician make optimal ordering decisions and improve adherence to evidence-based practice. For example, a specific diagnosis may have a set of orders associated with it. The CPOE application provides the use of the pre-programmed, provider or institution reviewed and approved orders to facilitate the process and guide the provider to follow accepted protocols for the diagnosis.

However a CPOE system requires orders and order sets be configured for this goal to be achieved.

4. 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

The fourth main reason health care organizations and providers implement CPOE is to improve the efficiency of health care delivery. CPOE applications accept orders into the system which are then communicated to the department and personnel to execute. Notification of the status is sent back. Thus a reduction in the time from placement of the order to its completion is realized. CPOE also saves a step as there is no need to re-enter data into an ancillary computer system so the time it takes for the ancillary department to complete the order is less.

However, effective CPOE implementation requires interfaces with existing information systems such as registration, pharmacy, laboratory, and electronic medical record systems.

Attributes of CPOE

Having covered the reasons why health care organizations and providers are adopting CPOE, attributes will be covered next.

The following CPOE attributes and their descriptions come from http://en.wikipedia.org/wiki/CPOE.

  • 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.

  • 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.

  • Responsiveness - users are not left hanging. Positive provider experiences are linked to application responsiveness. Providers expect CPOE to be highly responsive with rapid response time to speed their ordering sessions.

  • Response time - prompt response to input. Response time is considered to be the delay between the time at which an event is generated and the time at which some acknowledgment is made, e.g., acknowledgment of receipt, an estimated completion time, and ongoing progress such as a progress bar. In addition, providers may find variable response times almost as frustrating as a CPOE application that is all around slow.

  • Reliable – probability of failure-free operation. CPOE also needs to be reliable. As cited in http://en.wikipedia.org/wiki/Software_reliability, software reliability is “the probability of failure-free operation of a computer program in a specified environment for a specified time”. Providers expect CPOE to perform without interruption due to system shutdowns from crashes or even routine maintenance to facilitate the critical ordering process.

Functions of CPOE

Moving on, the next topic that will be discussed is CPOE functionality. CPOE applications may encompass only basic functionality or expand to more complex functionality where clinical decision support is used.

  • 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

For basic functionality, the focus is on the capture and transmission of the order ("order communication"). There may or may not be minimal access to knowledge resources and simple bi-directional communication.

  • Advanced: includes clinical decision support
    • Simple: drug-drug interaction checks, medication dose calculators
    • Complex: Alert of a drug allergy along with an alternative medication

The more advanced CPOE applications have some form of clinical decision support. However, when it comes to clinical decision support and CPOE applications, there are different levels of sophistication. An elementary level is simple clinical decision support where for example the capability to perform drug-drug interaction checks is possible. A complex level is when an alert is generated because of an identified drug allergy and an alternative medication is suggested to the provider. This interactive decision support goes a long way towards improvements in patient safety and quality.

CPOE and Clinical Decision Support (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 needs clinical decision support to reach its full value

According to HIMSS, “Clinical decision support system or CDSS is an application that uses pre-established rules and guidelines that can be created and edited by the healthcare organization, and integrates clinical data form several sources to generate alerts and treatment suggestions.”

To reach its full value, research shows CPOE needs to include clinical decision support.

Advantages of CPOE Over Paper-Based Systems

CPOE is a valuable tool and has many advantages when compared with 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
  • 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 (adverse drug event) reporting systems
  • Able to avoid specification errors
  • Available and appropriate for training and education
  • Available for immediate data analysis
  • Claimed to generate significant economic savings
  • 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

With all these advantages, the value of CPOE is apparent.

According to a HIMSS CPOE fact sheet, CPOE value extends beyond having an electronic record rather than a paper one. CPOE adds value to an organization by - Enhanced patient safety—medication errors are reported to be the largest cause of adverse hospital events. CPOE eliminates transcription error and clinical alerts can warn of allergies and drug/drug interaction.

  • Enhanced patient safety. Medication errors are reported to be the largest cause of adverse hospital events. CPOE eliminates transcription error and clinical alerts can warn of allergies and drug/drug interaction.

  • Reduced costs. Studies have found that adverse drug events can increase hospital stays significantly. Additional cost savings can be realized with clinical decision support that directs practitioners to lower doses or alternate medications.

  • Reduced variations in care by encouraging best practices. CPOE is a powerful tool in guiding practitioners in reducing unnecessary variation in care by encouraging best practices.

Major Barriers

Even with the recognition that CPOE is valuable, barriers to adoption and implementation do exist. They include:

  • Belief that physicians will not use computerized ordering. Physicians used to the paper method may resist switching over to the computerized system and adapting to it. The feeling is that it will take time that providers do not want to allow for.

  • Not a small or easy task. CPOE is complex. It requires the cooperation of many individuals and implementation involves representatives from many areas of operations. For example, CPOE requires many interfaces with other existing systems. CPOE also requires orders and order sets be configured. Even if the health care organization starts the order set development process with a standard, baseline collection format provided by a vendor, it is a time consuming process requiring the participation of numerous and disparate clinical departments.

  • Impact on workflow. CPOE affects workflow and process of all caregivers and ancillary. It is a disruptive technology that fundamentally changes the processes used to place, review, authorize, and carry out orders.

  • Risk. CPOE involves risk. Poorly designed user interfaces and unacceptable processing speeds can increase the odds of errors and therefore increase patient safety risks. A delay in order entry delays treatment and could result in mistakes.

  • Cost. CPOE is costly to implement and maintain. On their web site (http://www.nehi.net/news/nehi/40/the_clinical_and_financial_impact_of_cpoe), the New England Healthcare Institute estimated acquisition cost for a hospital CPOE system to be about $2.1 million and annual operating expenses of about $450,00 a year. Costs may differ depending on hospital size and level of existing IT infrastructure. An example of a cost is the continuous, frequent training and retraining needed as users adapt to CPOE.

e-iatrogenesis

  • “Patient harm caused at least in part by the application of health information technology”

In addition to the barriers previously identified, there is the issue of e-iatrogenesis. Although CPOE systems are designed to decrease errors they can be a source of errors if not designed correctly. Thus, CPOE can have a potential negative affect on patient care safety, quality and efficiency, as well as patient outcomes.

E-iatrogenesis, a term coined by Dr. Weiner and others, is “Patient harm caused at least in part by the application of health information technology.”

Actual or potential e-iatrogenic events related to CPOE errors have been discussed in published research. The results of one such study are found in the article, Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors by Dr. Koppel, et al, mentioned previously. A total of 22 situations were identified where CPOE increased the probability of medication errors. These are summarized in the next section.

Medication Error Risks

Dr. Koppel and others categorized the 22 situations into two groups: “information errors generated by fragmentation of data and failure to integrate the hospital’s several computer and information systems and human-machine interface flaws reflecting machine rules that do not correspond to work organization or usual behaviors.”

The information errors are:

  • 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
  • Conflicting or duplicative mediations

The human-machine interface flaws are staring with the top of the first column:

  • Patient selection
  • Wrong medication selection
  • Unclear log on/log off
  • Role of charting difficulties in inaccurate and delayed medication administration
  • Postsurgery “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

While CPOE has been a major initiative of US hospitals for over a decade, the recent passage of the HITECH Act statutorily requires the use of health information technology in improving the quality of health care, reducing medical errors, reducing health disparities, increasing prevention, and improving the continuity of care among health care settings. In support of the HITECH Act in meeting the statutory requirements, in the Medicare and Medicaid Programs; Electronic Health Record Incentive Program Final Rule the core set of measures was expanded to include the use of CPOE in the fundamental elements to improve patient care.

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 is considered to be a foundational element to many of the other objectives of meaningful use including exchange of information and clinical decision support. The Electronic Health Record Incentive Program Final Rule states the following with regards to CPOE. For Stage 1, CPOE is included in the core set of measures. A meaningful use objective for eligible professionals, eligible hospitals, and critical access hospitals is "Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines."

Only medication orders are included. At least 30% percent of all unique patients with at least one medication in their medication list seen by the eligible professional or admitted to the eligible hospital’s or critical care hospital’s inpatient or emergency department during the EHR reporting period have at least one medication order entered using CPOE. The threshold increases to over 60% for Stage 2. In addition, for stage 1 the transmission of the order is not included in the objective or the associated measure.

The Final Rule also clarified which healthcare professional can enter orders using CPOE as any licensed healthcare professional can enter orders into the medical record per state, local and professional guidelines.

CPOE’s Impact

  • CPOE can with CDS
    • Improve medication safety and quality of care
    • Reduce costs of care
    • Improve compliance with provider guidelines
    • Improve the efficiency of hospital workflow
    • Improve the efficiency
    • Improve compliance with evidenced-base practices

CPOE can also have a potential positive affect on patient care safety, quality and efficiency, as well as patient outcomes.

As cited in an AHRQ report Inpatient Computerized Provider Order Entry (CPOE): Findings from the AHRQ Health IT Portfolio, “When implemented together, CPOE systems and CDS can improve medication safety and quality of care and reduce costs of care. They can also improve compliance with provider guidelines, as well as the efficiency of hospital workflow.”

Adverse drug events can increase hospital stays significantly so any technology such as CPOE which can reduce ADEs can also reduce costs.

However, as previously pointed out, use of CPOE should not be pursued in isolation from other technologies. Entering orders in a system without providing clinical decision support during the order-entry process is likely to have limited benefits.

CPOE can also have a positive impact on efficiency. Any reduction in the time it takes to render patient care can potentially reduce the amount of time in the hospital. CPOE is a powerful tool in guiding practitioners in reducing unnecessary variation in care by encouraging evidenced-base practices. However, in order to optimize impact on efficiency, CPOE should be an integrated component of the clinical information system.

Summary

  • Major values
  • Common barriers
  • Positive and negative affect on patient care safety, quality and efficiency, as well as patient outcomes
  • Not a technology implementation
    • A redesign of a complex clinical process

California HealthCare Foundation. http://www.chcf.org/publications/2000/10/computerized-physician-order-entry-fact-sheet

While values are known, barriers do exist. Both positive and negative affects of CPOE on patient care safety, quality and efficiency, as well as patient outcomes have been documented in the literature. However, both patient safety and health care cost pressures along with the Federal incentives tied to meaningful use present a clear imperative to proceed with implementation of CPOE.

As pointed out in California HealthCare Foundation’s Computerized Physician Order Entry Fact Sheet sheet “CPOE is not a technology implementation, but a redesign of a complex clinical process, which integrates technology at key points to optimize ordering decisions…CPOE is an organizational change initiative, not an IT project.”

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