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For other articles and previous issues click here. May 9, 2005 CPOE
Uncertainty Recently, two studies, one questioning the effectiveness of computerized physician order entry systems, the other singing its praises, have raised concerns about the need for proper design and implementation. The practice of medicine is getting more complex, and computerization is hopefully helping to alleviate healthcare providers’ paperwork and other time-consuming tasks. Computerized physician order entry (CPOE) systems have been touted as one of the answers to reducing medical errors, but one hospital’s experience has caused it—as well as many others—to reconsider their CPOE systems. Between 44,000 and 98,000 Americans are killed each year by medical errors, according to a 1999 report by the Institute of Medicine. When considering all the benefits of CPOE, it’s reasonable to conclude that these systems can reduce medical errors if they are well-designed and utilized properly. Nearly 30% of electronic medical record (EMR) technology implementations fail, according to the Office of the National Coordinator for Health Information Technology. The reasons for failure include the fact that the EMR products, including CPOE, aren’t standardized and typically there needs to be a change in workflow for them to be effectively implemented. Physicians also don’t receive the implementation support they need to change their workflow strategies and habits. David J. Brailer, MD, PhD, the National Coordinator for Health Information Technology, points out that a lack of standardization in the EMR is a high-level barrier to physician acceptance and utilization. In response to Brailer’s statement, a private industry group has come together on its own to develop minimum criteria for security, interoperability, and functionality of EMR systems. Mark K. Leavitt, MD, PhD, was appointed chairman of this new coalition, the Certification Commission for Healthcare Information Technology (CCHIT). The CCHIT is first focusing on electronic health records (EHRs) in an ambulatory environment and will release its specifications for this setting in July. The CCHIT plans to issue specifications for EHR/EMR in various healthcare settings and environments. CPOE systems bring together information about the patient, which helps increase patient safety. For example, when doctors write test orders or prescription orders, CPOE systems are performing checks in the background regarding whether the patient is allergic to the drug or if the dosage is excessive. Alerts and reminders pop up if there is any contraindication, giving the physician a chance to change the order or provide additional data to substantiate his order. One Hospital’s Experience Today, Cedars-Sinai is still reviewing what went wrong and how a CPOE system can be designed and/or utilized more efficiently. “The CPOE technology was created in-house, and it was clunky and slow. Only a fraction of doctors was involved in the planning. This was a fairly dramatic change in the way physicians practice medicine. The implementation was not phased in; it was a ‘big bang’ type of introduction,” explains the director of Cedars-Sinai’s health information department. “I don’t think anyone here questions the value of CPOE. It’s the approach we are working on. Introducing a CPOE system is going to take time. Doctors definitely see the value of it when the information is easily accessible.” Cedars-Sinai had already developed a clinical repository, or EMR system, in-house, and developed the CPOE system to work in conjunction with it. The clinical repository contains patient lab results, and transcription, medical, administrative, and legal records. Physician orders are now being scanned into the hospital’s clinical repository for verification. “I don’t know if we would create our own CPOE again,” says the director. “It’s cost-prohibitive to do so.” A successful CPOE includes several elements, according to the director of Cedars-Sinai’s health information department. Chief among them are physician involvement, understanding the learning curve involved, and the dramatic effect CPOE has on the way physicians practice medicine. Also, physicians have different needs, thus they will utilize CPOE systems in different ways. Other Studies Demand Further
Review HIMSS says that if implemented properly, CPOE can help reduce medical errors. HIMSS recommends the following steps regarding the future of CPOE: exchange ideas with vendors, utilize newer versions of CPOE systems, and develop a forum for discussion and as the basis for improving the state of current CPOE systems. More research is needed to understand how to design and implement CPOE systems for optimal impact on healthcare delivery. “I think some of our concerns now center around what are human-machine interfaces,” says Scott Young, MD, a board-certified family practitioner and the director of health information technology at AHRQ. “How do we develop clinician information utilization around CPOE? There is tremendous opportunity for additional groundwork in developing CPOEs. We haven’t been able to integrate them enough into the medical environment to understand and see their shortcomings. Only 10% to 12% of hospitals in the country are integrating them now, which is an early integration.” Pat Wise, RN, MA, MSN, director of HIMSS’s EHR initiatives, notes that 100% provider acceptance is the key for CPOE utilization. CPOE system hardware and software must be consistent in the work process for providers to accept them. “CPOEs are a complex application to implement. They are the most critical of all applications on acceptance by physicians,” says Leavitt, who serves as medical director at HIMSS. “The systems have to be very carefully designed. If we don’t have clinicians entering their orders on these systems, we can’t implement EMRs, which require electronic orders, not orders transcribed hours later. It’s a challenge that we have to meet.” AHIMA Professional Practice Manager Carol Ann Quinsey, RHIA, CHPS, believes one of the biggest issues surrounding CPOE is how involved the physicians are in the planning and implementation from the beginning of the process. “The actual workflow of whatever electronic product that is used for order entry should be a logical and efficient workflow. If it’s not a smooth flow, it can really take a long [time to use]. A lot of physician CPOEs are tied to various alerts, such as for drug interactions. If you don’t balance the alerts with some modicum of sensibility, you’ll kill them [the physicians]. Balance their need to know with these alerts,” explains Quinsey. “Whether or not the physician has to document decisions about the alerts can also affect workflow. The CPOE system should give physicians the option of turning off an alert.” CPOE Selection & Implementation Success or failure of CPOE implementation, notes Wise, is attributed mainly to the implementation itself, not to the hardware or software. She advises practices and hospitals to look at a similar facility that has successfully implemented CPOE and study how they did it and learn from their mistakes and successes. Wise stresses the importance of looking at CPOE products from a large variety of vendors and involving a large number of staff members who will be using the system. “How does the technology you’re integrating impact your healthcare and information technology environment?” asks Young. “Get all of the stakeholders involved early on. Ask ‘What are the issues we’re trying to solve?’ Then, find a technological solution or clinical transfer solution to each problem. Spend a fair amount of time planning. Start small. Introduce one technology at a time, maybe in one department at first.” Young points out that for CPOEs to be utilized more efficiently, they need to be linked with evidence-based medicine. The system should have the ability to suggest medical treatment options. In outpatient environments, care is linked to evidence-based medicine just 6% to 7% of the time, he says. Utilizing evidence-based medicine could reduce errors by alerting physicians to potential allergies and medication interactions and by making prescriptions legible. CPOEs change how care is provided by restructuring the workflow. “The challenges with CPOE are an excellent opportunity for us to take those challenges and work to find solutions to them,” concludes Young. A recent Capgemini white paper provides advice on how to avoid pitfalls in CPOE and clinical systems implementation. It advises involving clinicians in every stage of system design and implementation. Lewis Redd, president of Capgemini Health, an information technology consultant, notes that clinical information systems should be viewed as tools that are used to improve the clinician’s workflow and implemented only after patient care and safety processes are in place. “Test the system heavily and be sure everything is in place,” advises Quinsey. “Volume testing is a big part of testing to be sure the new system can handle a large volume. Many failures in CPOE come from inadequate testing.” Quinsey notes that physician training is always an issue. Physicians are “really hard” to get into training sessions, but she recommends being efficient and teaching them only what they need to know, keeping the sessions as brief as possible. A brief tutorial over lunch that allows for some coaching time often works best. The President’s Plan “We’re very excited about the administration’s efforts and think very highly of [the mandate]. We believe that health information technology is a critical component in the quality, safety, and effectiveness of healthcare. [Health and Human Services] Secretary [Mike] Leavitt has been very visionary. It’s very exciting to see so much enthusiasm for [the EMR],” says Young. Wise appreciates the president’s vision for healthcare. “A nationwide EMR by 2010 is an excellent vision,” she says. “I think that kind of vision from our president is optimistic. A large amount of work needs to be done to make it a success. CPOE is just one component of EMR. Funding is another issue. In a lot of states, there may also be legislative obstacles or mandates.” Quinsey is optimistic about improvements in CPOE that will enhance the president’s plan. “I am actually extremely optimistic about this,” says Quinsey. “I’m hearing optimism from all sides, from community and rural hospitals, and from large hospitals. The interest [in a nationwide EMR] is there. What’s out there, technology-wise, 10 years from now won’t be what we have today. Another generation of CPOE products will come out, and the systems could potentially be quite different in 10 years than what they are today.” — Laura Gater’s medical and business trade articles have been published in Medical Imaging, 24x7, Podiatry Management, Veterinary Forum, Corrections Forum, and other national and online publications. |
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