computerized physician order entry (CPOE)

CPOE benefits

Using CPOEs in lieu of traditional paper charts has several benefits. CPOE can enhance patient safety by reducing or eliminating medication errors. By enabling healthcare providers to quickly transmit orders electronically, CPOE can improve efficiency when submitting medication, lab and radiology orders to their respective departments or facilities. CPOE can also streamline reimbursements by flagging orders that may require preapproval from insurance plans, reducing a return on initially denied insurance claims.

When integrated with clinical decision support systems (CDSSes) and electronic health records (EHRs), CPOE further optimizes patient safety and efficiency of care. There are several important functions built into CPOEs, such as safeguards that are available to check for potential adverse drug events.

CPOE system features

CPOE systems are designed to mimic the workflow of the paper chart. CPOE systems are often used in tandem with e-prescribing systems, which alert physicians and clinicians to a particular patient's drug allergies and current medications. CPOE systems were formerly frequently sold as stand-alone systems. Many EHR products now come equipped with CPOE modules that enable treating physicians to enter patient data electronically into text boxes and drop-down menus, rather than handwriting notes.

A CPOE system offers a variety of features, including some or all of the following:

• Ordering: Physician orders can be entered by the clinician into a workstation, laptop or secure mobile device versus writing orders on a paper chart.
• Patient-centered decision support: When integrated with CDSSes and EHRs, clinicians have up-to-date patient information, as well as a more complete medical history on the patient, enabling better care decisions.
• Patient safety features: CPOE enables doctors and nurses to make real-time patient identification, review medication dosage recommendations and screen for potentially adverse drug-to-drug or drug-to-disease interactions. This software can also check for patient allergies and treatment conflicts.
• Intuitive user interface: The order entry workflow is like that of traditional, paper-based order forms, enabling efficiency even among those who are new or infrequent users.
• Regulatory compliance and security: Access and information are secure and in compliance with state and federal guidelines.
• Portability: The CPOE system can accept and manage orders from all departments at the point of care through various devices, including wireless mobile laptops and tablets.
• Management: Reports are generated so they can be analyzed and evaluated, which helps determine if changes need to be made in staffing, productivity and inventory.
• Billing: Documentation is improved, referral and treatment preapprovals can be flagged and orders can be linked to diagnoses at the time of order entry.

Texting of CPOE orders is banned

Although texting on secure message platforms is commonplace in many healthcare organizations -- and the Centers for Medicare & Medicaid Services (CMS) recognizes the advantages of this technology -- patient orders are an exception.

CMS and the Joint Commission prohibit clinicians from texting any CPOE patient orders. CPOE is the preferred method of order entry by a provider, however, in all cases. "Texting of patient orders is prohibited regardless of the platform utilized," according to a 2017 CMS memo.

CPOE adoption

CPOE adoption, which initially struggled because of provider resistance, has improved, particularly as EHR systems have proliferated. A 2016 survey of more than 1,300 U.S. hospitals found that 95.6% of them used CPOE with clinical decision support, according to the July 2017 issue of the American Journal of Health-System Pharmacy.

A 2016 study by The Leapfrog Group and Castlight Health indicated that 64% of hospitals have CPOE systems that meet Leapfrog's qualifications -- such as 75% of inpatient medication orders going through CPOE. That figure was a large jump from 2010, when only 14% of hospitals had CPOE.

CPOE implementation is a major requirement for stage 1 meaningful use eligibility. According to the provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act, healthcare organizations that achieved meaningful use compliance by 2011 were eligible to receive incentive payments; those that failed to achieve that standard by 2015 would incur financial penalties. Meaningful use stage 1 criteria specify that 30% of patients must have their medication orders entered via CPOE. Meaningful use stage 2 expanded those criteria to mandate that the same percentage of radiology procedures be entered by CPOE. It is unclear, as of this writing in 2018, how changes to the meaningful use program proposed by President Donald Trump's administration will affect CPOE mandates.

The time and money it takes to install a CPOE system are two commonly cited drawbacks of the technology. The cost of a CPOE implementation can be in the millions, and yearly maintenance can add hundreds of thousands of dollars to that total. However, long term, those costs may be recouped through savings from decreased medical errors and adverse drug reactions among patients.

A CPOE implementation can be rolled out to different departments gradually, sometimes taking years to complete. Healthcare Information and Management Systems Society's (HIMSS) online CPOE resource lists six steps needed for an ideal CPOE implementation: initiating, planning, executing, monitoring/controlling, transitioning to operations and optimization/maintenance after the installation is complete.

Problems with CPOE

The effectiveness of CPOE directly links to how well clinical and pharmacy staff use it. Errors previously associated with poorly written clinical notes -- a bane of paper-based charting -- can now manifest themselves if clinicians incorrectly enter information in a CPOE system. For example, there is the potential a user could assign inaccurate dosages or enter orders for the wrong patient. Multitasking can amplify these entry risks.

Also, with new systems comes a learning curve for users. Training on how to properly use CPOE systems, as well as eliciting feedback from users and emphasizing the benefits of the system, are among the ways to reduce these errors.

Alert fatigue is another common problem a medical professional may deal with when using CPOE in combination with other health IT systems. Alert fatigue occurs when the user is exposed to an inordinate number of frequent alerts, such as visual messages or audible warnings, and consequently becomes desensitized to them. Ignoring routine alert messages embedded in the software applications and automatically clicking on prompts can lead to unintended consequences associated with potential medication errors or serious adverse advents.

To address this concern, some CPOE systems have created a "hard halt" safety feature that prevents further processing until a high-alert flag has been properly addressed and resolved. Other systems color-code alerts, with certain colors signifying alerts as serious or requiring a mandatory response.