Home

Cover Story

Table of Contents

E-Newsletter

Article Archive

Editorial Calendar

Datebook

Writers' Guidelines

Orgs/Links

Opinion Polls

Reprints

Forum

For other articles and previous issues click here.

June 13, 2005

CPOE — Building Electronic Safeguards
By Laura Gater
Radiology Today
Vol. 6 No. 12 P. 18

CPOE is designed to support doctors and improve patient safety by providing warnings if an entered doctor’s order appears to contradict information in the facility’s information system. Along with PACS and EMR, CPOE is expected to be a key part of putting decision-making information in the hands of physicians at the point of care—the clinical goal of healthcare information systems.

Computerized physician order entry (CPOE) systems have been touted as one of the answers to reducing medical errors. Between 44,000 and 98,000 Americans are killed each year by medical errors, according to a 1999 report by the Institute of Medicine.

CPOE systems bring together information about the patient that helps increase patient safety. For example, when doctors write test or prescription orders, CPOE systems are performing checks in the background regarding whether the patient is allergic to the drug or whether the dosage is excessive. Alerts and reminders pop up if there is any contraindication, giving physicians a chance to change the order or provide additional data to substantiate the order.

When considering all the potential benefits of CPOE, many in healthcare informatics believe linking CPOE to an image-enabled electronic medical record (EMR)—including PACS and RIS data—is the way to transform clinical care and reduce errors by putting the information physicians need to make decisions at their fingertips at the point of care.
But one hospital’s CPOE experience has caused it—as well as many others—to reconsider its physician order entry.

Nearly 30% of 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 needed to change workflow strategies and habits. David J. Brailer, MD, PhD, 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, 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, FHIMSS, was appointed chairman of this new coalition, the Certification Commission for Healthcare Information Technology (CCHIT). The CCHIT is 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.

One Hospital’s Experience
Cedars-Sinai Hospital in Los Angeles implemented a multimillion-dollar CPOE in late 2002, and three months later the hospital was forced to uninstall it after hundreds of physicians complained that orders were getting lost or weren’t being transmitted and that it was poorly designed. Cedars-Sinai is not the only hospital to have pulled its CPOE, although its experience may have been the most publicized because of the hospital’s size and status.

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 and will utilize CPOE systems in different ways.

The Agency for Healthcare Research and Quality (AHRQ) recently released a study about CPOE systems, “Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors,” which identified 22 situations in which the CPOE system increased the probability of medication errors. According to the study, the situations fell into two categories: information errors generated by fragmentation of data and hospitals’ many information systems; and interface problems between humans and machines, where the computer’s requirements are different from the way clinical work is organized. The AHRQ calls for careful and thoughtful implementation of CPOE systems to avoid facilitating certain types of errors.

Reducing Errors
The Healthcare Information Management Systems Society (HIMSS) believes 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 as the basis for improving the state of current CPOE systems.

“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 the 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.”

Workflow
American Health Information Management Association Professional Practice Manager Carol Ann Quinsey, RHIA, CHPS, believes one of the 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,” says 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.”

Selection & Implementation
“CPOE is generally a part of EMR software,” says Wise. “As the practice or hospital selects software, it needs to be very cognizant of its workflow. How easy is it to navigate through order entry? Make sure the physicians and providers in the practice try it out. Is the CPOE programmable? Can lab work and charts be reviewed? It’s not a case of ‘one size fits all.’ In an ambulatory practice, each physician can customize his own CPOE.”

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.

Wide Input
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,” says 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.

Last April, President Bush called for widespread adoption of interoperable EMRs within 10 years. Those in Cedars-Sinai’s health information department are optimistic about the nationwide EMR plan and realize that CPOE is a “significant portion” of the grand design.

Future Promise
“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 the 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, and other national and online publications.

Subscribe to Radiology Today Magazine!