CPOE and Patient Health

¶ … CPOE primary use to manage cost and quality in the physician and pharmacy interaction?

An electronic process that enables providers of health care to manage the results of orders entered in to a computer electronically is known as Computer Provider Order Enter or CPOE. In line with the reports of Institute of Medicine (IOM) titled, "To Err is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century," CPOE has commanded increased attention. Hospitals should be rewarded for introducing prescription systems as recommended by Leapfrog Group, which is a coalition of private and public providers of health care benefits. In ever-rising numbers, Health care systems are implementing CPOE as a way of improving both the quality of patient safety and care. The implementation of CPOE is, however, not only an information technology innovation, but it also encompasses delivery of health care in both ancillary and clinical departments. More than being just a simple technological innovation, it integrates technology at vital points to optimize and improve ordering by redesigning complex clinical processes (Steele & DeBrow, 2008).

In order for a prescription to be revised immediately at the entry point before being forwarded electronically for the medical action intended, the CPOE system uses data from the radiology, the pharmacy, laboratory, and patient monitoring systems to relay the nurse or physician's therapeutic and diagnostic plans. This action is meant to alert the provider about any contraindications or allergy that the patient may be experiencing. It is part of a system of clinical information that facilitates caregivers to transmit an order for laboratory or clinical test, medication or any other process into a computer directly. The system then relays the order to the relevant individual or department for execution. Real time clinical support decisions like suggestions for alternative medication or dosage, drug-allergy and drug-drug interaction monitoring, or warnings for duplicate therapy are some of the most innovative implementations of these systems (Osheroff, Pifer, Teich, Sittig, & Jenders, 2005).

An unexpected increase of error rates in the medical care of most health institutions in the U.S.A. was highlighted in a report publicized in 1999 by the U.S. Institute of Medicine (IoM) called 'To Err is Human.' This report brought forward the imperative need to minimize medical errors from hospitals and issues pertaining to the safety of patients. Patient safety has become a basic interest in various national health care systems from the time this report came into the limelight. As a result, a lot of work has been directed into devising new methods of improving health systems in most countries.

The aim of this research essay is to find out if the basic application of CPOE is to help manage quality and costs in the interaction between the pharmacy and the physician. A comprehensive history of CPOE, current policy proposals, and discourses about the subject are discussed in the rest of this essay.

History of the topic

5% to 9% of hospitals in the U.S. have now installed CPOE systems, according to citations from recent literature. Out of the 1000 hospitals that responded to the most recent survey carried out by Leapfrog hospital, only 4% had completely implemented the CPOE systems. The survey also revealed that out of the 67 hospitals for acute care in the Commonwealth of Massachusetts only 7 have put CPOE systems in place. In a different study, it was found out that only 15% of hospitals had partially or fully implemented CPOE system. This was out of 668 hospitals that participated in the study. Apart for the CPOE system, there are other intelligent or electronic systems that are also designed to minimize errors in medication. For example, in various hospitals there are applications that are computerized enabling physician's written orders to be electronically entered by other staff. These are basically 'capture and transmit' systems which have the capabilities of checking and verifying certain rules. They are commonly called transcribing systems or order document management systems

(Ormond, 2005).

Although they are not CPOE's there are pharmacy systems with support decision software that have proved effective in minimizing errors in medication. They are designed to produce records of orders after initiation by the prescriber either on paper or electronically. CPOE systems depend on systems with interfaces for clinical support decisions or CDSS that generate information, rules and logic about interaction of medications. Even without a CPOE, 10 CDSSs can be successfully implemented. For instance, a paper prescription may be written and given to a nurse for transcription after a prescriber has used a CDSS to research the drug for a drug-to-drug interaction (Ormond, 2005).

CPOE Functions

Besides CPOE systems that are home grown, there are at least 13 other vendors offering products of CPOE systems that can be integrated into or adapted to information technologies existing in hospitals or HIT systems. Some of the products are wraparound systems in place while others are modules that integrate into set of existing HIT products from one vendor. It is essential to appreciate the differences in the CPOE products, for instance, primary systems of CPOE provide sets of predefined orders or doses and names. While some applications provide templates and default values that give further guidance, others put a limitation on field entries that control dosage. Definitions, information, or routes regarding interaction of drugs may be provided by pull-down menus. Whereas certain functions may not be active, necessitating a search for a specific field by the subscriber, others are active and can automatically generate data. Surveillance systems that notify a physician when changes occur in a patient's clinical status or vital signs can be used with more advanced applications that are integrated into electronic medical records (EMRs) (Ormond, 2005).

Current policies and scholarly debate about the topic

Miller, Waitman, Chen and Rosenbloom examine the anatomy of decision support during inpatient Care Provider Order Entry (CPOE). They discuss empirical observations from a Decade of CPOE experience at the Vanderbilt hospital. Based on a decade of experience in evolving and implementing the WizOrder of Vanderbilt's CPOE or care provider order entry system for in-patients, the researchers illustrate a practical approach to the implementation of clinical support decision at the care point. The settings for inpatient care presents a peculiar chance to introduce decision support qualities that provide educational materials that are relevant and focused, influence how patients receive care and restructure clinical workflows based on CPOE. The precise method to the implementation of particular features of decision support within a CPOE system should entail a three-axis evaluation namely: the type of intervention to be created, when the intervention should be introduced into the workflow of the user, and how the intervention can be disruptive to the end user's workflow when the system is in use. When decision support is framed in this manner, it becomes easier for both clinical end-users and developers to forecast future changes to their systems when it is imperative to introduce new features of decision support (Miller, Waitman, Chen, & Rosenbloom, 2005);(Agency for Healthcare Research and Quality, 2015).

In studies by Gibson and Kuperman, the researchers explain that throughout the health care system information technology has been singled out consistently as a vital component requiring improvement. Allowing physicians to feed orders into a computer without having them handwritten first, CPOE is a relatively recent technology without any widely accepted best approaches to its limitations. This system basically alters the process of ordering which can result into misuse of health care services, under use or over use, a remarkable reduction in over use, decrease in medical errors, improved compliance with several forms of guidelines and shortening length of stay. In terms of technology and the process of organizational analysis, or system implementation, redesigning, user training and support, the costs of implementing CPOE are huge. However, this technology can produce great benefits, and therefore, it is an essential platform for future innovations and transformations in the healthcare system. Leaders of institutions delivering health services must support CPOEs as a crucial tool for the improvement of the quality of health care (Kuperman & Gibson, 2003)(Agency for Healthcare Research and Quality, 2015).

Bates, Avery and Classen described CPOE as a software that is employed in electronically writing orders of physicians in either the outpatient setting or within the hospital. With the proliferation of commercial CPOEs systems in various care setting, there is evidence that some methods of implementation may not attain the outcomes previously published and they may result to harm if not new mistakes. Consequently, fresh efforts to re-examine CPOE systems have been undertaken by groups that monitor the vendors and the vendors themselves. Major employers have also contributed to this process by initiating flight simulators to check how the CPOE systems perform after they have been implemented. The potential benefit of this move is to link the outcomes of similar programmes with compensation made possible by pay-for-performance initiatives. In actual practice, a lot of scrutiny about how effective these systems really are has been occasioned by the increasing key role the CPOEs play in health care. Such scrutiny has the advantage of potentially improving their ultimate efficacy (Classen, Avery, & Bates, 2007)(Agency for Healthcare Research and Quality, 2015).

De Keizer, Abu-Hanna and Eslami in their research give a systematic review of literature of the studies undertaken on the setting of outpatient safety; adherence to guidelines; efficiency and cost; usage and usability, satisfaction, time, and alerts. The inclusion criteria were met by 30 papers with original data on observational research designs, non-randomized clinical trials, and randomized clinical trials. Out of all the papers, only 4 evaluated the impact of CPOE on safety. The numbers of extreme drug occurrences were not significantly affected, but a single paper demonstrated a remarkable reduction in the frequency of errors in medication. Greater reduction in the costs of medication was seen in three studies but five other researches disputed this outcome although several other researchers indicated remarkable positive effects. However, the apparently limited numbers of research evaluations that have been published up to now do not give enough proof that the systems of CPOE increase safety and minimize costs in settings of outpatients. However, there is proof of increasing time for prescriptions, high rate of occurrences that are ignored, and increasing adherence to guidelines (Eslami, Abu-Hanna, & De. Keizer, 2007)(Agency for Healthcare Research and Quality, 2015)

Hurdle, Bennett, Hoffman Nebeker and Weir explained that researches have revealed that particular interventions that are computerized may limit mistakes in medication but only few of them have evaluated the drug's adverse effects (ADEs) within all stages of medication processes that are computerized. The frequency and form of ADEs on outpatients that took place after computerized medication administration and ordering systems was described. These descriptions included computerized physician order entry (CPOE).

From a random sample from admissions at a hospital for veteran administration, pharmacists were able to categorize ADEs from daily perspectives of medical electronic records. 9% of all ADEs resulted in serious harm while additional interventions and monitoring was seen in 22% and 32% in interventions, and another 11% in monitoring alone. 27% ought to have led to monitoring or interventions. Errors in medication linked to ADEs were seen in these stages: 13% in administration, 61% in ordering, 15% in dispensing, 25% in monitoring and 0% in transcription. After implementation of CPOE and associated medication systems that are computerized but do not have support decisions for selecting drugs, dosing and monitoring, increased incidences of ADEs may still take place. There is a need to remove obstacles that prevent implementing and adopting Computerized Physician Order Entry Systems in U.S. Hospitals (Nebeker, Hoffman, Weir, Bennett, & Hurdle, 2005)(Agency for Healthcare Research and Quality, 2015).

Articulate feasible and defensible policy proposal

National experts in patient safety and health care quality recommended to the Leapfrog Group to choose CPOE as its basic standard for safety because of the potential advantages for both professionals and patients. The original standard of CPOE of the Leapfrog Group was drawn from extensive examination of published studies and wide consultations with prominent experts in CPOE and medication errors. The standard in question has been reviewed and revised several times until now by including present input and data from the community of physicians and hospitals (The Leapfrog Group, 2014).

Proposal:

CPOE or computerized provider order entry for medication entered directly by any healthcare professional that is licensed to enter orders into the medical records per state should be used. Also, professional and local guidelines for creating the initial record should be in force (Centre for medicare and medicaid services, 2012). The proposal must:

Confirm that at least 75% of the orders of inpatients' medication orders are entered by a physician through a computer system that has software for preventing errors.

Through a test, it should be demonstrated that the records of inpatient CPOE system can reach physicians by at least 50% of the serious but common errors of prescription. This practice should be implemented only in adult hospitals.