COMPUTERIZED PHYSICIAN ORDER ENTRY Background

Several steps must take place before a hospitalized patient receives a medication ordered by a clinician: Ordering: the clinician must select the appropriate medication and the dose and frequency at which it is to be administered Transcribing: the clerk must read the order correctly and communicate it accurately to the pharmacist Dispensing: the pharmacist must check for drugdrug interactions and allergies, then release the appropriate quantity of the medication in the correct form Administration: the nurse must receive the medication and supply it to the correct patient A classic study of inpatient medication errors found that approximately 90% occurred at either the ordering or transcribing stage. These errors can be due to a variety of causes, including poor handwriting, ambiguous abbreviations, or simple lack of knowledge on the part of the ordering clinician. Computerized provider order entry (CPOE) refers to any system in which clinicians directly enter medication orders (and, increasingly, tests and procedures) into a computer system, which then transmits the order directly to the pharmacy. These systems have

become increasingly common in the inpatient setting as a strategy to reduce medication errors. A CPOE system, at a minimum, ensures standardized, legible, and complete orders and thus has the potential to greatly reduce errors at the ordering and transcribing stages. Studies of computerized physician order entry (CPOE) has yielded evidence that suggests the medication error rate can be reduced by 80%, and errors that have potential for serious harm or death for patients can be reduced by 55%,[4] and other studies have also suggested benefits

Features of CPOE systems

of the ideal computerized physician order entry system (CPOE) include: 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. Often uses medical logic module and/or Arden syntax to

facilitate fully integrated Clinical Decision Support Systems (CDSS). 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 "paperbased" 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 analysisfor patient safety events. Billing Documentation is improved by linking diagnoses (ICD-9-CM or ICD10-CM codes) to orders at the time of order entry to support appropriate charges.

Advantages
In theory, CPOE offers numerous advantages over traditional paper-based orderwriting systems. Examples of these advantages include averting problems with handwriting, similar drug names, drug interactions, and specification errors; integration with electronic medical records, decision support systems, and adverse drug event reporting systems; faster transmission to the pharmacy; and potential economic savings.

Disadvantages
Table. Types of Unintended Consequences of Computerized Provider Order Entry Systems More or new work for clinicians Unfavorable workflow issues Never-ending system demands Problems related to persistence of paper orders Unfavorable changes in communication patterns and practices

medical environment requires new ongoing changes in design to cope with unique patients and care settings, close supervision of Generation of new types of errors overrides caused by automatic Unexpected changes in an institution's systems, and training, testing and power structure, organizational culture, or re-training all users. professional roles Negative feelings technology toward the Overdependence on the technology CPOE presents several possible dangers by introducing new types of errors. Prescriber and staff inexperience may cause slower entry of orders at first, use more staff time, and is slower than person-to-person communication in an emergency situation. Physician to nurse communication can worsen if each group works alone at their workstations. Automation causes a false sense of security, a misconception that when technology suggests a course of action, errors are avoided. These factors contributed to an increased mortality rate in the Children's Hospital of Pittsburgh's Pediatric ICU when a CPOE system was introduced. In other settings, shortcut or default selections can override non-standard medication regimens for elderly or underweight patients, resulting in toxic doses. Frequent alerts and warnings can interrupt work flow, causing these messages to be ignored or overridden due to alert fatigue. CPOE and automated drug dispensing was identified as a cause of error by 84% of over 500 health care facilities participating in a surveillance system by the United States Pharmacopoeia. Introducing CPOE to a complex