Question

define who are target groups in the change of implementation of computer order entry in the hospital describe in detail

Answer 1

Computerized physician order entry (CPOE) has been promoted as an important component of patient safety, quality improvement, and modernization of medical practice. In practice, however, CPOE affects health care delivery in complex ways, with benefits as well as risks. Every implementation of CPOE is associated with both generally recognized and unique local factors that can facilitate or confound its rollout, and neurohospitalists will often be at the forefront of such rollouts. In this article, we review the literature on CPOE, beginning with definitions and proceeding to comparisons to the standard of care. We then proceed to discuss clinical decision support systems, negative aspects of CPOE, and cultural context of CPOE implementation. Before concluding, we follow the experiences of a Chief Medical Information Officer and neurohospitalist who rolled out a CPOE system at his own health care organization and managed the resulting workflow changes and setbacks.

Keywords: CPOE, EMR, implementation

Introduction

Computerized physician order entry (CPOE) has been promoted and championed as a component of health information technology by numerous political leaders^1,2 and consumer groups such as Leapfrog,³ which incorporated CPOE as a core quality measure in 2000.^4,5 The Health Information Technology for Economic and Clinical Health (HITECH) Act on February 17, 2009, specifically incentivized CPOE adoption with $19.2 billion in funds.⁶The drive to implement CPOE primarily comes from its presumed benefit in reducing medical errors. CPOE is a complex intervention, however; its implementation does not always reduce medical errors and occasionally augments them. Because neurohospitalists will increasingly interact with CPOE and the closely related phenomenon of clinical decision support systems (CDSSs) and will likely be expected to lead and master the attendant workflow changes, here we review the literature about CPOE. We begin with definitions and meaningful use, discuss CPOE compared to the (still) standard of care, proceed to CPOE and CDSS, and talk briefly about the potential pitfalls of CPOE and about qualitative approaches to CPOE. We then review a neurohospitalist (TY)’s experiences in implementing CPOE before offering concluding remarks.

Computerized Physician Order Entry Definitions and Meaningful Use

Although CPOE as a concept has evolved over time, in practice the meaning has changed little. In 2003, Harvard researchers defined CPOE as “…a variety of computer-based systems that share the common features of automating the medication ordering process and that ensure standardized, legible, and complete orders.”⁷ In 2010, as one of the meaningful use criteria for implementing electronic health records, the Centers for Medicare and Medicaid Services (CMS) defined CPOE as “…the provider’s use of computer assistance to directly enter medication orders from a computer or mobile device. The order is also documented or captured in a digital, structured, and computable format for use in improving safety and organization.”⁸ These 2 definitions (which admittedly focus on medications rather than physician orders at large) share in common the following features:

1. physicians entering the orders directly (not through a unit secretary);

2. physicians working through a digital interface (no handwriting);

3. standardization/structure (for example, not through word processed documents).

The first 2 follow naturally from the name; the latter is a more abstract point that follows from preexisting auditability requirements and leads to the more comprehensive CMS requirement of a “computable format.” In practice, all CPOE systems included in the 2003 study would have met the CMS standard.

CPOE implementation is one of CMS’s criteria for electronic medical record (EMR)’s “meaningful use,” criteria meant to ensure not just the implementation of EMRs but their active incorporation into patient care and workflow. CPOE appears in both the “eligible provider” and the “hospitals” lists of core objectives for stage I meaningful use, defined as entering medication orders through CPOE for at least 30% of patients in the practice or admitted to the hospital, respectively.⁹ Although the first 2 years of meaningful use have elapsed as of this writing, providers are still eligible for incentive payments if they implement stage I meaningful use in 2013 or 2014.¹⁰Prior to the meaningful use incentive, CPOE had limited uptake. According to 1 report, only 14% of all hospitals had achieved the meaningful use criteria mandated for CPOE as of 2010.¹¹ The “standard of care”—a mix of paper orders and others—was routine, especially at smaller hospitals. It remains to be determined whether the meaningful use incentives have altered this trajectory, and when and how frequently neurohospitalists will interact with CPOE as it comes online.

Computerized Physician Order Entry Compared to the Standard of Care

There are 33 publications that appear in a PubMed search restricted to “clinical trials” of CPOE as of March 24, 2013.¹² However, on review, only 2 of these publications are about the same randomized controlled trial of CPOE when compared to the standard of care. This paucity of the literature is unsurprising, as randomizing patients or even individual physicians to receive or deliver care through CPOE would be logistically challenging, would militate against a central principle of electronic workflow (ie, that information flow freely within the organization), and would likely not test the most theoretically beneficial components of CPOE (such as CDSS), which are often the last to be “rolled out.”¹³ For these reasons among others, there may be little incentive to study CPOE in an experimental fashion.

The singular trial to do so assessed physicians’ use of a minimalist “discharge software” system to generate discharge letters and medication reconciliation when compared to paper orders and usual discharge procedure. The first publication from this trial examined the effect of discharge software use by the randomized physicians on readmissions, emergency visits, and adverse drug events and found no difference compared to the standard of care group.¹⁴ The second assessed provider and patient attitudes toward the discharge process and found that patients were more prepared for discharge in the software group (but equally satisfied with it) and that outpatient providers rated the discharge quality higher but that inpatient providers found the process for discharge more onerous as well.¹⁵These mixed results apply only to the specific CPOE system evaluated, and CPOE systems are so complex and variable that generalizing from this experience would be inappropriate, but they do remind us that CPOE’s theoretical benefits are not always attained in practice.

Nonrandomized designs, especially before/after studies comparing CPOE to pre-CPOE practice, are more common, but the conclusions from these studies are also mixed. One showed a 10-fold reduction in prescription errors themselves when CPOE was implemented,¹⁶ and another showed reduced preventable adverse drug events in the hospital after implementation of CPOE.¹⁷However, the same trial showed an increase in all adverse drug events, while 3 additional trials showed reduced medication errors but not reduced adverse events.^18–20 Another showed complex associations between CPOE and laboratory and radiographic test ordering, with CPOE appearing to increase the ordering of some tests and decreasing others.²¹ Another study examined provider attitudes toward CPOE and empowerment and found that CPOE implementation was associated with a general fall in regard to CPOE and feelings of professional disempowerment.²² One study did however find a reduction in mortality of approximately 20% after CPOE implementation at a pediatric hospital.²³ These studies are summarized in Table 1. Taken together, they suggest neurohospitalists should question 1-sided portrayals of CPOE and be mindful of, and educate other providers about, CPOE’s impact on daily workflow and overall impact on outcomes (eg, preventable adverse events) rather than processes (eg, percent orders with complete information) alone
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