Computerized physician order entry (CPOE), sometimes referred to as computerized provider order entry or computerized provider order management (CPOM), is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care.
The entered orders are communicated over a computer network to the medical staff or to the departments (pharmacy, laboratory, or radiology) responsible for fulfilling the order. CPOE reduces the time it takes to distribute and complete orders, while increasing efficiency by reducing transcription errors including preventing duplicate order entry, while simplifying inventory management and billing.
CPOE is a form of patient management software. [1]
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In a graphical representation of an order sequence, specific data should be presented to CPOE system staff in cleartext, including:
Some textual data can be reduced to simple graphics.
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CPOE systems use terminology familiar to medical and nursing staff, but there are different terms used to classify and concatenate orders. The following items are examples of additional terminology that a CPOE system programmer might need to know:
The application responding to, i.e., performing, a request for services (orders) or producing an observation. The filler can also originate requests for services (new orders), add additional services to existing orders, replace existing orders, put an order on hold, discontinue an order, release a held order, or cancel existing orders.
A request for a service from one application to a second application. In some cases an application is allowed to place orders with itself.
One of several segments that can carry order information. Future ancillary specific segments may be defined in subsequent releases of the Standard if they become necessary.
The application or individual originating a request for services (order).
A list of associated orders coming from a single location regarding a single patient.
A grouping of orders used to standardize and expedite the ordering process for a common clinical scenario. (Typically, these orders are started, modified, and stopped by a licensed physician.)
A grouping of orders used to standardize and automate a clinical process on behalf of a physician. (Typically, these orders are started, modified, and stopped by a nurse, pharmacist, or other licensed health professional.)
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Features of the ideal computerized physician order entry system (CPOE) include:
In the past, physicians have traditionally hand-written or verbally communicated orders for patient care, which are then transcribed by various individuals (such as unit clerks, nurses, and ancillary staff) before being carried out. Handwritten reports or notes, manual order entry, non-standard abbreviations and poor legibility lead to errors and injuries to patients, . [2] A follow-up IOM report in 2001 advised use of electronic medication ordering, with computer- and internet-based information systems to support clinical decisions. [3] Prescribing errors are the largest identified source of preventable hospital medical error. A 2006 report by the Institute of Medicine estimated that a hospitalized patient is exposed to a medication error each day of his or her stay. [4] While further studies have estimated that CPOE implementation at all nonrural hospitals in the United States could prevent over 500,000 serious medication errors each year. [5] 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%, [6] and other studies have also suggested benefits. [7] Further, in 2005, CMS and CDC released a report that showed only 41 percent of prophylactic antibacterials were correctly stopped within 24 hours of completed surgery. The researchers conducted an analysis over an eight-month period, implementing a CPOE system designed to stop the administration of prophylactic antibacterials. Results showed CPOE significantly improved timely discontinuation of antibacterials from 38.8 percent of surgeries to 55.7 percent in the intervention hospital. [8] CPOE/e-Prescribing systems can provide automatic dosing alerts (for example, letting the user know that the dose is too high and thus dangerous) and interaction checking (for example, telling the user that 2 medicines ordered taken together can cause health problems). In this way, specialists in pharmacy informatics work with the medical and nursing staffs at hospitals to improve the safety and effectiveness of medication use by utilizing CPOE systems.
Generally, CPOE is advantageous, as it leaves the trails of just better formatting retrospective information, similarly to traditional hospital information systems designs. The key advantage of providing information from the physician in charge of treatment for a single patient to the different roles involved in processing he treatise itself is widely innovative. This makes CPOE the primary tool for information transfer to the performing staff and lesser the tool for collecting action items for the accounting staff. However, the needs of proper accounting get served automatically upon feedback on completion of orders.
CPOE is generally not suitable without reasonable training and tutoring respectively. As with other technical means, the system based communicating of information may be inaccessible or inoperable due to failures. That is not different from making use of an ordinary telephone or with conventional hospital information systems. Beyond, the information conveyed may be faulty or erratic. A concatenated validating of orders must be well organized. Errors lead to liability cases as with all professional treatment of patients.
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.
But, in general, the options to reuse order sets anew with new patients lays the basic for substantial enhancement of the processing of services to the patients in the complex distribution of work amongst the roles involved. The basic concepts are defined with the clinical pathway approach. However, success does not occur by itself. The preparatory work has to be budgeted from the very beginning and has to be maintained all the time. Patterns of proper management from other service industry and from production industry may apply. However, the medical methodologies and nursing procedures do not get affected by the management approaches.
CPOE presents several possible dangers by introducing new types of errors. [9] [10] 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. [11] In other settings, shortcut or default selections can override non-standard medication regimens for elderly or underweight patients, resulting in toxic doses.[ citation needed ] 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. [12] Introducing CPOE to a complex medical environment requires ongoing changes in design to cope with unique patients and care settings, close supervision of overrides caused by automatic systems, and training, testing and re-training all users.
CPOE systems can take years to install and configure. Despite ample evidence of the potential to reduce medication errors, adoption of this technology by doctors and hospitals in the United States has been slowed by resistance to changes in physician's practice patterns, costs and training time involved, and concern with interoperability and compliance with future national standards. [13] According to a study by RAND Health, the US healthcare system could save more than 81 billion dollars annually, reduce adverse medical events and improve the quality of care if it were to widely adopt CPOE and other health information technology. [14] As more hospitals become aware of the financial benefits of CPOE, and more physicians with a familiarity with computers enter practice, increased use of CPOE is predicted. Several high-profile failures of CPOE implementation have occurred, [15] so a major effort must be focused on change management, including restructuring workflows, dealing with physicians' resistance to change, and creating a collaborative environment.
An early success with CPOE by the United States Department of Veterans Affairs (VA) is the Veterans Health Information Systems and Technology Architecture or VistA. A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient's record at any computer in the VA's over 1,000 healthcare facilities. CPRS includes the ability to place orders by CPOE, including medications, special procedures, x-rays, patient care nursing orders, diets and laboratory tests.
The world's first successful implementation of a CPOE system was at El Camino Hospital in Mountain View, California in the early 1970s. The Medical Information System (MIS) was originally developed by a software and hardware team at Lockheed in Sunnyvale, California, which became the TMIS group at Technicon Instruments Corporation. The MIS system used a light pen to allow physicians and nurses to quickly point and click items to be ordered.
As of 2005 [update] , one of the largest projects for a national EHR is by the National Health Service (NHS) in the United Kingdom. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practices in England access to the National Programme for IT (NPfIT). The NHS component, known as the "Connecting for Health Programme", [16] includes office-based CPOE for medication prescribing and test ordering and retrieval, although some concerns have been raised about patient safety features. [17]
In 2008, the Massachusetts Technology Collaborative and the New England Healthcare Institute (NEHI) published research showing that 1 in 10 patients admitted to a Massachusetts community hospital suffered a preventable medication error. The study argued that Massachusetts hospitals could prevent 55,000 adverse drug events per year and save $170 million annually if they fully implemented CPOE. The findings prompted the Commonwealth of Massachusetts to enact legislation requiring all hospitals to implement CPOE by 2012 as a condition of licensure. [18] [19]
In addition, the study [20] also concludes that it would cost approximately $2.1 million to implement a CPOE system, and a cost of $435,000 to maintain it in the state of Massachusetts while it saves annually about $2.7 million per hospital. The hospitals will still see payback within 26 months through reducing hospitalizations generated by error. Despite the advantages and cost savings, the CPOE is still not well adapted by many hospitals in the US.
The Leapfrog's 2008 survey [21] showed that most hospitals are still not complying with having a fully implemented, effective CPOE system. The CPOE requirement became more challenging to meet in 2008 because the Leapfrog introduced a new requirement: Hospitals must test their CPOE systems with Leapfrog's CPOE Evaluation Tool. So the number of hospitals in the survey considered to be fully meeting the standard dropped to 7% in 2008 from 11% the previous year. Though the adoption rate seems very low in 2008, it is still an improvement from 2002 when only 2% of hospitals met this Leapfrog standard.
A prescription, often abbreviated ℞ or Rx, is a formal communication from a physician or other registered healthcare professional to a pharmacist, authorizing them to dispense a specific prescription drug for a specific patient. Historically, it was a physician's instruction to an apothecary listing the materials to be compounded into a treatment—the symbol ℞ comes from the first word of a medieval prescription, Latin recipere, that gave the list of the materials to be compounded.
A medical error is a preventable adverse effect of care ("iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.
An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.
Brigham and Women's Hospital (BWH) is the second largest teaching hospital of Harvard Medical School and the largest hospital in the Longwood Medical Area in Boston, Massachusetts. Along with Massachusetts General Hospital, it is one of the two founding members of Mass General Brigham, the largest healthcare provider in Massachusetts. Robert Higgins, MD, MSHA serves as the hospital's current president.
A clinical decision support system (CDSS) is a health information technology that provides clinicians, staff, patients, and other individuals with knowledge and person-specific information to help health and health care. CDSS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients, clinical guidelines, condition-specific order sets, focused patient data reports and summaries, documentation templates, diagnostic support, and contextually relevant reference information, among other tools. CDSSs constitute a major topic in artificial intelligence in medicine.
Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.
A Patient Safety Organization (PSO) is a group, institution, or association that improves medical care by reducing medical errors. Common functions of patient safety organizations are data collection, analysis, reporting, education, funding, and advocacy. A PSO differs from a Federally designed Patient Safety Organization (PSO), which provides health care providers in the U.S. privilege and confidentiality protections for efforts to improve patient safety and the quality of patient care delivery
Purkinje Incorporated pioneered pen computing for comprehensive clinical management of patients by physicians in 1991 with the "PureMD" ontology-anchored medical record was later rename Dossier that allowed physician order entry, knowledge-based clinical decision support, and billing from clinical note-taking recorded on a tablet computer. In1994 and 2007, "Dossier" was respectively awarded the "OCTAS of excellence" and the "TEPR award for standalone eprescribing systems". Dossier's impact of on clinical redaction was evaluated in two peer-reviewed studies. "Purkinje software and services" currently serve over 13,000 physicians in clinics, community health centers, and hospitals throughout North America. The company provides health software and related services in the areas of practice management, electronic health records, personal health records, and electronic prescribing. In addition, Purkinje provides a series of professional services to physician practices including billing services, transcription, and medication dispensing.
First Databank (FDB) is a major provider of drug and medical device databases that help inform healthcare professionals to make decisions. FDB partners with information system developers to deliver useful medication- and medical device-related information to clinicians, business associates, and patients. FDB is part of Hearst and the Hearst Health network.
Health information technology (HIT) is health technology, particularly information technology, applied to health and health care. It supports health information management across computerized systems and the secure exchange of health information between consumers, providers, payers, and quality monitors. Based on a 2008 report on a small series of studies conducted at four sites that provide ambulatory care – three U.S. medical centers and one in the Netherlands, the use of electronic health records (EHRs) was viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system.
Electronic prescription is the computer-based electronic generation, transmission, and filling of a medical prescription, taking the place of paper and faxed prescriptions. E-prescribing allows a physician, physician assistant, pharmacist, or nurse practitioner to use digital prescription software to electronically transmit a new prescription or renewal authorization to a community or mail-order pharmacy. It outlines the ability to send error-free, accurate, and understandable prescriptions electronically from the healthcare provider to the pharmacy. E-prescribing is meant to reduce the risks associated with traditional prescription script writing. It is also one of the major reasons for the push for electronic medical records. By sharing medical prescription information, e-prescribing seeks to connect the patient's team of healthcare providers to facilitate knowledgeable decision making.
The Veterans Health Information Systems Technology and Architecture (VISTA) is the system of record for the clinical, administrative and financial operations of the Veterans Health Administration VISTA consists of over 180 clinical, financial, and administrative applications integrated within a single shared lifelong database (figure 1).
A chief medical informatics officer is a healthcare executive generally responsible for the health informatics platform required to work with clinical IT staff to support the efficient design, implementation, and use of health technology within a healthcare organization.
Barcode technology in healthcare is the use of optical machine-readable representation of data in a hospital or healthcare setting.
Clinical point of care (POC) is the point in time when clinicians deliver healthcare products and services to patients at the time of care.
The Health Information Technology for Economic and Clinical Health Act, abbreviated the HITECH Act, was enacted under Title XIII of the American Recovery and Reinvestment Act of 2009. Under the HITECH Act, the United States Department of Health and Human Services resolved to spend $25.9 billion to promote and expand the adoption of health information technology. The Washington Post reported the inclusion of "as much as $36.5 billion in spending to create a nationwide network of electronic health records." At the time it was enacted, it was considered "the most important piece of health care legislation to be passed in the last 20 to 30 years" and the "foundation for health care reform."
The adoption of electronic medical records refers to the recent shift from paper-based medical records to electronic health records (EHRs) in hospitals. The move to electronic medical records is becoming increasingly prevalent in health care delivery systems in the United States, with more than 80% of hospitals adopting some form of EHR system by November 2017.
David Bates is an American-born physician, biomedical informatician, and professor, who is internationally renowned for his work regarding the use of health information technology (HIT) to improve the safety and quality of healthcare, in particular by using clinical decision support. Bates has done work in the area of medication safety. He began by describing the epidemiology of harm caused by medications, first in hospitalized patients and then in other settings such as the home and nursing homes. Subsequently, he demonstrated that by implementing computerized physician order entry (CPOE), medication safety could be dramatically improved in hospitals. This work led the Leapfrog Group to call CPOE one of the four changes that would most improve the safety of U.S. healthcare. It also helped hospitals to justify investing in electronic health records and in particular, CPOE. Throughout his career, Bates has published over 600 peer reviewed articles and is the most cited researcher in the fields of both patient safety and biomedical informatics, with an h-index of 115. In a 2013 analysis published by the European Journal of Clinical Investigation, he ranked among the top 400 living biomedical researchers of any type. He is currently editor of the Journal of Patient Safety.
Federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic health records. The US Congress included a formula of both incentives and penalties for EMR/EHR adoption versus continued use of paper records as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the, American Recovery and Reinvestment Act of 2009.
Autonomous pharmacy is an approach to medication management that seeks to create a more automated and data-driven process for medication inventory and dispensing. The main concept behind autonomous pharmacy is to use technology in place of manual medication processes in order to help healthcare providers reduce medication errors, decrease costs and save staff time. Autonomous pharmacy may use a combination of hardware, software and technology-enabled services to allow pharmacists to more effectively manage medication dispersal.