Computerized Provider Order Entry
Not that long ago, when a patient came to see a provider, staff would go to medical record department to find a paper chart. The chart was accumulative of the patient’s medical history. Orders were done on paper and prescriptions were hand-written on prescription pads. As a result of illegible handwritten prescriptions and transcription errors, an environment of decreased efficiency, and medication errors was created that put patient safety in jeopardy. The purpose of this paper is to discuss the benefits and disadvantages of CPOE in relation to medication orders.
Example of Computerized Provider Order Entry
CPOE has been around since the 1970’s. CPOE became more popular when the Center for Medicare and Medicaid (CMS) established a need for meaningful use of electronic health records (EHR) to improve care for the patient. CPOE is one way to fulfill the HITECH and CMS mandate. Although the cost of CPOE is extensive, the benefits of improving patient outcomes and decreasing medication errors provides enough resource to justify the cost. CPOE an application that allows providers to directly enter orders into the electronic medical record. CPOE allow providers to electronically enter medication orders, laboratory, admission, radiology, referrals and procedure orders. With the EHR, the provider is able to review the patient’s health record quickly. They are also able to enter orders, review plans of care and see all provider notes. After the providers enters orders into the EHR via CPOE, the orders are electronically sent to the designated department such as the pharmacy. While ordering medications, the system will check for drug interactions, allergies and double check dosage amounts. This reduces errors, improves patient care, and decreases cost from duplications and errors.
Benefits of using CPOE in relation to placing medication orders includes
• Decreasing medical errors by improving legibility of orders.
• Decrease adverse drug events, or medication errors that cause harm, and increase cost.
• CPOE removes unapproved abbreviations and acronyms.
• Increase the speed and efficiency of pharmacy receiving orders and dispensing medications.
• Ability for an off-site consulting provider to review the charts, and place orders while off-site. Increases patient satisfaction with patient centered care and allows patient not to have to travel to specialist.
• Increase in coordination of care between health care disciplines.
• Immediate alerts on dosage amounts, allergies, and drug allergies while using CPOE.
With any technological change, there is bound to be disadvantages and/or barriers. Some of the most commons disadvantages of CPOE for medication ordering include
• Providers are hesitant to change. CPOE requires training and time to learn how to use it. If providers continue to write orders on paper and some orders in the EHR, the records are mixed and potential for errors increases.
• Alarm/alert fatigue. Providers begin to ignore alert boxes due to the frequency of the warnings.
• Lack of technical support to assist users with order entry difficulties, system crashes, updates, maintenance down-time, interoperability and poor set-up to match provider needs.
• Incorrect selection of medications from either drop-down menus or selecting incorrect boxes.
• Standardization of medical terminology is necessary to allow the application to work at its full potential.
• Potential to enter orders into wrong medical record.
• Discontinue or modify failures. When providers modify medication order instead of discontinuing. This can result in duplicate orders, double doses of medications, and conflicting medications.
• Procedure linked medication that fail to get cancelled when a procedure is cancelled.
• Failure to catch IV fluid diluents compatibility with medications.
• Failure to release sign and held medication orders.
In the mother baby unit, we frequently have multiple providers entering orders for a patient. I have recently encountered situations where each provider is entering their own order set, and the computer program is not picking up on duplicate orders. For example, family practice provider places labor/delivery/postpartum order set. Then anesthesia places a second order set for the epidural. The patient goes to surgery and the OB/GYN surgeon places a third set of order for pre and post-op medications. This will give us three set of orders, of which, duplicate orders are present. The EHR program only searches for duplicate orders within one order set. It will not search for duplicate orders across different order sets. If each provider orders Tylenol, the only way the computer system detects the duplicate order is if the same provider puts in two Tylenol orders. A second example of CPOE difficulties is when the providers selects all when entering the orders and does not pay attention to the orders being placed. Recently a provider ordered four medications to be given. None of the orders were appropriate for the patient. The nurse used critical thinking skills and chart review and discovered these medications should not be given. After the provider was contacted to clarify the orders, he admitted that he just checks all of the boxes because he doesn’t have time to look everything up. There were four potential medication errors that would have resulted in adverse drug events. The orders are only as good as the information being entered. The computer program did not know if the orders we appropriate, it was only able to check the dosages, interactions and allergies.