Computerized Provider Order Entry (CPOE) systems replace standard handwritten medical orders with a fully digitized procedure in which clinicians submit orders and their recipients fulfill them all electronically. In just a decade’s time, CPOE systems have integrated into inpatient and outpatient healthcare settings throughout the nation.
Computerized Physician Order Entry
CPOE stands for Computerized Physician Order Entry. Like electronic health records (EHR) CPOE takes a formerly inefficient, repetitive yet essential manual procedure and converts it to a more efficient and standardized digital format.
The US Office of the National Coordinator for Health Information Technology (ONC) describes the term CPOE as referring "to the process of providers entering and sending treatment instructions – including medication, laboratory, and radiology orders – via a computer application rather than paper, fax, or telephone."
In other words, a CPOE system provides a means for clinicians to place medical orders of various types electronically over a secure internet service rather than writing and transmitting paper orders.
Today, digital prescribing using CPOE in some form, far surpasses classic, and increasingly outdated, handwritten prescribing. According to the US Office of the National Coordinator for Health Information Technology (ONC), by the close of 2015, 84% of federally-run acute care settings had CPOE systems implemented. For that same time period, another ONC report found that over half of outpatient medical practices had implemented e-prescribing, the more common form of CPOE in outpatient settings. There are current trends to make e-prescribing the only way to provide prescriptions from the provider to the pharmacist.
The National Quality Forum (NQF) cites CPOE as one of the "30 Safe Practices for Better Healthcare".
Handwriting prescriptions poses a number of inefficiencies and risks that were unavoidable until the advent of CPOE. The original impetus for devising CPOE systems was to make the process of ordering and administering medications to patients safer and more efficient.
Modern CPOE systems enable far more than just prescription ordering, however. Clinicians can now use them for all sorts of orders, including consultations, tests, and procedures.
While the proliferation of CPOE has largely been a benefit to patients and clinicians alike, it has also provided ample evidence of some of the dangers and unplanned consequences of digitally transforming an entire component of the healthcare system.
For example, CPOE has proven to cut down on medication errors in hospitals, but learning the new technology has slowed down many physicians’ workflows. CPOE has also not, as yet, proven to cut down significantly on patient mortality.
"Computer Provider Order Entry (CPOE) has revolutionized the way physicians and other providers direct patient care in multiple settings," explains the National Institutes of Health (NIH.)
How Computerized Physician Order Entry Works
As the federal Agency for Healthcare Research and Quality (AHRQ) lays out on their Patient Safety Network (PSNet), there are four steps to the process of prescribing and administering medications to patients, regardless of how it's conducted either on paper or electronically. Each step exposes providers and patients to different vulnerabilities, each of which CPOE aims to address at least to some extent.
- Order: The clinician determines the most appropriate medication, dose, and frequency to order so as to provide the patient with the best treatment for his or her ailment, lest the ailment persists or exacerbates.
- Transcribe: If the prescription is handwritten, the pharmacist, pharmacy tech, or another recipient must be able to read and understand it, lest delays or prescription errors could possibly occur.
- Dispense: The pharmacist checks for medication allergies and interactions before releasing the amount of medication in the form that the clinician ordered. Here is another stage at which medication errors can occur, including those that could have unintended consequences for the patient.
- Administer: Finally, the patient or their authorized representative receives the medication in a timely manner with the proper dosage to carry out the clinician’s instructions. In typical outpatient scenarios, it is generally the responsibility of the patient or their caregiver to carry out this final step in the process. Although in hospital settings, nurses generally carry out this charge.
CPOE and CDSS (Clinical Decision Support System) Workflows
Normally, practices and hospital systems pair CPOE systems with a clinical decision support system, or CDSS in order to further help prevent medication errors. CDSS systems are particularly effective during the ordering and administering phases of the ordering process.
CDSS systems provide dosage and administration method recommendations and sometimes safety information as well, such as interactions or allergy risks.
In this way, the most advanced CDSS system can help prevent errors of both commission and omission. Using a CPOE and CDSS system together can further help prevent errors in other kinds of orders as well, such as tests, procedures, and consultations.
Customizing CPOE Systems
Practices and facilities can customize their CPOE system to work best for their unique circumstances and needs. For instance, you can set varying levels of security parameters based on the potential degrees of access, confidentiality, and HIPAA concerns, among other factors, involved in the transactions conducted over your organization’s particular CPOE system.
You can also customize a CPOE system by the following criteria
- User interface elements: Such as radio buttons and drop-down menus, based on the requirements and limitations of a given interaction
- Workflow: Such as order sets and preference personalization
- Safety features: Certain CDSS systems might offer allergy and interaction checklists. These include, but aren't limited to, drug-disease, drug-food, and drug-drug alerts.
In order to ensure the CPOE system you design is customized optimal for your organization, you must regularly test, map, and modify it as necessary. Note that, as your needs change, your CPOE system may need to change as well. This would then require additional mapping and testing to ensure optimal functioning and avoid patient harm, process gaps, and wasted staff effort.
The key to the effectiveness of any CPOE system is its ability to make it easier for clinicians to make the right decisions for patients and efficiently process orders for their proper health care.
Benefits of Computerized Physician Order Entry
CPOE helps to prevent many common medical ordering issues and improves medical ordering overall in a number of ways, among them by:
- Averting issues with handwriting, specification, drug interactions, and similar drug names, among others
- Integrating efficiently with EHR (electronic health records,) CDSS, and adverse drug event reporting systems
- Transmitting orders faster to the appropriate pharmacy, lab, or radiology department
- Offering suggestions for alternative treatments or tests that could be safer or more affordable.
The following explores some of these key advantages of CPOE in greater detail.
Reduce Errors and Improve Patient Safety
According to one study, 90% of hospital inpatient medication errors occurred during the ordering or transcribing phase of the process. The causes included:
- Illegible handwriting
- Unclear abbreviations
- Clinician ignorance
By providing a previously unavailable level of standardization, CPOE helps to ensure that all providers in your practice or system produce complete and legible orders, thereby helping the organization cut down on errors.
What’s more, CPOE tech typically includes built-in support tools that can check for drug allergies, drug-drug interactions, drug-food interactions, drug-disease interactions, and other possible issues.
This helps providers make integral clinical decisions. One such added concern is whether a medication is age-appropriate, as medications either recommended or advised against for elderly or pediatric patients.
With CPOE, providers can submit orders digitally. This helps practices more efficiently transmit radiology orders to radiology facilities, laboratory orders to labs, and medications to pharmacies so they can fill them more quickly and accurately.
In some cases, an order may require pre-approval from a patient’s insurance plan. With CPOE integrated into your electronic practice management system, you can identify instantly all orders requiring pre-approval. This can cut down considerably on insurance claim denials.
Evidence of Effectiveness
The early evidence of CPOEs effectiveness in meeting its developers’ intentions helped to solicit the federal funding that has led to the now-widespread proliferation of CPOE in multiple kinds of healthcare settings, both inpatient and outpatient.
One way CPOE has shown itself to be effective is in its ability to prevent errors in prescribing medications.
According to a meta-analysis of research compiled in 2013, CPOE reduced the likelihood of medication prescription errors over orders printed on paper by nearly half. That amounts to over 17 million errors of just that form alone prevented annually in US hospitals.
Studies also found e-prescribing systems are similarly effective at preventing prescription errors. As suggested earlier, these are CPOE systems that providers use mainly in outpatient contexts in order to directly transmit prescription orders to pharmacies.
Drawbacks and Risks of CPOE Systems
Finally, successfully implementing any new system into a medical practice or facility requires an awareness of the potential risks and drawbacks that any new system might pose. In the case of CPOE, those may include:
- Over-dependence on the CPOE technology
- Unplanned changes to the organizational culture, professional roles, or power structure of an organization
- The creation of new kinds of errors
- The additional effort required by the staff and clinicians
- Negative reactions from staff and clinicians toward and about the technology
- Undesirable shifts in the practices and patterns of communication
- Difficulty managing persistent paper orders
- Constant tech support issues
- Interference with the workflow
By staying acutely attuned to these possible risks and drawbacks of implementing a CPOE system in your practice or facility, you can be better prepared to compensate for them and modify the system appropriately to eliminate or ameliorate those concerns.
While learning to use a new technology could temporarily impede some clinicians’ workflows and not all errors can be averted using CPOE, such as in the dispensing and administering stages, the early evidence overwhelmingly supports the benefits of CPOE systems for improving ordering efficiency, reimbursements, and patient safety.
These benefits are especially prevalent when CPOE systems are combined with other digitized healthcare systems like EHRs and CDSSs.
While CPOE systems are far from perfect in averting all potential problems, the more CPOE is vulnerability tested and utilized in real-world applications, the better engineers can improve it to fulfill its intended purpose. Meanwhile, the clear and proven advantages of CPOE systems already show them to be superior to archaic paper ordering.