Computerized Physician Order Entry: a focus on medication prescription

Nicolette de Keizer & Saeid EslamiDept Medical InformaticsUniversity of Amsterdam

Outline

Definition and context Advantages of CPOE Disadvantages of CPOE Outcome measures and examples Same system other outcome

What is Computerized Physician Order Entry (CPOE)?

Ordering of tests, medications, and treatments for patient care using computers

Involves electronic communication of the orders

Often use rules-based methods for checking appropriateness of care

CPOE, EHR and DSS

EHR

Documentation

Medication

Test reports (EKG, PFT)Radiology, lab results

CPOE

DSS

CPOE

Has a positive influence on patients’ outcome

Has a negative influence on patients’ outcome

CPOE Advantages

Automate ordering process Reduces Order Errors

Standardized, legible complete orders

DSS/Alerts Data collected on variances in

practice

Case Example

Metformin is prescribed to a patient with an elevated creatinine level. A drug-lab interaction alert warns that

use of this medication could result in an increased risk of fatal lactic acidosis.

Case Example

A physician prescribes warfarin for a patient with chronic atrial fibrillation.

System: vitamin K rich food likely to interfere with

the efficacy of the drug. Specific patient information

Example DSS in CPOE – medication prescription

Allergy Age (check drug name and dose) Duplicate drugs on active orders,

not one-time Severe drug interactions

Drug-drug, drug-food Dose maximum Drugs with opposite actions

CPOE Disadvantages

Errors still possible Alerts Multiple steps Access

PubMed indexed papers on CPOE

0

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80

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120

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160

<2000 2000 2001 2002 2003 2004 2005 2006

no. of papers

CPOE

Has a positive influence on patients’ outcome

Has a negative influence on patients’ outcome

On which outcome measure?

Outcome measures

Adherence to guideline Alerts - user response Time Safety

Medication errors ADEs (mortality)

Cost and Efficiency Medication costs Pharmacists interventions

Satisfaction, usage and usability

Example CPOE improves adherence to guideline

Teich JM et al. Arch Intern Med. 2000 Oct 9;160(18):2713-4.

Example CPOE reduce errors

Potts studied ADE rates in 13,828 medication orders before/after CPOE implementation at Vanderbilt Children’s PICU:

Potts AL, Barr FE, et al. Pediatrics. 2004 Jan;113(1 Pt 1):59-63.

• Brigham and Womens' Hospital, Boston introduced a CPOE

• After implementation, the rate of intercepted Adverse Drug Events (ADE) doubled!

• Reason: The system allowed to easily order much too large dosages of potassium chloride without clear indicating that it be given in divided doses.

• Bates et al The impact of computerized physician order entry on medication error prevention. JAMIA 1999, 6(4), 313-21.

Example CPOE introduces errors

pre period1 period2 period3

Potential ADEs/1000 pt-days

15.8 31.3 59.4 0.5

Example CPOE introduces errors

Association with increased PICU mortality: 2.8% 14 months before CPOE 6.4% 5 months after CPOE

Han YY, Carcillo JA, et al. Pediatrics. 2005 Dec;116(6):1506-12.

Example CPOE reduce costs

Cost: $3.7 million

implementation $ 600,000 to $1.1

million operational costs

Results: Decreased drug costs ADE cost is

approximately $4,700

Brigham and Women’s Experience: Cost-Effective

Kausal R et al. J Am Med Inform Assoc. 2006; 13(3): 365-7

CPOE and cost

Huge variation in actual costs based on hospital size and complexity of system Hardware and Software: $1-$5 million Staff training Ongoing maintenance Total costs for large, fully integrated

systems could be up to $60 million Costs will decrease when DSS is

geared to cost reduction

Usability Problems

Potential selection errors Similar medication names Similar patient names Overly trust default values

Influence workflow and communication Physician resistance

Frequent data entry required Must not require additional time Most decision-support steps must be turned off

to encourage use “Not-invented-here” syndrome

• Health information systems has to deal with the actors, the artefacts, and their interaction.

CPOE as a Sociotechnical intervention

CPOE =socio-technical systems

Same system other outcome

Upperman vs. Han same hospital: Pittsburgh Childrens

Hospital other outcome measure: ADE vs mortality

Han vs. Del Beccaro Same CPOE Different hospitals Same outcome measure (mortality)

Upperman et al. J Pediar Surg. 2005;40:57–59; Han et al. Pediatrics. 2005 Dec;116(6):1506-12; Del Beccaro. Pediatrics 2006;118;290-295.

Upperman et alPre-CPOE Post-CPOE

Verbal order regulatory compliance

80% 95%*

All ADEs 0.3 0.37

Harmfull ADEs 0.05 0.03*

* p<0.05

Han et al

Pre-CPOE Post-CPOE

Mortality 2.80% 6.57%*

* p<0.05

Del Becarro et al

Pre-CPOE Post-CPOE

Mortality 4.22% 3.46%

Same results for:

• transported patients

• congenital cardiovascular disease patients

Upperman vs Han

Surrogate outcome measures such as medication errors and ADEs are not sufficient

More studies on mortality are necessary

Han vs. Del Beccaro

Methodological differences: Han used unbalanced before after

periods Del Beccaro did not correct for case

mix differences in before vs after period Populations Han vs. Del Beccaro were

not comparable

Han vs. Del Beccaro

Pittsburgh implemented too fast without pilot and usability testing: Order entry only allowed when patient

physically entered hospital All medication in central pharmacy Pharmacy processed order only after

complete activation by nurse Go live without necessary order sets

Han vs. Del Beccaro

Seattle hospital learned from Pittsburgh Factors influencing successful

implementation: response time and user time meeting information needs (e.g.using order

sets) multidimensional integration with workflow Involvement leaders, support staff, clinicians training improvement through evaluation and learning

Will a CPOE improve quality of care?

Yes if you implement it the right way!!

Successful CPOE implementation

Technical Infrastructure: EHR Drug information database DSS

Sociotechnical implementation strategy Usability pilots Teams of informaticians, physicians, nurses, clerks,

therapists Strong leader and good project management Training and support

R. Gardner: “implementation is 90% organizational and political and 10% technical”