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Computerized Physician Order Entry:
Eight Steps to Optimize Physician Workflow
Floyd Eisenberg, MD, MPH, and Alan S. Barbell
What Is Computerized Physician
Order Entry?
The Institute of Medicine’s (IOM)
report on errors in the healthcare
delivery system, To Err is Human,
was first published in 1999.1 The second IOM report, Crossing the Quality
Chasm, published in 2001, provided
strategic direction to recreate the U.S.
healthcare delivery system to make it
safe, effective, patient-centered, timely, efficient, and equitable.2 Close on
the heels of To Err is Human, additional market forces arose to drive the
development of effective solutions.
Most notable of these are requirements from the Leapfrog Group
(http://www.leapfroggroup.org/) and
the Institute for Safe Medication
Practices (http://www.ismp.org/),
which have set clear accountability on
the healthcare delivery system to
deliver safer, more effective care.
One major strategy to improve safety
and reduce adverse medication errors
is computerized physician order entry
(CPOE). CPOE can be defined as a
complex process through which the
physician enters patient care orders
directly into a computerized healthcare information system. To achieve
the expectation of reducing adverse
drug events (ADEs), the clinical system must perform interactive clinical
decision support functions, warning
physicians of potential interactions,
dosing irregularities, and inconsistencies with patient factors (e.g., allergies, pregnancy, etc.). Clearly, healthcare purchasers will seek proof of
the efficacy of CPOE to enable ADE
prevention. Working with First
Consulting Group, the Leapfrog
Group is currently evaluating patient
safety testing criteria to provide a
nationally standardized scoring system
of computerized physician order
entry implementations.3
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CPOE — Will Physicians Leap to
the Task?
Standard testing criteria for CPOE is
essential from the perspective of
health system accountability.
However, true success in utilization
by physicians requires careful attention to the individual physician’s
workflow. CPOE is not just a software
application, nor is it even a set of
applications. Rather, it is a process —
a set of tools, which, properly implemented, can enable the desired outcome — safe, efficient, and effective
patient care. Successful implementations of computerized physician order
entry systems are few for many reasons, not the least of which is physician acceptance of a process otherwise viewed as clerical. Focusing on
basic information technology infrastructure and addressing clinical decision support capability are the essential first steps to achieve patient and
healthcare purchaser expectations for
safety. Successful management of the
physician workflow, however, is
equally important.
What Makes Computerized
Physician Order Entry Systems
Successful?
Clinical utilization must be addressed
from the perspective of the physician
user to achieve value from implementation of the system. Some process
reengineering may be required to successfully automate components of the
workflow previously managed by
manual checks and balances with
variable success. The complete physician order entry workflow includes
eight essential steps, described
below in terms that parallel the physician’s actions.
1. Access to System
2. Select a Patient
3. Review Data
4. Enter Data
5. Sign/Confirm Order
6. Order Is Processed
7. Receive Results/Take Action
8. Outcomes and Accountability
Are Measured
Figure 3. CPOE – Eight-Step Physician Workflow
1
Access to System
2
Select a Patient
3
➤
Review Data
4
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Enter Data
5
Sign/Confirm Order
6
Order Is Processed
7
Receive Results/Take Action
8
Outcomes and Accountability Are Measured
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1. Access the System
Access includes system availability
(up time), network connections,
speed of sign-on (including security
checking), availability of a sufficient
number and types of appropriate
devices, and connectivity to downstream departments and individuals.
2. Select a Patient
The ability of individual physicians to
access patient information.
Components include:
• Patient registration
• Patient census — individual
provider and group(s)
• Cross-patient worklists (to view
all alerts, new results, etc.)
3. Review Patient Data — User
Interface and Data Components
These functions include individual
patient summaries and integrated,
knowledge-based access to appropriate information when needed (i.e.,
enhanced clinical workflow). The user
interface must provide a simple flow
of information to the physician, based
on physician expectations and
patient-centric needs, with minimal
requirement for searching. Data components must meet a critical mass
such that most, if not all, data elements required for patient care are
accessible in one location to enhance
workflow efficiency. This component
of the workflow is complex due to
multiple types of data required for
appropriate clinical decision making
(structured, unstructured, images,
waveforms, video, etc.). Interactive
decision support capabilities are
required to enable efficient and safe
clinical care decisions during the
action step of ordering.
4. Enter Data
This function enables direct entry of
orders into the system. Included in
the order entry process are specific
structured data entries (specifically
allergies, weight, and other data,
depending on order type) required
for clinical checking and alerts. This
function can be optimized to drive
appropriate coding for the billing
process as well. Such data entry is a
subcomponent of a full clinical docu-
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mentation strategy. Order entry can
be departmental or multi-departmental (common orders) and can occur
by order sets common to the
provider’s specialty, the patient’s diagnosis, or the patient’s problem(s).
a. Order sets require analysis by clinical teams within each institution.
Order sets can reduce variability
(under- and over-utilization) and can
promote best practices to meet center
of excellence criteria.
b. Consequent orders (orders
required because of a preceding
order, often specific to individual clinical services and/or the institution)
should be identified.
c. Clinical decision support is also
required as an integral component of
the order function. Such decision
support includes several levels of
checking or alerts including, but not
limited to:
• Duplicate studies, procedures,
medications
• Conflict checking
• Tests/procedures
(e.g., radiology or laboratory procedures that must be performed
in specific order)
• Medication interaction checking
• Medication/allergy checking
• Medication minimum/maximum
dosage checking (minimum or
maximum allowable dose based
on age, weight, height)
• Cost-related checking, which can
be optimized to drive appropriate
coding for the billing process
• The most cost-effective
studies/medications offered to
the physician first
• Alerts provided for choices no
longer clinically necessary or for
those choices that may have less
costly alternatives
• Appropriate medication dosage
calculation based on patient-specific data (e.g., height, weight,
age, renal function)
• Appropriate medication and
study recommendations based on
patient requirements and
diagnosis (may accomplish with
order sets)
• Appropriate management of
high-risk procedures based on
accepted national or hospital-spe-
cific patient care protocols (e.g.,
ventilator management, diabetic
care, etc.)
5. Sign/Confirm Order
The final review of the orders placed
in the session provides for electronic
signature and appropriate routing for
countersignature. Appropriate checking that the physician is credentialed
in the institution and is privileged to
order the specific treatment or
service requested.
6. Order Is Processed
Important to note is that this is the
first of the eight-step process that is
passive; it is not an action step from
the perspective of the physician’s
workflow. Order processing is, however, one of the more complex components of the CPOE process.
Accurate and efficient processing is
essential to managing efficient quality
outcomes:
a. Processing orders implies notification based on priority (acuity of the
order) as well as to whom, how, and
where notification should occur.
b. Following notification, confirmation
to and from the receiving department
is required with respect to the appropriateness of the order.
c. Additions or changes to the order
are communicated in a loop-back
process, which may be partially or
completely automated.
d. The service ordered must be timed
and/or scheduled.
e. Dispensing and/or availability of
floor stock must be managed.
f. Performance of the treatment or
service must be completed and the
result recorded. For medication
administration, this step includes completion of the medication administration record (MAR) with indication,
where appropriate, of related patient
factors and response(s).
Documentation may be structured
(e.g., laboratory result, vital signs,
specific coded result components),
unstructured (free text), or mixed
(structured with unstructured
sub-sections).
g. The outcome/result must be communicated to the appropriate clinicians (physicians, nurses, etc.).
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h. Charges are captured as a byproduct of the ordering process.
7. Receive Results and Take Action
Patient monitoring and event monitoring, which notifies the appropriate
clinician in the appropriate manner.
Such notification may occur by various methods, depending on the acuity of the notification requirement
(i.e., severity of the result) and the
preferences of the clinician receiving
the information. The workflow may
then loop back to steps 3 (review
information), or 4 (enter information/order) as clinically appropriate.
In addition, this function can be optimized to drive appropriate coding for
the billing process.
8. Outcomes and Accountability
Are Measured
Similar to item 6, this process step is
passive from the perspective of the
physician. However, systematic collection of information is essential to
assist with the institutional analysis of
efficiency, efficacy, and safety.
Process measurements are also
required to monitor utilization of
CPOE components.
While ADE prevention is the goal,
careful measurement of ADEs is a
complex process. Literature studies
have included complex processes for
case identification, verification, and
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interrater reliability.4,5 Establishing
standard high-level “dashboard” indicators as an inherent system component based on operational processes,
organizations should improve performance by:
• Identifying alerts that trigger
inappropriately, interfering with
physician workflow
• Optimizing the timing and messaging provided by specific alerts
• Providing blinded peer comparison performance data to continuously improve health system performance
Benefits are most commonly achieved
through process measures (items 1
and 2):
1. Operational processes (e.g., system
utilization and compliance with individual interventional decision support
alerts and reminders)
2. Clinical processes (e.g., rates of
organizational and individual compliance with standardized care recommendations as provided in order sets,
rates of avoided or potential ADEs
based on compliance with
interactive alerts)
3. Clinical outcomes (e.g., improvement in patient functional performance and resolution of clinical disease processes — these outcomes are
often the least standardized and the
most complex to measure in the
healthcare industry)
In short, CPOE is a complex
process; it is much more than a standard software application used to
reduce medication errors. To effectively reduce ADEs, physicians must
be willing to use the system and to
receive individual benefits from that
use. Such benefits can be achieved
only through careful attention to the
physician’s workflow. Addressing that
workflow cannot be isolated to a single clinician category. Appropriate
management of orders and error prevention can occur only if the process
includes a team effort with coordination of nurses, other clinicians, and
ancillary departments to meet administrative goals. CPOE, therefore, is not
an isolated process; it requires attention to the components of the electronic patient record (EPR) as well as
the interactions clinicians have with
that record. Workflow, from the perspective of the physician, other clinicians, the facility, and most of all, the
patient, is key to success.
About the Authors
Floyd Eisenberg, MD, MPH, is a
physician consultant with Siemens in
Malvern, Pennsylvania.
Alan S. Barbell is product marketing
administrator with Siemens in
Malvern, Pennsylvania.
References
Committee on Quality of Health Care in America, Institute of Medicine.
To Err is Human: Building a Safer Health System. Washington, DC:
National Academy Press, 1999.
1
Bates, D. W., Leape, L. L., Cullen, D. J., Laird, N., Petersen, L. A., Teich,
J. M., Burdick, E., Hickey, M., Kleefield, S., Shea, B., Vander Vliet,
M., and Seger, D. L. “Effect of Computerized Physician Order Entry
and a Team Intervention on Prevention of Serious Medication
Errors,” Journal of the American Medical Association, 1998, 280,
1311-1316.
4
Committee on Quality of Health Care in America, Institute of Medicine.
Crossing the Quality Chasm: A New Health System for the 21st
Century. Washington, DC: National Academy Press, 2001.
2
Raschke, R. A., Gollihare, B., Wunderlich, T. A., Guidry, J. R.,
Leibowitz, A. I., Peirce, J. C., Lemelson, L., Heisler, M. A., and
Susong, C. “A Computer Alert System to Prevent Injury from
Adverse Drug Events,” Journal of the American Medical
Association, 1998, 280, 1317-1320.
5
Delbanco, S., and Classen, D. First Consulting Group and the Business
Roundtable’s Leapfrog Group to Develop Testing Methodology for
Computer-Based Physician Order Entry (CPOE) Systems,
http://www.fcg.com/webfiles/NewsRelease/20010419b.asp,
April 19, 2001.
3
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