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Columns C L I N I C A L I N F O R M A T I C S 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 16 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 Journal of Healthcare Information Management — Vol. 16, No. 1 Enter Data 5 Sign/Confirm Order 6 Order Is Processed 7 Receive Results/Take Action 8 Outcomes and Accountability Are Measured Columns C L I N I C A L 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- I N F O R M A T I C S 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.). Journal of Healthcare Information Management — Vol. 16, No. 1 17 Columns C L I N I C A L 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 I N F O R M A T I C S 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 18 Journal of Healthcare Information Management — Vol. 16, No. 1