Computerized Physician Order Entry

On July 20, 2006, the Institute of Medicine at the National Academy of Sciences published a report (Aspden, Wolcott, Bootman, & Cronenwett, 2006) recommending that by 2010 every health-care organization be equipped to receive prescriptions electronically. This decision was, in part, due to combining the results of statistical analyses of medication errors in hospitals, nursing homes, and outpatient clinics. This study estimated that more than 1.5 million patients were adversely affected by medication errors every year (Johnston et al., 2006). Medication errors take place at several stages of administering a drug, including the prescribing, ordering, dispensing, and administering phases of drug management (Sakowski et al., 2005). Recent research studies have suggested that the majority of medication errors occur between the ordering and dispensing phases of prescription drug order management (Patterson, Cook, & Render, 2002; Sakowski et al., 2005).Medical errors that lead to adverse events in the delivery of health care are most commonly attributed to medication. These medical errors are commonly referred to as adverse drug events, or ADEs (Morimoto, Ghandi, Seger, Hsieh, & Bates, 2004). In 1997 medical errors killed between 44,000 and 98,000 people in the United States, which was greater than the 43,458 killed in automobile accidents, 42,297 killed by breast cancer, or the 16,516 killed by AIDS in that same year (Kohn, Corrigan, & Donaldson, 1999). Among all medical errors, ADEs are the leading cause of death (Sakowski et al., 2005). ADEs can be traced back to errors at every stage of the prescription drug management process (Morimoto et al., 2004), but approximately 62% of these errors occur during the ordering and dispensing phases of prescription drug management (Sakowski et al., 2005).Medication errors continue to adversely affect patient safety in health care (Johnston et al., 2006). Pharmacy is one area of medication management where reducing the risk of errors can increase the quality of patient care. Eliminating medication errors that lead to ADEs is especially critical in nursing homes, where the average patient is taking between five and nine medications, and 20% of the population is using more than 10 medications (Lau, Kasper, Potter, & Lyles, 2004). Since more medication is administered to nursing home residents, and they tend to be more sensitive to drugs, the frequency of ADEs in nursing homes is higher than in other health care settings (Lau et al., 2004;Rochon et al., 2005). In the elderly nursing home population, ADEs are more likely to be fatal (Schmader et al., 2004).Computerized physician order entry (CPOE) is a technology tool for which research has suggested a positive correlation with reduced medication errors (Rochon, 2005; Shulman, Singer, Goldstone, & Bellingan, 2005). CPOE is defined as “an electronic application that allows physicians to directly enter orders for drug therapy, diagnostic tests, and requests for consultations” (Rochon, 2005, p. 1780).The benefit of computerized physician order in the effort to reduce medication errors is well established by extensive research. Baldouf-Sobez et al., 2003; performed a pretest/posttest study of adverse drug events at Danville Regional Medical Center in Virginia. By performing a metaanalysis of the cost of adverse drug events the researchers determined that the average cost of adverse drug events is $3,474. Danville Regional Medical Center was able to avoid 10 to 12 adverse drug events each day which, based on the calculated average cost, worked out to an annual savings of $840,809 during the year ending December 31, 2002. In addition, the time saved worked out to a reduction equivalent to 0.5 full-time equivalent (FTE).Shulman, Singer, Goldstone, and Bellingan (2005) performed a time-based pretreatment/posttreatment study that compared hand-written prescription orders with CPOE. In their study, they implemented a CPOE system in a 22-bed intensive care unit at a London teaching hospital. By comparing the incidence of medication errors prior to CPOE, as well as 2, 10, 25, and 37 weeks after implementing CPOE, they found that in this study the number of errors were reduced at the introduction of CPOE, and further reduced over time. The study was designed to measure incidence of errors, but not the type of error. It is, therefore, worth noting that three errors that could have led to permanent harm or death occurred in the CPOE environment, so the study makes no claims as to the types of errors that could be eliminated.Rochon et al. (2005) performed an observational study of CPOE in the nursing home setting. This study was significant because prior to this study, research on implementing this type of technology in nursing homes was rare. The CPOE system implemented in this particular facility also included a clinical decision support system (CDSS), which is a series of “reminders, prompts, and advice regarding issues such as drug selection, doses, interactions, drug allergies, and the need for corollary orders” (p. 1780). This study of a geriatric care hospital with 300-bed chronic care hospital, 472-bed nursing home, and 200-bed residential unit in Toronto, Ontario, produced several insights to the successful implementation of CPOE systems in nursing homes. For example, the motivating force behind implementing CPOE with CDSS should be enhanced patient safety. Also, the prescribing issues that are unique to nursing homes require customizations in software design that accounts for the ways that geriatric treatment differs from standard treatment, as well as accommodates the unique regulatory environment. Furthermore, adding CDSS to a CPOE system is a critical part of eliminating known causes of ADEs in elderly patients. The result of their observation was a recommendation of formal study of the possible correlation between CPOE and reduced ADE risk in nursing homes.Conversely, Koppel et al. (2005) identified 22 factors where using CPOE versus a paper-based order entry system could possibly generate more errors. Koppel et al. criticized the current body of research on using CPOE to reduce ADEs for a number of reasons. These reasons included its quantitative focus on studying the reduction of potential ADEs versus reducing actual ADEs, as well as a qualitative focus on physician satisfaction with the ease of using CPOE versus studying its actual efficacy. Koppel et al. went on to cite how very few studies identify the features within CPOE that increase the risk of error, including “ignored false alarms, computer crashes, and orders in the wrong medical records” (p. 1198), which they believed belied the inherent risks associated with the human factors associated with implementing CPOE.The Koppel et al. study was a mixed qualitative and quantitative study of a 750bed tertiary-care hospital that used CPOE extensively between 1997 and 2004. The qualitative portion of the study consisted of structured interviews with hospital staff that were involved with the use of the CPOE system (i.e., physicians, nurses, nurse-managers, pharmacists, IT managers, and house staff), as well as shadowing and observation. The quantitative portion of the study consisted of a written questionnaire administered to house staff. Their study revealed 22 potential sources of medication errors that could be categorized as either information errors due to fragmented data, or human-machine interface flaws that increased the potential for human error. Several of these flaws were identified as common or frequent in the operation of the research setting. Koppel et al. identified five courses of action that needed to be followed in implementing CPOE that would reduce this risk: design the technology around the work processes; continually reevaluate the technology in the clinical context; be aggressive about addressing technology problems; understand not only the errors, but the stories behind the errors; and plan for “continuous revisions and quality improvement” (2005, p. 1202).The prevalence of ordering errors, as evidenced by the work of researchers such as Gurwitz et al. (2005), as well as Lau, Kasper, Potter, and Lyles (2004) suggests that a significant risk of errors lies in the ordering phase of the prescription care process. While Koppel et al. (2005) suggested that computerized order entry has risks that could cause problems, the system that was studied was an antiquated client server system that did not have the userfriendly characteristics of a more modern design that includes an Internet browser as human-machine interface in a Microsoft Windows environment. With the heavy advantages shown in the use of CPOE, both with and without clinical decision support (Baldouf-Sobez et al., 2003;Rochon et al., 2005; Shulman et al., 2005), the future of CPOE will only improve as the graphical user interfaces and implementation processes continue to improve to address Koppel’s concerns.Now that it has been established that CPOE is a beneficial telemedicine application in the quest to eliminate medication errors, our discussion must turn to how a system such as this is deployed. The deployment process for CPOE requires a clinical review phase, a technology implementation phase, a validation phase, a training phase, a go live phase, and a closeout phase. The remainder of this article will focus on these phases and what each might entail, based on the author spending a year in the field deploying these types of systems.In the clinical review phase, the project manager and a clinical subject matter expert will meet with the pharmacy and with the facility to discuss the clinical practices that will determine how the user interface and the data will be structured. This discussion will seek to clarify nomenclature, hours of administration, Signature codes (which tie particular administration instructions to hours of administration), and any other policies and procedures that might be relevant to the implementation. It is critically important that during this phase the proper communication channels are established and that the project manager ensures that the project team, pharmacy, and nursing home are all using the same lexicon. Inconsistencies of any kind among these three groups will lead to time-consuming rework and sometimes might completely undermine the success of the project. It is for this reason that the subject-matter expert should be a clinician (registered nurse, licensed practical nurse, or registered pharmacist) experienced in long-term care. This clinician will help to establish the project team’s credibility and to help the team to foresee any pitfalls that might otherwise go undetected by the untrained eye.During the technology implementation phase, the subject matter expert will typically be different from the subject matter expert of the clinical review phase. This person should be more of a technician than a clinician. This phase requires the project team to ensure that the proper infrastructure is in place for a successful deployment of CPOE. This means ensuring that the proper Internet access is in place, as well as computers that meet the minimum requirements for the application. Nursing homes and institutional pharmacies will have varying levels of sophistication in this area, so you must be prepared to lead the way in cases of facilities with lower levels of tech savvy. The important point will be to coordinate this phase with the clinical review phase to ensure that the infrastructure that is put in place is compatible with the clinical operations of the facility.The validation phase is probably the most critical phase of the entire project. During this phase, legacy information is converted from existing medical records to an electronic medical record that includes information on the patient and the patient’s medications. The time attached to this process will vary depending on whether the legacy data is in hard copy or electronic form. If the legacy data are in electronic form, the likelihood is high that a process can be created to automate the transfer of data from the legacy system to the database for the CPOE system. On the other hand, if the legacy data are in hard copy, a significant amount of time will be dedicated to manual data entry. This poses two problems. First, manual data entry is extremely time consuming and therefore expensive. The project manager must work with both the nursing home and the pharmacy to establish what resources each is willing to contribute to this effort. Setting clear expectations here is a must, as failure to do so could result in disputes and delays. Second, once the data are transferred, the likelihood of human error creeping into the validation process is much higher.When the data have been translated, they must then be validated. This step must be made the responsibility of the nursing home, which is ultimately responsible for the patient’s well-being on a daily basis. Whether resources from the project team, pharmacy, or the nursing home completed the data entry, the nursing staff is responsible for the accuracy of the resultant electronic medical record in comparison to the patient’s medical chart. The project manager must take the lead in working with the facility’s administrator and director of nursing to make this clear. They must then work together to identify the resources required to complete this final validation step in compliance with the agreed schedule for completion.Proper deployment of a CPOE System also requires a well-designed and wellmanaged program for training. The choice that project managers must make as relates to training is whether the training will be delivered in a traditional classroom or whether distance tools will be used. The tradeoffs between the two are essentially dependent on an analysis of the needs and capabilities of the pharmacy and nursing home personnel and then the availability of the technology. The project team should enlist the expertise of a person trained in instructional technology and distance education to make this sort of determination. Diagnosis of the needs and capability of the trainees can be complex, so an individual trained in systematic analysis of goals, learners, and learning context is critical during this stage (Dick, Carey, & Carey, 2004). The writer recommends the Dick and Carey model for this process, as it is a proven model for designing and developing instruction whether distance tools or other means will be used.Figure 1 is a sample flow chart of the major steps associated with creating and maintaining patient records for a CPOE system. This set of major steps is based on an analysis of the goals for the instruction based on the tasks that learners will need to master during the course (Dick et al., 2004). Each of these steps will be further broken down into chunks that will result in the creation of individual learning objects for the task.Breaking these major steps down into subsets comes during the development of the instructional analysis, a much larger diagram that is used as a point of reference to design and develop individual learning experiences.Tables 1 and 2 are examples of the analysis of the learner and learner context within a sample nursing home. Understanding the learners and their workplace context will be critical in determining what type of instruction will be appropriate for the sites where the deployment will take place. The table shows that collecting data on learners can come from observation, interviews, and surveys (Dick et al., 2004). The goal in these steps is to determine the implications of the characteristics of the learners and their workplace context, so that the most appropriate instructional delivery method and content can be developed.Much of this information will be quite similar among pharmacies and nursing homes, so as a time-saving measure the writer recommends judiciously reusing as much of the information as possible. The appropriateness of classroom versus online instruction will come out in the differences between locations in terms of readiness of the staff for self-paced versus instructorpaced learning. Eventually, as a project team, a set of standard training materials for both online and classroom training will be the result. The team will then need to adapt the learning materials for each individual deployment. The training phase is time consuming and must be well-planned and then well-executed. Constant contact with the leadership at the pharmacy and at the nursing home is required to ensure that this phase is successful and timely in order to ensure that the system goes live on time.The moment of truth in any deployment of CPOE is the day that the system goes live. This process is probably the most labor-intensive portion of the deployment because the project team spends a lot of time on-site in a high-touch mentoring role with the end-users. The key to success of this phase is the ensure that the facility has a set of “CPOE Champions” on-site who are designated by the site leadership and made available to the project team to ensure that the support provided by the project team can be translated into ongoing support within the organization that continues after the project team has exited the site.If all of these processes go well, the team will be ready to exit the site. The facility will then need to be prepared to operate self-sufficiently with 24-hour technical support provided by the software company, usually via telephone and/or e-mail. The most successful deployments are completed without the need for any return visits by the project team, thus allowing the pharmacy and the facility to work together to communicate and deliver the right medications for the right patient, at the right time, in the right dosage, and using the right route. This set of “rights” is known in the clinical community as the “five rights” and conformance to these five rights determines whether or not a medication error has occurred. Based on the research presented above, if the CPOE deployment goes well, violation of any of these five rights can be significantly reduced.Based on input from the Institute of Medicine, technologies like computerized physician order entry systems are key to the future of improving patient safety. This is especially true in the case of elderly patients who make up a majority of the population of our nation’s nursing homes. Since research supports the assertion that CPOE reduces medication errors, it is wise for nursing homes to partner with their institutional pharmacy partners to ensure that these technologies are implemented as soon as possible. Many institutional pharmacy organizations are developing their own CPOE technologies or partnering with software development companies to make these technologies available to nursing homes at a reasonable cost.It is in the best interest of everyone in our society, due to the direct and indirect cost of medication errors and adverse drug events, to ensure that these technologies are deployed quickly and effectively. In order to make this happen, project teams must be assembled and trained to integrate clinical, technological, and instructional design capabilities to ensure the most effective and efficient use of resources during deployment. This means proper planning of every step from clinical review to go live and mentoring to ensure that the technology and the expertise is resident in both pharmacy and nursing home to meet the five rights of medication administration and to eliminate medication errors.

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