What is computerized physician order entry (CPOE)?

Who uses a CPOE?

CPOE systems are mostly used by healthcare providers in inpatient and ambulatory settings. The providers may be large, medium or small hospitals or clinics. With CPOE, authorized and licensed healthcare personnel -- such as physicians, physician assistants, nurses, medical assistants and pharmacists -- can electronically enter all of the following types of orders into a computer application:

• Medication orders
• Laboratory testing orders
• Other procedure orders
• Admission orders
• Radiology orders
• Referrals

Other authorized personnel can then access these orders and take appropriate action. The overall goal is always to maximize patient safety and optimize patient outcomes by minimizing errors. Adopting computerized prescribing over hand-written prescribing (HWP) in clinical settings also improves communication between various care team members, which can positively affect both the quality and cost of care.

CPOEs are also useful in intensive care units (ICUs). In comparison to HWP, a CPOE system can reduce the number of medication errors in ICUs, such as the omission of drug dose, units or frequency, dose errors, incorrect drug prescriptions or a failure to prescribe the required drug to a particular patient. By minimizing such errors, CPOEs can contribute to reducing a patient's length of stay in the ICU and reduce the potential for irreversible patient harm and even death.

CPOE systems are also useful in settings that use continuous drug infusions with critically ill patients. By standardizing drug concentrations and streamlining the process of ordering, compounding and administering continuous infusions, CPOE can reduce errors related to all steps of this process. Furthermore, CPOE orders include dose-rate tables that enable nurses to spend less time checking the infusions and make fewer dosage errors.

CPOE benefits

Using CPOEs in lieu of traditional paper charts has several benefits for both clinicians and patients.

CPOE can enhance patient safety by improving order standardization, legibility and accuracy. In doing so, CPOE can reduce -- and, in many cases, even eliminate -- medication errors that can jeopardize patients' health and lives.

By enabling healthcare providers to quickly transmit orders electronically, CPOE can improve efficiency when users submit medication, lab and radiology orders. Standardized electronic orders are easier to read and act on, allowing clinical services like pharmacies and pathology labs to complete orders faster and better coordinate their care efforts.

When integrated with a clinical decision support system (CDSS) and EHR systems, CPOE supports healthcare practitioners by providing real-time information related to diagnoses and treatments. Such integrations also enable healthcare organizations to accomplish key goals:

• Improved medication safety.
• More efficient decision-making workflows.
• Lower cost of care.
• Better compliance with applicable regulations and guidelines.

CDSS/CPOE integration also helps to optimize patient safety and quality of care. Several important functions are built into CPOEs, such as safeguards to check for drug interactions and potential adverse drug events. CDSS tools can also check for medication allergies and contraindications, and users can add custom rules to validate that a medication order aligns with weight-based dosing guidelines. These functionalities enable care providers to avoid making costly mistakes that may adversely affect the patient's health and safety.

CPOE systems can also streamline reimbursements for healthcare organizations and providers. The software can be integrated with practice management software to flag orders that may require preapproval from insurance plans, enabling organizations to reduce the potential for denied insurance claims.

CPOE drawbacks

CPOE benefits notwithstanding, its implementation can also introduce some issues into healthcare settings.

A new system can create additional documentation work for medical personnel, contributing to clinician burnout. It also requires them to adopt modified workflows. Any modification to clinical workflows takes time to implement safely, and there is increased risk of delays and errors during the transition period. A new system always has a learning curve for users, but healthcare's stakes are especially high. Organizations can minimize these risks with robust training programs, phased implementation and a mechanism for soliciting and incorporating user feedback and suggestions.

A CPOE with poorly designed workflows can cause delays and errors in clinical processes. Errors can manifest if clinicians enter incorrect information, such as inaccurate dosages, or unknowingly submit orders for the wrong patient.

One way to address these issues is to modify the user interface to minimize human error, such as by building order sets with radio buttons instead of checkboxes to prevent clinicians from accidentally selecting unwanted medications. Extensive decision-support rules can also play a significant role in catching user errors. Users may make mistakes without these safeguards, such as selecting duplicate or conflicting items. Such mistakes can be dangerous to patients and increase the organization's liability risk.

Ideally, CPOE should use standardized order sets for common processes like patient admissions so that personnel can avoid searching the entire order catalog each time. Otherwise, even simple processes can become unnecessarily tedious and time-consuming.

At the same time, too many rules and comprehensive order sets for all orders can drain users' time. One way to maintain a balance between too few and too many order sets is to allow clinicians to "favorite" predefined order sentences in the CPOE system and set appropriate defaults for each clinical setting (admissions, transfers, specific clinical pathways, etc.).

Alert fatigue is another common problem when using a CPOE. When users are exposed to too frequent alerts, they may become desensitized. They may then either ignore routine alert messages or accidentally click on prompts. Either action can result in unintended consequences or serious adverse advents like medication errors that endanger patients' lives and risk the organization's reputation.

To address this concern, some CPOE systems have created a "hard halt" safety feature that prevents further processing until a high-alert flag has been properly addressed and resolved. Other systems color-code alerts, with certain colors signifying alerts as serious or requiring a mandatory response.

Finally, two other common drawbacks are the time and money needed to install a CPOE system. The cost of CPOE implementation can be in the millions, and yearly maintenance can add hundreds of thousands of dollars. If converting from paper records, an organization must also consider the time and expense of digitizing historical data and capturing it in a new system. However, those costs may be recovered long-term through more efficient care delivery savings.

CPOE system features

Many EHR products now come equipped with CPOE modules that enable treating physicians to enter patient data electronically into text boxes and drop-down menus, rather than handwriting notes and orders. That said, CPOE systems are designed to mimic the simple workflows of paper charts and orders to make order entry easy for physicians and other users.

These systems are often used in tandem with e-prescribing systems, which alert physicians and clinicians to a particular patient's drug allergies and current medications.

A CPOE system offers a variety of features, including some or all of the following:

• Device support. Physicians and clinicians can enter orders into a workstation, laptop or secure mobile device.
• Patient-centered decision support. When integrated with CDSS and EHRs, clinicians can make better care decisions based on up-to-date patient information and a more complete medical history.
• Patient safety features. CPOE enables clinicians to identify patients in real time, review medication dosage recommendations and screen for potentially adverse drug-to-drug or drug-to-disease interactions. The software can also check for patient allergies and treatment conflicts.
• Drug-disease interaction module, clinical rule engine and alerting. The CPOE system sends automatic alerts if a clinician enters a drug that is contraindicated for a patient.
• Recommendations. Some CPOE systems provide recommendations to implement clinical practice guidelines and clinical care pathways. Clinicians can also embed toxicology information, local policies, and drug and disease monographs to enhance clinical decisions and patient safety.
• Standardized order sets. Built-in, standardized order sets for common processes facilitate smooth workflows and help users to save time. Order sets include appropriate headings, sub-headings, and options so even novice users can place effective, correct, legible orders within the system.
• Intuitive user interface. The order entry workflow is like traditional, paper-based order forms, enabling efficiency even among those new or infrequent users.
• Regulatory compliance and security. The system secures information to protect it from breaches. It also complies with various healthcare regulations to ensure that using organizations don't inadvertently fall into non-compliance.
• Single system for all departments. The CPOE system can accept and manage orders from all departments through various devices at the point of care.
• Reports. The system generates human-friendly, actionable reports that management or technology teams can analyze and evaluate to determine if staffing, productivity and inventory changes are needed.
• Billing support. Documentation is improved, referral and treatment preapprovals can be flagged, and orders can be linked to diagnoses at the time of order entry to ensure accurate and timely billing.

Texting of CPOE orders

Texting on secure message platforms is commonplace in many healthcare organizations. Over the years, the Centers for Medicare and Medicaid Services (CMS) has evolved its stance on texting patient orders and has become more accepting.

According to a 2017 CMS memo, healthcare providers were allowed to text patient information to each other, as long as a secure texting platform was used. However, the same memo prohibited clinicians from texting patient orders.

In 2024, CMS revised its position. In a memo dated Feb. 8, 2024, CMS stated that hospitals and critical access hospitals may text patient care information and orders if they use a HIPAA-compliant secure texting platform. Additionally, the organizations must take steps to minimize patient privacy and confidentiality risks and ensure that the information transmitted into the EHR is accurate, properly filed, retained and accessible only to authorized users.

CPOE adoption

CPOE adoption, which initially struggled because of user resistance, has become widespread, particularly as EHR systems have proliferated.

CPOE implementation was a major requirement for healthcare providers to provide their eligibility for stage 2 and stage 3 of CMS's Meaningful Use (MU) program. These objectives were first included in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program, now known as the Medicare Promoting Interoperability (PI) Program.

According to the provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act -- which created MU -- healthcare organizations that complied with MU stage 2 had to record more than 60% of medication orders, more than 30% of laboratory orders and more than 30% of radiology orders using a CPOE system. To comply with MU stage 3 in 2018 and beyond, providers had to record more than 60% of medication orders, more than 60% of laboratory orders and more than 60% of diagnostic imaging orders using a CPOE.

Best practices for successful CPOE implementation

Implementing CPOE can be a challenging and overwhelming endeavor for many healthcare organizations. These best practices can make the process go smoother:

Plan the implementation

Meticulous planning is essential to ensure that the organization chooses the right product, with the appropriate level of vendor support, and can minimize disruptions during the introduction of a new IT system (in this case, a CPOE system). A proper plan considers the required design elements and controls to safeguard sensitive data. It should also consider clinician workflows and take into account the needs of those who will be using the system.

Identify a CPOE champion

A CPOE champion or superuser is someone who will rally their peers and help promote the potential benefits of a new CPOE system. This person should be able to share their knowledge about the system with other users, thus bolstering employee confidence and enthusiasm.

The CPOE champion should also be able to conduct training prior to implementation, which can shorten the learning curve for all users and minimize workflow disruptions once the system is part of the live environment.

Involve clinical staff in decision-making

Organizations should involve clinical staff during CPOE selection and implementation. Actively seeking their input and feedback can help to minimize resistance to change and foster a culture of trust in the new system and workflows.

Conduct a pilot test

Before introducing the CPOE system to the entire community, organizations can conduct a pilot test with a smaller group of users. These users can test the tool, review its functionalities and suggest improvements or modifications. A successful pilot can also generate enthusiasm throughout the organization as staff discuss their experiences with peers.

Roll out the tool incrementally

A CPOE implementation should occur gradually by role group, department, unit or clinical setting (e.g., inpatient, outpatient and procedural areas). This approach enables implementation teams to observe the tool in a real-world environment with different user groups. They can also identify performance issues or software bugs early, solicit feedback and suggestions from early-implementation groups, and refine the tool to maximize its overall usefulness.

Support users with training and education

Training is essential to ensure that users know how to use the tool. The training program should cover the tool's workflows, functionalities and security features. Ideally, training should be available in different formats to meet different learning styles -- at-the-elbow training, live group workshops and self-guided modules and reference materials -- and tailored to different roles and specialties. Users should also have a mechanism to ask questions and provide feedback about the tool. Additionally, providing users with standardized PDF order sets, reminders and other resources can reduce barriers and encourage CPOE adoption.

Minimize the potential for alert fatigue

Alert fatigue can lead to poor decision-making, which can be harmful or even fatal in clinical settings. One way to reduce CPOE alert fatigue is to minimize clinically inconsequential alerts. Technology teams can do this by personalizing alerts to patients' clinical contexts and by clearly distinguishing between high- and low-severity alerts in the system.

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