Implementing, using computerized physician order entry

Computerized physician order entry -- sometimes called computerized provider order entry or computerized prescriber order entry and abbreviated CPOE -- is the part of a health care information system that lets physicians and other health care professionals write drug prescriptions, order tests and provide other instructions electronically rather than on paper. The orders are then transmitted electronically to the lab, radiology center, pharmacy or wherever else they are to be fulfilled. Newer models of CPOE systems sometimes include clinical decision support technology, which provides information on drug allergies, drug interaction and dosage.

Who is required to use a computerized physician order entry system?

Using CPOE is one core criterion for meaningful use as spelled out in the HITECH Act. Part of the American Recovery and Reinvestment Act, the HITECH Act gives hospitals and eligible providers who meet meaningful use criteria a series of incentive payments via Medicare and Medicaid programs.

In meaningful use stage 1, which providers have until the end of 2013 to meet, a CPOE system must be used for at least 30% of all orders. The figure rises to 60% of all orders in meaningful use stage 2 and 80% in meaningful use stage 3.

What are the main benefits, and drawbacks, to using a CPOE system?

Proponents of computerized physician order entry maintain that it can lead to fewer medical errors, reduce red tape that physicians have to deal with, speed patient care and treatment, and save hospitals money. According to a 2009 study by the Massachusetts Technology Collaborative and the New England Healthcare Institute, a CPOE system could save a hospital as much as $2.7 million annually.

However, there have been well-documented unintended consequences of CPOE, and the financial incentives under meaningful use have led some providers to rush implementations, according to the Health Information and Management Systems Society (HIMSS) CPOE working group wiki. The result is "inconsistency across units," since the use of computerized physician order entry is often forced upon physicians and clinical personnel by upper management.

What is the cost of implementing CPOE, and why hasn’t technology been adopted more quickly on a wide scale?

By mid-2011, just one in six U.S. hospital employees was using CPOE technology. Replacing a paper-based order-writing system with computerized physician order enter -- much like replacing any age-old system with a new one -- can cause disruptions to the existing environment, and users tend to be resistant to disruptions in their routine. Implementation can be complex and time-consuming, sometimes requiring many changes in workflow and complicated integration with existing systems and processes.

The cost of deploying and maintaining a CPOE system, including training personnel, has also been a deterrent for many providers. According to the Massachusetts Technology Collaborative and New England Healthcare Institute study, CPOE costs hospitals $2.1 million in the initial implementation outlay and $435,000 a year for maintenance.

Another impediment is that, for the most part, CPOE systems were originally designed for hospitals rather than physicians. They were typically tightly linked to hospital information systems and did not include effective clinical decision support, such as information on alternative drugs, dosages and interaction among drugs.

Despite these hurdles, both the pace and depth of CPOE adoption have increased. Prior to the HITECH Act, about 87 hospitals per year implemented a CPOE system, according to KLAS Research. Since then, the number has risen to 233 hospitals per year.

What factors should be considered in planning a CPOE implementation?

A substantial volume of research has grown around the implementation of computerized physician order entry systems. The Physician Order Entry Team at Oregon Health & Science University is one such example.

The researchers at OHSU, funded by the National Institutes of Health, found that a successful implementation depends on a complex interaction among technical, organizational and contextual factors. Organizational factors include vision, strategy, commitment from top leadership, resources (including infrastructure and staff), an environment of trust, a culture of learning, a solid financial plan and dedicated funding.

Technical factors at the strategic level, meanwhile, include security, customization, access, data assurance and interoperability. Organizations also need to think about the technical aspects of the system from the user perspective. How intuitive, efficient and time-consuming is the user interface? Do clinicians view the system as clerical work and resist it as such?

By all accounts, change management is key to a successful implementation. As the CPOE working group at HIMSS put it: "CPOE projects are more about organization-wide change than IT implementation." Addressing these changes means answering two key questions:

• Does the new system operate fast enough for clinicians and what effect does it have on communication?
• What impact does it have on workflow, and did clinicians understand how it would change their jobs?
• The integration must be planned carefully, and users must be ready for it.

OHSU researchers recently examined a link between CPOE and clinical decision support and found that many of the factors leading to successful CPOE implementation are related to the CDS component of the systems. When CPOE is used in conjunction with CDS, both costs and errors can be reduced. These findings are consistent with a recent study of CPOE use at Brigham and Women's Hospital in Boston, where it was found that computerized physician order entry was most likely to be used by personnel already using an electronic health record or other clinical application. 

Should a CPOE system be rolled out incrementally or all at once?

HIMSS points out that most organizations to date have gone with an incremental rollout, initially leaving out some units that have different workflows. The incremental approach can be done by location or by specialty. The latter can be less complicated, since it deals with a limited number of order sets at a time.

While an incremental approach may be easier, an all-at-once approach has the advantages of highlighting to end users the importance of the new technology, eliminating the need for dual processes and making a clean break from paper-based order entry. 

What are the main steps of a CPOE implementation?

Implementing computerized physician order enter is, by all accounts, no easy task. Some organizations have taken years to get through it. HIMSS breaks implementation into six stages -- initiating, planning, executing, monitoring and controlling, transitioning to operations and optimization and maintenance.

The HIMSS CPOE wiki provides tips for each stage of implementation. For example, executing a CPOE system -- that is, designing, building and preparing for it to go live -- involves a dozen steps that cover software installation, training, governance, support and more. HIMSS also sets out 22 building blocks that it deems fundamental to implementation.

Caron Carlson has been covering IT and telecommunications for more than 15 years, writing for a variety of business and trade publications. Her resume includes stints as a senior editor at eWeek and the Washington Bureau Chief for WirelessWeek. Let us know what you think about the story; email [email protected] or contact @SearchHealthIT on Twitter.