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Quotes Of The Year - Paul Shetler - "Its not Your Health Record it's a Government Record Of Your Health Information"


H. L. Mencken - "For every complex problem there is an answer that is clear, simple, and wrong."

Tuesday, January 20, 2009

Computerised Physician Order Entry (CPOE) – Wrinkles, Trials and Tribulations

The following excellent lead article appeared in Health Date Management for January 2009.

CPOE: It Don't Come Easy

Howard J. Anderson, Executive Editor
Health Data Management, January 1, 2009

Focusing on the need to dramatically reduce medical errors, many patient safety advocates have urged hospitals to implement computerized physician order entry systems.

By shifting from paper-based or verbal orders to electronic ordering, advocates say, hospitals can eliminate errors caused by illegible handwriting or ambiguous voice messages. In addition, CPOE systems include decision support functions that steer physicians to making appropriate decisions based on medical evidence. And they provide alerts that warn physicians about orders for drugs or procedures that have the potential to harm their patients.

But so far, only about 8% of U.S. hospitals have implemented CPOE, the Leapfrog Group estimates. And a recent study by the Washington-based employer consortium found that hospitals that have adopted the technology are facing some serious challenges.

Some 100 hospitals recently used Leapfrog's CPOE Evaluation Tool, which offers scenarios for testing certain order entry functions. And the results were disappointing, says Leah Binder, Leapfrog's CEO.

For example, although the vast majority of drug allergies were caught by the systems, some were not. Also, some hospitals' CPOE systems failed to offer an alert that a drug should be taken with food. And a few hospitals' systems even failed to prevent a potentially fatal medication order in the simulation.

"It's extremely complicated to set up these systems properly," Binder says. "They have to be updated continually. There are always going to be bugs that hospitals need to address on an ongoing basis."

Hospitals face the challenge of customizing the off-the-shelf software to meet their specific needs, Binder adds. "These are not plug-and-play systems," she stresses.

Many experts also warn that hospitals must take extraordinary steps to avoid "alert fatigue" caused by vendors' systems that are pre-programmed to display so many alerts that physicians begin to ignore most of them. Moreover, successful deployment of CPOE requires time-consuming re-engineering of care processes, they stress.

The key to using CPOE to consistently prevent medical errors, Binder argues, is to continually test the technology and refine it. All 33 hospitals that were top scorers in the Leapfrog Group's annual quality survey used the CPOE evaluation tool to help them qualify for the recognition (see sidebar, page 22).

"Many institutions have no idea of how they are doing on providing decision support," says David Bates, M.D., chief of the general medicine division at Brigham and Women's Hospital, Boston. "The CPOE evaluation tool helps leadership to measure where they are with decision support."

Refining The Tool

Bates helped Leapfrog Group refine the tool, providing feedback that the initial version was far too difficult to use and did not focus on the most common orders that affect patient safety. By using the revamped tool, hospitals can more precisely target their efforts to refine decision support in their CPOE systems, the physician says.

"We have a long list of things that we want to add that we haven't gotten around to yet," he says. "The tool helped us refocus our efforts."

But another physician whose organization used the tool says the test focused far too heavily on the triggering of alerts and not enough on testing the logic embedded in decision support.

"We need to test the actual functioning of the order sets," says Charles Ross, M.D., chief medical information officer for Summa Health System, which owns six hospitals in Ohio. The key to a successful CPOE deployment, Ross stresses, is building logic into the order sets that, rather than triggering an alert, steers the doctor to the right decision.

For example, a well-designed CPOE system would prevent doctors from ordering certain drugs to treat pneumonia, rather than displaying various alerts about the inappropriate drugs that could be ignored.

"If you met all the requirements of the Leapfrog tool, it would lead to some over-alerting of physicians," contends Lori Idemeto, pharmacy informatics specialist at Virginia Mason Medical Center, Seattle.

She observed, however, that the tool helped the organization identify some areas for improvement. For example, the hospital tweaked its order sets to provide more guidance on single and cumulative drug dose limits.

Vastly more here:


A full layout version of the article is available here:


There is a great deal of good advice and understanding about how to get CPOE right from the ground up in this article and it is strongly recommended for careful reading – especially for those involved in planning such implementations in Australia. Taking notice of the lessons here can make the difference between success and failure (which with CPOE is a real risk!).


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