Computerized Physician Order Entry: a focus on medication prescription

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Computerized Physician Order Entry a focus on
medication prescription

• Nicolette de Keizer Saeid Eslami
• Dept Medical Informatics
• University of Amsterdam

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Outline

• Definition and context
• Advantages of CPOE
• Disadvantages of CPOE
• Outcome measures and examples
• Same system other outcome

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What is Computerized Physician Order Entry (CPOE)?

• Ordering of tests, medications, and treatments
  for patient care using computers
• Involves electronic communication of the orders
• Often use rules-based methods for checking
  appropriateness of care

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CPOE, EHR and DSS
Documentation
DSS
Medication
EHR
Test reports (EKG, PFT)
Radiology, lab results
CPOE
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CPOE

• Has a positive influence on patients outcome
• Has a negative influence on patients outcome

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CPOE Advantages

• Automate ordering process
• Reduces Order Errors
• Standardized, legible complete orders
• DSS/Alerts
• Data collected on variances in practice

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Case Example

• Metformin is prescribed to a patient with an
  elevated creatinine level.
• A drug-lab interaction alert warns that use of
  this medication could result in an increased risk
  of fatal lactic acidosis.

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Case Example

• A physician prescribes warfarin for a patient
  with chronic atrial fibrillation.
• System
• vitamin K rich food likely to interfere with the
  efficacy of the drug.
• Specific patient information

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Example DSS in CPOE medication prescription

• Allergy
• Age (check drug name and dose)
• Duplicate drugs on active orders, not one-time
• Severe drug interactions
• Drug-drug, drug-food
• Dose maximum
• Drugs with opposite actions

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CPOE Disadvantages

• Errors still possible
• Alerts
• Multiple steps
• Access

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PubMed indexed papers on CPOE
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CPOE

• Has a positive influence on patients outcome
• Has a negative influence on patients outcome
• On which outcome measure?

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Outcome measures

• Adherence to guideline
• Alerts - user response
• Time
• Safety
• Medication errors
• ADEs (mortality)
• Cost and Efficiency
• Medication costs
• Pharmacists interventions
• Satisfaction, usage and usability

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Example CPOE improves adherence to guideline
Teich JM et al. Arch Intern Med. 2000 Oct
9160(18)2713-4.
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Example CPOE reduce errors

• Potts studied ADE rates in 13,828 medication
  orders before/after CPOE implementation at
  Vanderbilt Childrens PICU

Potts AL, Barr FE, et al. Pediatrics. 2004
Jan113(1 Pt 1)59-63.
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Example CPOE introduces errors

• Brigham and Womens' Hospital, Boston introduced a
  CPOE
• After implementation, the rate of intercepted
  Adverse Drug Events (ADE) doubled!
• Reason The system allowed to easily order much
  too large dosages of potassium chloride without
  clear indicating that it be given in divided
  doses.
• Bates et al The impact of computerized physician
  order entry on medication error prevention. JAMIA
  1999, 6(4), 313-21.

pre period1 period2 period3
Potential ADEs/1000 pt-days 15.8 31.3 59.4 0.5
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Example CPOE introduces errors

• Association with increased PICU mortality
• 2.8 14 months before CPOE
• 6.4 5 months after CPOE

Han YY, Carcillo JA, et al. Pediatrics. 2005
Dec116(6)1506-12.
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Example CPOE reduce costs
Brigham and Womens Experience Cost-Effective

• Cost
• 3.7 million implementation
• 600,000 to 1.1 million operational costs
• Results
• Decreased drug costs
• ADE cost is approximately 4,700

Kausal R et al. J Am Med Inform Assoc. 2006
13(3) 365-7
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CPOE and cost

• Huge variation in actual costs based on hospital
  size and complexity of system
• Hardware and Software 1-5 million
• Staff training
• Ongoing maintenance
• Total costs for large, fully integrated systems
  could be up to 60 million
• Costs will decrease when DSS is geared to cost
  reduction

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Usability Problems

• Potential selection errors
• Similar medication names
• Similar patient names
• Overly trust default values
• Influence workflow and communication
• Physician resistance
• Frequent data entry required
• Must not require additional time
• Most decision-support steps must be turned off to
  encourage use
• Not-invented-here syndrome

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CPOE as a Sociotechnical intervention

• Health information systems has to deal with the
  actors, the artefacts, and their interaction.

CPOE socio-technical systems
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Same system other outcome

• Upperman vs. Han
• same hospital Pittsburgh Childrens Hospital
• other outcome measure ADE vs mortality
• Han vs. Del Beccaro
• Same CPOE
• Different hospitals
• Same outcome measure (mortality)

Upperman et al. J Pediar Surg. 2005405759
Han et al. Pediatrics. 2005 Dec116(6)1506-12
Del Beccaro. Pediatrics 2006118290-295.
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Upperman et al
Pre-CPOE Post-CPOE
Verbal order regulatory compliance 80 95
All ADEs 0.3 0.37
Harmfull ADEs 0.05 0.03
plt0.05
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Han et al
Pre-CPOE Post-CPOE
Mortality 2.80 6.57
plt0.05
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Del Becarro et al
Pre-CPOE Post-CPOE
Mortality 4.22 3.46

• Same results for
• transported patients
• congenital cardiovascular disease patients

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Upperman vs Han

• Surrogate outcome measures such as medication
  errors and ADEs are not sufficient
• More studies on mortality are necessary

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Han vs. Del Beccaro

• Methodological differences
• Han used unbalanced before after periods
• Del Beccaro did not correct for case mix
  differences in before vs after period
• Populations Han vs. Del Beccaro were not
  comparable

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Han vs. Del Beccaro

• Pittsburgh implemented too fast without pilot and
  usability testing
• Order entry only allowed when patient physically
  entered hospital
• All medication in central pharmacy
• Pharmacy processed order only after complete
  activation by nurse
• Go live without necessary order sets

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Han vs. Del Beccaro

• Seattle hospital learned from Pittsburgh
• Factors influencing successful implementation
• response time and user time
• meeting information needs (e.g.using order sets)
• multidimensional integration with workflow
• Involvement leaders, support staff, clinicians
• training
• improvement through evaluation and learning

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Will a CPOE improve quality of care?

• Yes if you implement it the right way!!

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Successful CPOE implementation

• Technical Infrastructure
• EHR
• Drug information database
• DSS
• Sociotechnical implementation strategy
• Usability pilots
• Teams of informaticians, physicians, nurses,
  clerks, therapists
• Strong leader and good project management
• Training and support
• R. Gardner implementation is 90 organizational
  and political and 10 technical