Making Computerized Provider Order Entry Work (Health Information Technology Standards)


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Yet the value of this functionality is increased by adding clinical decision support CDS systems. By running electronic rules in the background, decision support can check for a variety of potential errors.

Inpatient Computerized Provider Order Entry (CPOE)

Examples include drug interactions, patient allergies to prescribed medications, medication contraindications, and renal- and weight-based dosing. Despite its advantages, less than 5 percent of U. The AHRQ health IT portfolio consists of grants and contracts that have planned, implemented, and evaluated the impact of various information technologies on the quality, safety, and efficiency of health care delivery.

This report focuses on a sample of ten grants from the Transforming Healthcare Quality through Information Technology THQIT initiative that supported implementation or evaluation of inpatient CPOE to improve care for patients, increase efficiency, and contain costs. Our analysis of the grants presents a snapshot of their activities, mostly as they are completing their implementation cycles. The scope of our analysis was limited to challenges that grantees faced during development, implementation, or evaluation of a health IT intervention.

AHRQ encourages individual grants to disseminate final outcomes through peer-reviewed journals, trade publications, and other dissemination vehicles. The National Resource Center NRC interviews with lead investigators were the primary source of information for this report. Prior to conducting semistructured interviews, we developed questions and shared them with all of the lead investigators via email. This process enabled the NRC to collect from investigators candid accounts of their core project design elements, key challenges, lessons learned, and future directions for inpatient CPOE use within their respective hospitals.

These pragmatic stories are presented below. This subset of the AHRQ grantees and contractors who have implemented or are in the process of implementing inpatient CPOE come from geographically diverse areas in the United States, with three coming from urban areas and six from rural areas Table 1.


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The fact that the majority of THQIT grantees implementing inpatient CPOE are from rural settings and are using commercial CPOE systems is important to note, since predecessor CPOE implementation efforts have primarily occurred in large, academic medical centers with internal technology development teams. Each inpatient CPOE project in the AHRQ portfolio has implemented a commercial system, which will allow evidence on outcomes from a variety of commercial systems to be gathered in the future. The focus of this analysis is on best practices observed during the implementation of a commercial CPOE system, however, and not on reported evidence of clinical or financial outcomes.

Each CPOE system employed a CDS element to provide clinicians with access to evidence-based guidelines, prompts, and alerts at the bedside. These projects indicate that the use of CPOE should not be pursued in isolation from other technologies; that is, simply entering orders in a system without providing clinical decision support during the order-entry process may have limited benefit.

In order to optimize impact on quality, safety, and efficiency, CPOE should be an integrated component of the health IT system. Major themes from the interviews are discussed below and include staffing, resource allocation, clinical steering committees, project scope, workflow, order set design, vendor relations, interoperability, customization and system integration, demonstration systems, training, technical support, and alert fatigue.

Continuous, frequent training and retraining are critical to the success of inpatient CPOE initiatives; this can be difficult for small and rural facilities. For example, one project did not have any full time physicians on staff, so providers used CPOE infrequently while they were taking inpatient calls.

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Because clinicians did not retain the skills needed to use the software, frequent retraining was necessary. Several grantees created demonstration systems that allowed clinicians to interact with systems that were physically separate from the planned production system. Typically, super-users or implementation team members visited the areas in which the clinicians were using the demonstration systems. Clinicians could ask questions of the implementation team, often in a one-on-one environment. This approach put clinicians at ease with computer training, and it was often more efficient for implementation team members.

Qualified personnel who understand both clinical and IT domains improve the chances of success when planning for, implementing, and evaluating health IT. Ideally, such personnel should be involved from the start of the planning process. Yet several AHRQ project directors indicated that personnel who have both clinical and IT expertise are scarce, especially in rural areas. Urban medical centers also have reported difficulty in locating and retaining health IT staff because they are unable to offer salaries that are competitive with those offered by the corporate sector.

Several approaches for securing and using qualified personnel were described by AHRQ investigators. One project hired 2. A third project trained existing, internal clinical and IT staff during the planning phase. All three strategies were found to be helpful in addressing the challenge of identifying qualified staffing for health IT projects.

Understanding workflows and redesigning inefficient processes are critical steps to ensuring successful adoption of CPOE. CPOE is a disruptive technology that fundamentally changes the processes used to place, review, authorize, and carry out orders. Researchers and practitioners have written extensively about the importance of workflow redesign when implementing CPOE.

Computerized Provider Order Entry - an overview | ScienceDirect Topics

Before selecting a CPOE solution, there is no substitute for conducting a needs assessment and gathering requirements to determine product and workflow needs. Rather, CPOE should be viewed as a solution to a recurring patient safety problem. Although they required a significant investment of time during the early stages of planning, process redesign efforts enabled projects to identify and correct weaknesses in existing information processes. This enabled them to integrate electronic ordering effectively into their clinical workflow.

Some grantees used manual techniques e. Others used mapping software e. Mapping software can help end users and project implementation teams to visually represent workflow needs during system design and training. Diagramming the full cycle of how an order is tracked through a system, from inception to completion and notification, is critical to showing how existing and redesigned processes impact system performance.

For instance, grantees indicated that the use of a CPOE system significantly impacted the workflow of unit clerks, a finding that must be considered in the redesign process. When using a paper-based system, unit clerks are able to track and manage the ordering process.

Introduction to Health IT Systems

For example, a unit clerk may be able to intercept a duplicate, paper-based test order. In an electronic order environment, the unit clerk may not be able to review orders before they are delivered to their recipient e. This has the potential to impact negatively the workflow of other hospital departments. Implementers should recognize that some tasks will be reassigned to different personnel, others will be eliminated, and some new tasks will be added. Another lesson from grantees is that it is important to avoid automating an inefficient manual process from the paper world.

Organizations must allocate resources and time for CPOE implementation. Identifying adequate resources both financial and human for health IT planning, implementation, and maintenance is a challenge for all health care organizations. Particularly for small-to-medium-sized health care organizations, capital expenses for CPOE present a roadblock.

Other factors that constrain greater adoption of CPOE systems include shrinking organizational budgets and competing IT projects.

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Computerized Physician Order Entry

The AHRQ projects were required to utilize other funding sources, including payers, State-based loan programs, and organizational IT budgets to finance their systems. To identify such funding, hospital administrators, boards of directors, and other key stakeholders engaged in strategic planning and demonstrated strong commitment to implementing CPOE. To use CPOE to improve the health care delivery process, it is necessary for implementers e. In order to address these new responsibilities some adjustments in remuneration or responsibilities may be necessary.

Hospitals must find a way to compensate clinicians for the time they spend on preparation for and implementation of CPOE. Grantees emphasized the importance of establishing and maintaining good relationships with CPOE vendors throughout the implementation lifecycle. Delays in project planning and implementation are common. Implementation delays reported by the grantees varied, ranging from 6 to 18 months. Frequently, project delays are due to delays in product delivery, updates, and integration. For example, during the planning process the vendor may advocate that the hospital delay implementation by 6 months in anticipation of a new version of the product.

Grantees reported that waiting for the future version often involved more time than originally estimated by the vendor. In addition, grantees found that software updates delivered in the middle of the implementation process can be time-consuming to install and test. It is often the case that updates interfere with previously well-functioning systems. Grantees said maintaining a good relationship with the vendor during project challenges can help to facilitate faster and more efficient resolution of issues.

Because of the frequency of the delays, grantees recommended that hospitals include delay and negligence penalties when negotiating contracts. AHRQ grantees found that when smaller organizations banded together, they were able to negotiate financial discounts on products and services. Community alliances may involve other hospitals, physician practices, and area clinics. One AHRQ grant involved an independent, not-for-profit organization that had been formed to serve ten critical access hospitals in a region. Large groups and entities not only have the opportunity to negotiate discounts, but also can influence the functionality of the product in the future and create a user community to help facilitate long-term improvements in a product.

One advantage of such committees is that they provide a neutral ground for making key decisions. The steering committees usually consisted of volunteers and involved significant time commitments from participating clinicians. During implementation, careful consideration of the benefits and potential impact of available feature requirements or changes in scope is necessary. As stakeholders gain a more comprehensive understanding of CPOE capabilities, it is common for users to be tempted to modify or increase user requirements.

This change usually results in additional delays and costs that must be considered and prioritized by the project team. Grantees recommended that projects adhere to the original requirements and scope for the contracted vendor system and institute a process to evaluate additional organizational needs and changes in scope. The potential impact of changes in scope during implementation underscores the importance of addressing a comprehensive requirements development process during the vendor scoping and contracting process. If custom vendor development is needed, or the needed capability is in a future product release, the implementation timing and cost may be affected.


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A CPOE system requires that hundreds of orders and order sets be configured. This is a cumbersome process that requires the participation of numerous and disparate clinical departments in a hospital.

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Each of the nine grantees featured in this document started their order set development process by using a standard, baseline collection format provided by a vendor. Some grantees received this functionality from their CPOE vendor directly, while others purchased it from a different vendor specializing in the delivery of order sets. The grantees emphasized that, although they began with a baseline collection tool, the order set development process was time consuming.

They typically required between 6 and 8 months to customize the baseline collection in order to meet the needs and expectations of the hospitals and clinicians. Although time consuming, the process of developing and customizing order sets can have a positive impact on overall CPOE implementation.

Making Computerized Provider Order Entry Work (Health Information Technology Standards) Making Computerized Provider Order Entry Work (Health Information Technology Standards)
Making Computerized Provider Order Entry Work (Health Information Technology Standards) Making Computerized Provider Order Entry Work (Health Information Technology Standards)
Making Computerized Provider Order Entry Work (Health Information Technology Standards) Making Computerized Provider Order Entry Work (Health Information Technology Standards)
Making Computerized Provider Order Entry Work (Health Information Technology Standards) Making Computerized Provider Order Entry Work (Health Information Technology Standards)
Making Computerized Provider Order Entry Work (Health Information Technology Standards) Making Computerized Provider Order Entry Work (Health Information Technology Standards)

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