The implementation of informational technologies in the health sector can be seen to fundamentally change the medical practice and the interrelation between the medical staff and the patients. The informational processes are existent in the all the sectors of medicine and health. The accuracy of the functioning of the sector in general, and the effectiveness of its control, highly depends on the ordering of the informational processes. Nevertheless, the most important factor in the implementation of informational systems in the field of medicine, specifically related to patients and their health, is reducing the errors and the mistakes resulted from the manually operated processes.
At the end of 1999, a report was published in the US by the Institute of Medicine in which the number of patients dying due to medical errors is as high as 98,000 annually. (Kohn, Corrigan, & Doyle, 2000). Among them are approximately 7,000 patients who die from medication errors.
Thus, it can be seen that the direction of emphasis in informational systems. One of the approaches taken toward increasing the safety of the patients is in using Computer Physician Order Entry -also called Computerized Provider Order Entry (CPOE), a system with support mechanisms of medical decisions, which is able to control the prescription of medication, in order to avoid mistakes caused by the incompatibility of the medication, their side effects and etc. In that regard, this paper provides an overview and analysis of CPOE, in terms of its implementation and success, as well as the factors influencing its usage.
Overview and Definition
CPOE is defined as “an application that allows health care providers to use a computer to directly enter medical orders electronically in inpatient and ambulatory settings, replacing the more traditional order methods of paper, verbal, telephone, and fax.” (AHRQ Resource Center, 2009). CPOE represents a variety of systems, which share common features related to medications’ ordering automation. The common form of CPOE might represent an interface with Clinical Decision Support System (CDSS), which is able to provide standardized complete orders by accepting typed and complete format. Regarding CDSS the main clinical decisions might include providing suggestions regarding drug doses, routes and frequencies. (Kaushal & Bates, 2009). Additionally, the main characteristics of CPOE systems might include the following:
- The realization of support mechanisms of physicians’ decisions acceptance
- Remote access to treatment information and patients’ examination
- Simple to learn and easy to use
- High speed of system’s work.
CPOE was identifies as one of three measures of patients’ safety by The LeapFrog Group, a consortium of more than 90 Fortune 500 companies and other large public and private health care sector purchasers. According to a report published by the aforementioned consortium, CPOE usage can reduce prescribing errors in hospitals by more than 50%. (Meadows & Chaiken, 2002). Additional benefits include helping the rest of the medical staff, where the orders produced are legible, complete and were checked for “medication contraindications, dosing errors, duplicates, or potential conflicts with specific patient data.” (Meadows & Chaiken, 2002).
Principle of Work
Basically, CPOE is an application which provides a comparison between the entered information and an existent updated database of information. Once a physician enters the patient’s prescription in a computer, an immediate feedback will be received, containing clinically important information regarding the prescribing decision. The process implies a connection between the newly ordered drug therapy to clinical, drug and laboratory information.
Comparing the existent information regarding the prescriptions already being taken by the patient, the system will consider the existent information and will guide the decision toward increased safety. An example can be seen through prescribing antidepressant drug for a patient taking psychoactive medication. Once the order is entered, the system will analyze the newly entered data with that of the already prescribed drugs, and display a warning about the potential for “oversedation, confusion, delirium and falls.” (Rochon, Field, Bates, Lee, & et al., 2006) The warning will display the indicated drugs and the dose recommended of the new drug.
Analyzing the pattern of drugs’ error occurrence, a study which evaluated events in 18 such facilities in the United States, monitoring nearly 3000 people for a total of 28 839 resident-months, found that the most errors occurs at ordering and monitoring phases. In that regard, it can be assumed that in case the orders were entered into the computer using CPOE, the outcomes might have been different. (Rochon, et al., 2006).
Literature Review
There are many studies which evaluated CPOE, in terms of the benefits, the costs and the efficiency of the implementation of new systems. It can be stated that, the studies of the implementation of CPOE dominate the field of informational systems in medicine. In that regard, it should be noted that the implementation process is still slower than anticipated. In a study conducted on the extent and the functionality of CPOE in seven Western countries, it was shown that U.S. and Netherlands have the highest rate of implementation, whereas in Germany, the United Kingdom, France, Switzerland, and Australia show rates indicative of poor integration if any. (Aarts & Koppel, 2009). Among the guidance developed on CPOE implementation, a consensus statement was released based on a qualitative research that indicated the main consideration. The considerations were outlined through the following categories:
- Motivation for implementation
- Vision, Leadership, and Personnel
- Costs
- Workflow, Health Care Processes
- Value to Users/Decision Support Systems
- Project Management and Staging of Implementation
- Technology
- Training and Support
- Learning/Evaluation/Improvement (ASH, STAVRI, & KUPERMAN, 2003).
In terms of the motivation for implementation, which generally influences the funding and the clinical leadership, a study was conducted in 2006 on the alternative reasons for low CPOE implementation. This study showed that CPOE is related to the hospital ownership and teaching status, where despite the benefits of CPOE implementation, as of 2006, only an estimated 4-10 percent of U.S. hospitals have fully implemented CPOE.
In terms of the costs and the possible financial benefits, few studies addressed such issues, where most of them extend beyond the medication-related events. Accordingly, the costs of the systems themselves can be considered as a serious barrier, where as of 2004 the costs for have ranged from “$3 million to $10 million, depending on hospital size and level of existing IT infrastructure”; “As one CIO stated, CPOE was “the most expensive project I had ever done in my twenty-nine years of doing hospital software.” (Poon, Blumenthal, Jaggi, Honour, & et al., 2004)
Accordingly, it should be noted that the system themselves are not flawless, neither is the usage of the system completely eliminate the possibility of errors. A study conducted of providers working with a CPOE system identified 22 types of medication error risks. The study indicated mistakes such as “fragmented display of orders, pharmacy inventory display of drug doses that were confused with recommended dosages, and ignored renewal orders for antibiotic therapy when notices were placed in the paper chart and not in the computer.” (Rochon, et al., 2006) Additionally, some assessed flaws can result in the rejection of the system, as it was seen in the example of Cedars-Sinai Medical Center in Los Angeles. In 2003, the physicians of the aforementioned center, after a period of exploitation of a computer-based patient record with large investments in such system, rejected such system and reverted to the traditional method, where the cause was the low reaction of the system.
Electronic Health Systems and the Health of the Patients
Taking the measures of effectiveness of CPOE, in particular, and Electronic Health Systems (EHS) in general, the main questions that should be asked: is a there a direct influence on the health of the patients. Answering such question, the main area of consideration is the narrow specification of such systems directed toward raising the effectiveness of treatment as well as the safety of the patients. Thus, it can be said that such systems are made to help the help system and the medical personnel.
In that regard, assessing the influence of EHS, the main area of medical errors basically associated with medication prescribed in subsequent treatments. In that sense, a study assessing the mortality and the morbidity of the patients, it was shown that despite the 40% decrease in medication error rates, no differences were shown in actual patient morbidity or mortality. (Berger & Kichak, 2004) Nevertheless, in aspects not related to prescription, such as the work of the staff and the information value of the medical history, such systems can prove beneficial in terms of effectiveness and efficiency of the patients’ treatment. Such aspects can be seen through avoiding excessive examination, reducing the time needed for the physicians for a recurrent examination of the patient.
Conclusion
The constant integration of the IT in different sectors of the society is working toward decreasing the costs, increasing the efficiency and reducing the errors intrinsic to the manual operation of the common processes. In that regard, it can be concluded that the integration of the IT and the sector of medicine, which can be seen through CPOE systems, the advancements made reflects the success of the selected approach. However, the low implementation rate of CPOE systems, even in developed countries, outlines the need for more researches that will assess the reasonability of integrating the systems on larger scale. Additionally, it can be seen that the system itself is in need for improvements in terms of flexibility and functionality. Accordingly, the success of such systems will result in integrating other areas of the medical sectors with the IT.
References
Aarts, J., & Koppel, R. (2009). Implementation Of Computerized Physician Order Entry In Seven Countries. Health Affairs, 28(2), 404-414.
AHRQ Resource Center. (2009). Computerized Provider Order Entry. US Department of Health&Human Services. Web.
ASH, J. S., STAVRI, P. Z., & KUPERMAN, G. J. (2003). A Consensus Statement on Considerations for a Successful CPOE Implementation. Journal of the American Medical Informatics Association, 10, 229–234.
Berger, R. G., & Kichak, J. P. (2004). Computerized Physician Order Entry: Helpful or Harmful? Journal of the American Medical Informatics Association, 11(2), 100-103.
Kaushal, R., & Bates, D. W. (2009). Computerized Physician Order Entry (CPOE) with Clinical Decision Support Systems (CDSSs). AHRQ Resource Center. Web.
Kohn, L. T., Corrigan, J. M., & Doyle, D. J. (Eds.). (2000). To err is human: building a safer health system: Committee on Quality of Health Care in America, Institute of Medicine.
Meadows, G., & Chaiken, B. P. (2002). Computerized physician order entry: A prescription for patient safety. Nursing Economics, 20(2), 76-77, 87.
Poon, E. G., Blumenthal, D., Jaggi, T., Honour, M. M., & et al. (2004). Overcoming Barriers To Adopting And Implementing Computerized Physician Order Entry Systems In U.S. Hospitals. Health Affairs, 23(4), 184-190.
Rochon, P. A., Field, T. S., Bates, D. W., Lee, M., & et al. (2006). Clinical application of a computerized system for physician order entry with clinical decision support to prevent adverse drug events in long-term care. Canadian Medical Association. Journal, 174(1), 52-54.