Computerized Physician Order Entry: a focus on medication prescription Nicolette de Keizer & Saeid Eslami Dept Medical Informatics University of Amsterdam

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

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

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

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

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

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.

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

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

CPOE Disadvantages Errors still possible Alerts Multiple steps Access

PubMed indexed papers on CPOE

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

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

Example CPOE improves adherence to guideline Teich JM et al. Arch Intern Med Oct 9;160(18):

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 Jan;113(1 Pt 1):59-63.

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), Example CPOE introduces errors preperiod1period2period3 Potential ADEs/1000 pt-days

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 Dec;116(6):

Example CPOE reduce costs Cost: $3.7 million implementation $ 600,000 to $1.1 million operational costs Results: Decreased drug costs ADE cost is approximately $4,700 Brigham and Womens Experience: Cost-Effective Kausal R et al. J Am Med Inform Assoc. 2006; 13(3): 365-7

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

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

Health information systems has to deal with the actors, the artefacts, and their interaction. CPOE as a Sociotechnical intervention CPOE = socio-technical systems

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. 2005;40:57–59; Han et al. Pediatrics Dec;116(6): ; Del Beccaro. Pediatrics 2006;118;

Upperman et al Pre-CPOEPost-CPOE Verbal order regulatory compliance 80%95%* All ADEs Harmfull ADEs * * p<0.05

Han et al Pre-CPOEPost-CPOE Mortality2.80%6.57%* * p<0.05

Del Becarro et al Pre-CPOEPost-CPOE Mortality4.22%3.46% Same results for: transported patients congenital cardiovascular disease patients

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

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

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

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

Will a CPOE improve quality of care? Yes if you implement it the right way!!

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