1. CPOE: Solving Old Problems; Creating New Ones Ronald E. Lay, M.S., R.Ph. Pharmacy Supervisor The Penn State Milton S. Hershey Medical Center rlay@psu.edu PSHP 40 th Annual Assembly Harrisburg, PA October 1, 2008

2. For centuries, the written prescription has been the means of communication between a physician and a pharmacist.

3. With CPOE, pharmacists shift from assuring appropriate transcription to assuring the appropriateness of therapy.

4. Problems associated with order entry vs. CPOE ORDER ENTRY Patient identification Legibility Completeness Appropriate abbreviations Transcription errors CPOE Start times Duplications Interactions Medical appropriateness Prescriber resistance

5. To many pharmacists, the written order is a security blanket

6. Some components of the medication use process change with CPOE, many remain the same. Ask yourself, “How did we do it on paper?”

7. You can use tools to assure orders are entered completely and correctly by the presciber Order sentences Care sets Default order parameters Required fields

8. When you take away the written order, many pharmacists ask: How will I know if the order is correct? What will I check it against? How do I know the correct drug was selected? How do I know the order is entered on the correct patient?

9. Consider the amount of time pharmacists are spending trying read faint name stamps, illegible handwriting and to comply with JCAHO regulations such as unapproved abbreviations, dose and frequency ranges and prn reasons

10. Doctors really are human and will do what is easiest for them

11. CPOE eliminates many problems and frustrations associated with medication ordering Legibility Completeness (required fields) Abbreviations Appropriateness (dose, frequency, route) Access to patient information (integrated medical record) More even distribution of order receipt Use of evidence based medicine through order sets More timely turn-around

12. Transmission of the written order from the nursing unit to the pharmacy is no longer an issue. Manual pick-up Faxing Optical scanning

13. Yet, CPOE creates a whole new set of problems: Prescriber resistance Prescriber compliance Shortcuts or bypass of system Lack of knowledge & understanding Timing of doses Duplications “Rule overload” Downtime

14. Yet, CPOE creates a whole new set of problems: Increased expectations Increased workload Lack of attention to detail Lack of flexibility Increased integration of system with others Must be easy for users Limitations of system Incorrect information can still be entered

15. Needs for CPOE (or how to avoid the problems) Thorough training Understanding of inter-disciplinary processes Institution-wide policies on how to address problems Enhancement of clinical skills

16. Training needs System functionality Physician ordering processes eMAR Nursing tasking and documentaion (“think like a nurse”) Impact of total integration

17. The focus of pharmacists can shift more towards the evaluation of the clinical appropriateness of the order.

18. Using decision support Interaction checking Dose checking Allergy checking Duplication checking Rules

19. Order verification can be done from anywhere: Central pharmacy Satellite pharmacy Nursing unit Office Home

20. Impact on Workload

21. You may choose to verify orders you previously ignored Plain IV’s Flushes Discontinued Rescheduled

22. Impact on Workflow

23. QUESTIONS