Updated: Feb 24
Your emergency department (ED) recently switched over to an electronic health system (EHR). While you slowly adjust your clinical workflow, you find all the dictating, clicking and typing cumbersome and “slows you down”. You wonder how this innovative technology seemingly has become the foremost barrier to your clinical care and how this technology could ever improve patient care?
These frustrations and concerns are common sentiments as many EDs across the country are switching to EHRs. In this month’s post, we will explore one aspect of this change with computerized physician order entry (CPOE) systems and the way they can decrease the rate of adverse drug events. We will also discuss some of the new problems that CPOE can potentially have on your clinical care and ways to mitigate them.
Adverse drug events (ADEs)
We have previously discussed ADEs in this series, with reducing medication errors being a priority area for continuous quality improvement. Figure 1 is a generic and simplified process map (see our previous post on how you can create your own here) illustrating common places where preventable ADEs can occur.
What is a CPOE?
A CPOE system is an information system integrated with other clinical information systems where various steps required to give a treatment to a patient are computerized.(1) When using a CPOE, the following processes commonly are affected:
Identification of a patient to prescribe a medication by the clinician
Specification of the medication dose, route, frequency, and duration
Confirmation of the prescription and electronic transmission to the pharmacy
Electronic validation of selected prescriptions by a pharmacist
The medication is then dispensed, administered and the status flag is marked as administered
CPOEs can be implemented with varying levels of functionality and integration with existing electronic systems. Features can include basic medication order presets with the most common route, dose, duration, and frequency. They can include protocols with titration parameters such as electronic diabetic ketoacidosis protocols that may display dose adjustments based on laboratory findings. Other features include frequency reminder alerts, allergy notification, and medication interaction cross-verification as well as department-specific preferred treatment guidelines for common conditions. These features play different roles in the reduction of ADEs.
What are the advanced applications of CPOEs?
When the CPOE is fully integrated with an EHR, the advanced capabilities of electronic prescriptions can be leveraged. This would allow for automating various validation steps including the use of decision support systems that can make a suggestion based on the standard medication used for a given diagnosis based on many patient data points and allergy information contained within the EHR.
What are the proven benefits of CPOEs?
There are few studies of high quality pertaining to the impact of CPOEs, however, the evidence seems to indicate that there is a benefit associated with their use. One study evaluated the potential for the reduction of errors using a CPOE and suggested that 81.5% of their errors could have been prevented.(2) A systematic review by Nuckols and colleagues reviewed the benefits of using CPOEs and revealed a greater than 50% reduction in medication errors and preventable ADEs.(3) They did not observe further variations based on the type of deployed CPOE system. Even in the advent of poor benefit, refinements and customization of CPOE remain the best method to gain the highest benefits.
Can CPOEs lead to ADEs?
Replacing human interaction with automated processes is one well-known way to reduce medical errors. However, potential pitfalls of using electronic prescription do exist and include incorrect data entry such as selecting the wrong patient, a medication with a similar name, or even the wrong dose. Alert fatigue, when one gets desensitized to too many notifications, is another new pitfall that CPOE systems introduce. Means to reduce these errors include training, limiting the amount of user data entered, pre-filled prescriptions, and validated algorithms. An example of a validated algorithm is when abnormal prescriptions are detected, the user will be notified and be required to further validate and confirm the prescription. Furthermore, continuous monitoring of the outcomes will help identify the potential need for improvements and allow for software upgrades or safety steps to be implemented.
Despite the best implementation strategy, CPOE is not a definitive solution to medication safety but a powerful tool to aid in existing patient safety infrastructure. Moving from analogue to a digital system is a large cornerstone change to your department that requires continuous quality improvement to fit your institution’s system of care.
What is my role with CPOE?
As with any EHR functionality, the user experience is paramount to its success. Moreover, with usability issues, users tend to come up with workarounds. This is suboptimal at times as it can create extraneous workflow steps and possible opportunities for increased errors. So if it is impeding your workflow, or adding extraneous steps without providing benefit, then talk to your informaticians or EHR vendors. Ask about how to optimize the user interface, the CPOE options, and how to better integrate it with your workflow. One common misconception is that CPOE assists only with medication orders. With the increasing use of machine learning, CPOE systems can start to recognize your common orders, allow you to create and store order preferences, and streamline the process. This can be applied to medication, imaging, consultation, allied health orders, and beyond. If optimized, the system not only may reduce errors, but may also streamline the workflow.
You recall a recent example of how your EHR's built-in CPOE tool helped correct a dosing error in a medication before it was administered to one of your patients. Whew! You begin to wonder how often these near misses occur and will pitch an idea to start keeping track of these occurrences at your next departmental meeting.
Copyedited by: Jung-In Choi
Burke L, Weill B. Information technology in pharmacy. In: Information Technology for the Health Professions. 4th ed. Pearsons; 2012:188-190.
Hug BL, Witkowski DJ, Sox CM, et al. Adverse Drug Event Rates in Six Community Hospitals and the Potential Impact of Computerized Physician Order Entry for Prevention. J GEN INTERN MED [Internet]. 2009 November; 31-38. Available from: DOI:10.1007/s11606-009-1141-3
Nuckols TK, Smith-Spangler C, Morton SC, et al. The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Syst Rev [Internet]. 2014 June. Available from: DOI:10.1186/2046-4053-3-56