Can a computer physician order entry and computer decision support provide benefit by improving patient safety, reducing medication and other errors, improving quality, and aiding in compliance for hospital organizations? Studies and research show that the usage of these systems provides many advantages over the present paper based order entry system and provide healthcare organizations with multiple benefits.
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Medication errors are a big problem in healthcare and top the list of harm that is placed upon patients in the United States everyday. These errors are preventable. Computer Physician Order Entry (CPOE) is a network technology that when coupled with a Clinical Decision Support (CDS) system can be a valuable tool in reducing the incidence of medication errors. (Dixon, Zafar, 2009, para 6) CPOE is most effective when used in conjunction with a healthcare organization’s Electronic Medical Record (EMR) system. (Felkey, 169) CPOE coupled with CDS are network technologies that can benefit healthcare organizations in many ways. The Joint Commission (JCAHO), Healthcare Facilities Accreditation Program, (HFAP), and the National Quality Forum (NQF) all place patient safety high on their list of goals and best practice suggestions. One of JCAHO’s core measures is the patient safety related standard which dictates “the prevention of accidental harm through the analysis and redesign of vulnerable patient systems (e.g. the ordering, preparation and dispensing of medications.” (JCAHO, 2010) HFAP and NQF have several Safe Practices demonstrated in their online crosswalk that demand healthcare organizations address the issues of patient safety directly; following is a list: performance improvements that reduce harm to patients, identifying and mitigating safety risks and hazards to drive down preventable patient harm, healthcare organization must develop, reconcile, and communicate an accurate patient medication list throughout the continuum of care, and the safe adoption of CPOE. (HFAP & NQF 2009) JCAHO, HFAP, and HQF all work closely with the Centers for Medicare & Medicaid Services (CMS) to set patient safety and quality compliance standards for US healthcare organizations. Many providers follow guidelines imposed by the CMS for coding and payment.
According to the Institute of Medicine (IOM) “at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals as a result of medical errors that could have been prevented”. (IOM, 1999) The FDA stated in their 2005 report that medication errors result in at least one death per day and 1.3 million injuries per year in the United States. (as cited in Figge, 2009, para 1) Walker states that “of all the steps in the medication use process, the areas most associated with errors are prescribing and administration”. (2008, para 2)
CPOE is a mobile capable network technology that allows a physician to enter orders electronically for medication, laboratory services, imaging, procedures and admissions from almost anywhere at anytime. (Dixon, Zafar, 2009, para 4) This mobile functionality can improve a physician’s efficiency allowing them to use their precious little down time to get more things done in less time. The wireless capability of CPOE can allow it to communicate with Personal Digital Assistants (PDA). A Harris Interactive Poll reported that “18 percent of the nation’s physicians reporting using a PDA as an integral part of their professional duties”. (as cited in Ying, 2003, pg 59) This functionality gives physicians who employ the PDA technology the capability to input orders on the go and between other tasks in their busy daily work schedules; allowing more flexibility and efficiency in the physician’s workflow.
When fully integrated with an EMR, the CPOE/CDS system can generate alerts by looking for drug interactions, medication contraindications, dosing and frequency suggestions based on current information contained in the patient’s EMR, the pharmacy formulary and the CDS system clinical support databases. (Dixon, Zafar, 2009, para 5) Some information that could be compared and evaluated includes the medications that the patient is presently being prescribed against the patient’s diagnosis, co-morbidities, and vital statistics. The CPOE/CDS system uses evidence based medical information and would be customized by the hospital organization using selected guidelines, protocols, and algorithms. (Walker, 2008, para 18) The CDS can be programmed to look for errors based on the data sets the healthcare organization has selected. The system can then alert for errors and offer suggestions for medication dosing, medication administration, and treatment plans tailored to the individual patient. Remmlinger, documented potential benefits of CPOE including eliminating lost orders and illegible handwriting, improving the consistency of documentation, reducing variances in care, improving consideration of the patient’s clinical data, and improving coded data for outcomes analysis. (as cited in Gray & Felkey, 2004, pg 192, Figure 1)
Eliminating most handwritten clinical data in healthcare organizations is a priority that the IOM and the Institute for Safe Medication Practices has suggested for healthcare; CPOE and CDS systems are two initiatives that can facilitate this objective. (Walker, 2008) The IOM has also suggested that healthcare organizations implement process improvements when implementing healthcare technology. (AHRQ 2009) Since the CPOE is an electronic order system, illegible handwriting is no longer entered into the system because paper orders have been eliminated and all order entry is done electronically. The present ordering system allows for verbal orders to be given over the telephone, written and submitted in person or faxed. The numerous possible avenues an order can follow to get into the hospital order entry system invite a multitude of opportunities for things to go wrong. Paper orders can be virtually impossible to read at times due to illegible handwriting, over-handling, and image copying issues. Remmlinger notes that one of the quality improvements seen with CPOE is eliminating lost. (as cited in Gray & Felkey, 2004, pg 192, Figure 1) Data is entered directly into the CPOE system; eliminating the need for a patient to carry the order. Paper orders also require a scanning process to enter the order into the electronic environment adding another step in the process where errors can occur; pages can be missing, scan badly, or get indexed incorrectly. This step in the workflow process also contributes to a lag in the time between when the order is received by the healthcare organization and when it actually enters the patient’s medical record. The elimination of handwritten orders used in the order entry system cuts out the risks associated with the handwritten and/or paper order; providing safety for the patient and improved quality. By removing illegible handwriting from the system this ensures that every order is readable and available in real-time. (as cited in Gray & Felkey, 2004, pg 192, Figure 1) The extra work generated by a paper order is eliminated as well, making for an efficient and complete ordering process and on time documentation. This saves everyone time, improves processes which in turn saves money for the patient and the healthcare organization. Process improvements like this contribute to complete, timely, and accurate documentation making for a safer and more accurate real-time picture of the patient’s status at any given time from virtually any location, while implementing best practices as recommended by JCAHO, HFAP, and the NQF.
Dosing for drugs becomes more standardized when using the CPOE/CDS system; by assessing the individual patient’s vital statistics included in their EMR.T. (as cited in Gray & Felkey, 2004, pg 192, Figure 1) The CDS can calculate dosing by using patient information such as current age, weight, height which is included in their EMR and then comparing that information with the recommended dosage given in the pharmacy formulary. The CPOE/CDS also uses evidence based decision support and can give outcomes analysis based on the current plan of care or give suggestions based on an alternate plan of care. The CDS can predict possible outcomes based on historic data when coupled with alternate plans of therapy.
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CPOE also promotes efficiency gains by checking the EMR for duplicate orders for clinical tests and other therapeutic events that have already been performed. (as cited in Gray & Felkey, 2004, pg 192, Figure 1) Duplicated orders will cause an alert to be generated, resulting in the avoidance of unnecessary testing or other clinical events. This is much safer for the patient considering some clinical tests such as contrast Cat Scans are performed with inherent risk involved. The CPOE/ CDS system checks for duplicate orders therefore improving patient safety, saving time, money and providing better coordination of care while allowing for best resource utilization.
A 2005 CPOE study presented an improvement report that showed a 50% reduction in medication errors with CPOE, eliminated illegibility and transcription errors after implementing a commercial CPOE system. (Grandville, Kupetsky, Molinari, & Campbell, 2005) Another 2005 study found a 7.6% error rate resulting in 143 errors out of 1879 prescriptions. (Gandhi, Weingart, Seger, Borus, Burdick, Poon, Leape, &Bates, 2005) Analysis of the findings: basic CPOE sites had a similar rate of incidence; while employing advanced dosing and frequency checks could have prevented 95% of potential Adverse drug Effects. (ADE). (Gandhi et al, 2005) This finding supports the recommendation given by the IOM suggesting CPOE and CDS should be implemented together to provide the best possible technology to improve patient safety and quality of care.
CPOE CDS systems benefit a healthcare organization by improving patient safety through goals and best practices that help reduce medication prescribing and administration errors and offer process improvements that increase efficiency by reducing duplication of services, improve quality while saving money and time for both patients and the healthcare organization. Improvements in processes along with the careful implementation of technologies assist healthcare organizations to be compliant with increasing requirements imposed by various agencies and providers.
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