IMPORTANCE OF COMPUTERIZED PROVIDER ORDER ENTRY

Computerized Provider Order Entry was created to reduce the problem of the past--- the illegible hand-written prescriptions. CPOE can significantly enhance patient safety by: 1. Reminding the ordering clinician of a patient’s allergy to a specific medication and suggest alternatives or how to manage a reaction 2. Alerting the clinician of drug-drug interactions, educate on the severity and mechanism of action and provide advice on managing them. 3. Checking the dosages against the patient’s physical parameters, and provides dosing history and warn the clinician of potential problems and how to alter a course of therapy 4. A CPOE system for medications that is integrated with diet orders and diagnoses can alert providers of dangerously incongruent ordering scenarios such as ordering insulin for an NPO patient or teratogenic drugs in pregnant patient. 5. Facilitating appropriate monitoring with any potentially risky therapy, such as linking orders for liver function tests with thiazolidinediones and reminding ordering providers to monitor tardive dyskinesia in patients on neuroleptics. 6. Promoting safety at the point of order selection by detaching “sound-alike” drugs into separate order menus organized by pharmacological class or clinical indication, or by displaying drug names in “tall-man” lettering.

As a result of To Err is Human, the Leapfrog Group is convened. This organization is a consortium of purchasers of healthcare plans whose members based their purchases on quality improvement and consumer involvement as evidenced by four “leaps,” or recommended practices: computerized provider entry; evidence-based hospital referral; use of ICU specialists or “intensivists”; and adherence to the Leapfrog Safe Practices Score. Included in the Safe Practices Score is a set of recommended alerts and clinical reminders which healthcare systems are encouraged to employ in their HER: * Drug-allergy alert * Drug-drug interaction * Drug-laboratory result alert (digoxin level, lithium level, theophylline level, INR, creatinine) * Drug-monitoring laboratory test alert (LFTs with statins, THS with amiodarone, electrolytes with angiotensin converting enzyme inhibitors) * Drug-diagnosis alert (pregnancy, G6PD deficiency) * Drug-diet interaction (including NPO, TPN) * Individual dose checking * Cumulative dose checking * Physical incompatibilities (calcium and ceftriaxone) * Preventive health clinical reminders
In addition to quick orders and order sets, most CPOE programs offer a structured order entry interface or “order dialog” that references an architectural system of interrelated files of order elements, and allows providers to build an order de novo by selecting from various order components. This file architecture is referred to as the medication masterfile.
Once a drug is selected, the order dialog should not allow the provider to make the ambiguous or dangerously contradictory selections in dosage, routes of administration, or administration frequency, but rather offer appropriate, safe choices to ordering clinicians first, according to the drug selected. For example, it should not be possible to indicate an intravenous route for a medication intended to be administered intramuscularly only. Indications should be easily selected for inclusion in prescription directions for the patient or administering nurse, and should be merely selectable text that appears in the directions but computable data that can be searched and aggregated for medication use evaluations, billing purposes and research.
Through the use of electronic access and signature codes, electronically-enabled identification cards, and biometric devices utilizing optical or fingerprint scanners, CPOE can verify the identity of the ordering provider and prevent order forgery and other sources of diversion and fraud.
Studies have shown that CPOE, through initially expensive, can realize significant net savings to healthcare systems overtime, due to better drug and staff time utilization, and fewer adverse drug events. The organization and presentation of order menus can help can help promote hospital-preferred, evidence-based order selection.
Considerations must be given to how and where clinicians place orders, and menus must be designed to support and enhance that action by varying scenarios and by clinicians of different levels of clinical and technical expertise. The master order menu architecture might include menus of quick orders sorted by ordering scenarios; by ordering location such as the ER, women’s clinic, or surgical ICU; by order-receiving service (pharmacy, laboratory, radiology), by chronic and acute diseases, and by listing orderable items alphabetically.