Cpoe way forward

Presented at Indian Conference on Medical Informatics and Telemedicine, ICMIT 2005, IIT Kharagpur, India
COMPUTERIZED PHYSICIAN ORDER ENTRY: WAY FORWARD
Dr Pankaj Gupta
BDS, PGDCA, Dip. Bioinfo.
Ex-Project Manager,
FCG Software Services (India) Pvt Ltd.
HM Towers, Brigade Road, Bangalore
India
dr_pankajgupta@yahoo.com
ABSTRACT
CPOE is seen by most renowned organizations worldwide
as the answer to reducing medical errors by bringing in a
major breakthrough in the area of patient safety. CPOE
standards came into being primarily as a result of the
Institute of Medicine‘s 1999 report on medical errors and
the subsequent coming together of Fortune 500 employers
to form the ‗‗The Leapfrog Group‘‘. The Leapfrog Group
preferentially directs the employees‘ healthcare to those
institutions that install clinical systems compliant to
CPOE standards. Adoption of CPOE has resulted in
benefits to some; however there is considerable
skepticism in the market against CPOE. This paper
discusses the potential benefits of CPOE in a clinical
system. At the same time, it shows that the computer
systems in hospital environment need to evolve to enable
CPOE deliver on its promise.
KEY WORDS
CPOE, The Leapfrog Group, Institute of Medicine (IOM)
Introduction
44,000 - 98,000 people die in the USA hospitals each year
as a result of medical errors that could have been
prevented.1
These facts were cited in the Institute of
Medicine‘s report of 1999, which was based on estimates
from two major studies in the USA. Even using the lower
estimate, preventable medical errors in hospitals exceed
attributable deaths to such feared threats as motor-vehicle
wrecks, breast cancer, and AIDS. As a result of the IOM
report, Fortune 500 employers in the USA found that
though a lot of healthcare standards were being put in
place, but patient safety still remained an area where
focus was needed to reduce errors and thereby control the
spiralling medical costs and premiums. This led to the
formation of The Leapfrog Group with the aim of
improving patient safety. Developing Computerized
Physician Order Entry (CPOE) standards is one of the
many initiatives from The Leapfrog Group to improve
patient safety.
It has been found that lot of deaths happen due to human
error at the physician‘s order entry stage itself. CPOE is
aimed at alerting the physician about potentially
dangerous/erroneous orders before the orders are really
executed, thereby facilitating a solution for this long-
standing issue in medical set up. The testimony to the
benefits of CPOE is that more than 10% of U.S. hospitals
now have CPOE.
The CPOE concept has existed for a long time and now
The Leapfrog Group is laying down the standards to give
it a proper direction. Large Healthcare-IT vendors are
already putting efforts to make their clinical systems
CPOE compliant. However the obstacle is that many
clinical systems from different vendors still do not talk to
each other. The Computer systems in hospital
environment have to evolve a lot before the true benefits
of CPOE can be realized. Large Healthcare-IT vendors
have to play a responsible role in integrating the Health
delivery industry, and thereby move towards a greater
patient safety.
IOM study and CPOE
The starting point of thought provoking discussions on
patient safety has been the Institute of Medicine‘s
(IOM‘s) report ‗To Err is Human, Building Safer Health
Systems‘1, 2
. The IOM pointed out that 44,000 to 98,000
deaths happen every year in the USA due to preventable
medical errors. Errors are costly in terms of psychological
discomfort, diminished satisfaction and loss of trust in the
healthcare system by patients, and loss of morale and
frustration in health professionals. More US citizens die
in a given year as a result of medical errors than from
motor vehicle accidents, breast cancer, or AIDS. Beyond
their cost in human lives, preventable medical errors have
been estimated to cost (including the expenses of
additional care necessitated by errors, lost income and
household productivity, and disability) between $17-29
billion per year in hospitals in USA. 1
Shortly after this report was made public, the Business
Round Table founded The Leapfrog Group, a national
association of Fortune 500 chief executive officers

(CEOs). The Leapfrog Group focuses on 3 main areas of
patient safety — CPOE, ICU Staffing and Evidence based
hospital referrals. The Leapfrog Group was created to
‗‗help save lives and reduce preventable medical mistakes
by mobilizing employer purchasing power to initiate
breakthrough improvements in the safety of health care
and by giving consumers information to make more
informed hospital choices.‘‘ 2
The intent of The Leapfrog Group is to preferentially
direct their corporate members‘ health care to those
organizations that adhere to patient safety standards
specified in the guideline documents based primarily on
the IOM report2
.
The IOM study has had its fair share of criticism
especially from the physicians. However it has been the
principal argument for the push for adoption of patient
safety standards like CPOE.
What is CPOE?
Computer physician order entry (CPOE) systems are
electronic prescribing systems that intercept errors when
they most commonly occur — at the time medications are
ordered. With CPOE, physicians enter orders into a
computer rather than on paper; these orders are then
integrated with patient information, including laboratory
and prescription data. The order sets are automatically
checked for inappropriate/dangerous orders before they
are executed. Over a period of time many clinical decision
support systems have come out with CPOE concepts.
However, The Leapfrog Group has now laid down a set of
standards for the computer programs for alerting health
care providers to potentially harmful therapeutic decisions
before orders are processed.
The Leapfrog Group includes the following language in
their CPOE Fact sheet. ―In order to fully meet Leapfrog‘s
CPOE Standard, hospitals must:
1. Assure that physicians enter at least 75% of
medication orders via a computer system that
includes prescribing-error prevention software;
2. Demonstrate that their in-patient CPOE system
can alert physicians of at least 50% of common,
serious prescribing errors, using a testing
protocol now under development by First
Consulting Group and the Institute for Safe
Medication Practices;
3. Require that physicians electronically document
a reason for overriding an interception prior to
doing so.‘‘3
Why CPOE?
One of the IOM report‘s main conclusions is that the
majority of medical errors do not result from individual
recklessness or the actions of a particular group – this is
not a ―bad apple‖ problem. More commonly, errors are
caused by faulty systems, processes, and conditions that
led people to make mistakes or fail to prevent them. 1
Errors happening due to illegibility of Physician notes in
the clinical setting have been a long-standing and ever
present complaint from the paramedical staff
(pharmacists, nurses & other ancillary staff). Electronic
Medical Records (EMR) solves the illegible physician
notes issue to a large extent. However, EMR leaves scope
for human error at the stage of physician order entry
itself. This is where CPOE standards fill the gap to
prevent erroneous or dangerous orders to get past the
Physician stage.
Mistakes can be best prevented by designing the
healthcare systems in a way that makes it more difficult
for people to do something wrong and easier for them to
do it right. Medication process provides an example
where implementing better systems will yield better
human performance and reduce errors.
CPOE Evolution
Decentralized and fragmented nature of healthcare
delivery system has been the oft-cited problem that has
contributed to medical errors. When patients see multiple
providers in different settings, none of whom have access
to complete information, it becomes easier for things to
go wrong.1
Fully integrated Hospital IT infrastructure,
EMR, and computer based data capture and data storage
are pre-requisites for institutionalizing CPOE standards.
Computer systems have evolved in the hospital
environment over a period of time. The early computer
systems in the hospitals were essentially stand-alone
islands of patient data that could not communicate with
other systems in the same department, let alone the other
systems in the hospital.
Nowadays, most hospitals are investing time and effort
for integrating various stand-alone systems across
departments to reduce errors during double entry of
patient data and enable physician order execution in near
real-time.
Fig. 1 below shows that the computer systems in hospitals
are evolving from stand-alone data collection mode to an
integrated healthcare enterprise (IHE). Once the systems
are integrated the stage is set to institutionalize CRM
(consumer relationship management), evidence based
medicine and the topmost layer of patient safety-- CPOE.

Fig 1: Evolution of CPOE
Today all of the large clinical systems vendors are making
sincere efforts to make their own products CPOE
compliant. However the reality is that the hospital can
have islands of computer systems installed/ built at
various periods of time by different product vendors.
Large Healthcare-IT vendors have to come out of
business silos and move to open standards to help Health
delivery industry for integrating the stand-alone systems
and tiding over the chasm. Only then, true CPOE can be
implemented enterprise wide.
CPOE Alerts
CPOE standards recommend that alerts be given to the
Physician for basic to expert level warnings. The range of
alerts varies from the drug allergy and drug overdose
(basic alert) to contraindication based on individual‘s
laboratory studies (expert alert).
Basic level alerts are simple alerts for allergy to penicillin
and overdose of antihistamine. Whereas alerts for unusual
drop in blood clotting time and prothrombin laboratory
values in patient‘s charts due to increasing dose of anti-
coagulant like warfarin is an expert level alert.
Alerts need a huge enterprise-wide knowledge base to
operate in the backend. Some of the medical knowledge is
readily available whereas some of it is still state, region
and hospital specific. Expert/ Advance level alerts e.g.
drug-lab-document alert will need data from across
different hospital systems. These systems need to be
integrated to yield full benefits of CPOE.
Potential Benefits of CPOE
CPOE systems can be remarkably effective in reducing
the rate of serious medication errors. A study led by
David Bates MD, Chief of General Medicine at Boston‘s
Brigham and Women‘s Hospital, demonstrated that
CPOE reduced error rates by 55% — from 10.7 to 4.86
events per 1000 patient days. Preventable ADEs declined
17% from 4.69 to 3.88 per 1000 patient days, while non-
intercepted potential ADEs declined 84% from 5.99 to
0.98 per 1000 patient days. The prevention of errors was
attributed to the CPOE system‘s structured orders and
medication checks.3,4
CPOE has paid other dividends. Length of stay at
Wishard Memorial Hospital in Indianapolis fell by 0.9
days, and hospital charges fell by 13% after
implementation of CPOE. A recent study at Ohio State
University also identified substantial reductions in
pharmacy, radiology, and laboratory turn-around times,
and there was a reduction in length of stay in one of the
two hospitals studied.3
Some of the benefits of CPOE include:
Prompts that warn against the possibility of drug
interaction, allergy, overdose etc.
Accurate, current information that helps
physicians prescribe the new drugs as they are
introduced into the market
Drug-specific information that eliminates
confusion among drug names that sound alike
Improved communication between physicians
and pharmacists
Reduced healthcare costs and hospital stay due to
improved efficiencies.
CPOE Evaluation application by FCG
First Consulting Group (FCG) had developed the
methodology to help hospitals evaluate whether their
CPOE systems meet the Leapfrog CPOE standards. Now
FCG has also developed the CPOE evaluation application
for The Leapfrog Group. This web-based application is
expected to be used by 5000 hospitals across US to test
their CPOE compliance.
Flip Side of CPOE
Physicians and medical staff need real time access to data
that is relevant to the case at hand. They need to be able to
record a maximum amount of information in a minimum
amount of time and in such a way that it is most useful to
other health care professionals involved in the handling of
this patient. It is totally unacceptable if the alerts do not
appear real time and increases the physician‘s time per
patient.
Decision support systems also suffer from the problem of
an overdose of reminders, alerts, or warning messages.
This delay can be dangerous in emergency situations.
CPOE compliant systems are infamous for ―…causing
cognitive overload by overemphasizing structured and
‗Complete‘ information entry‖ 5
.

There is a rather large grey zone of informal management,
which can be entirely rational given the everyday
organization and exigencies of health care work. In
emergency and some other special situations, orders may
be entered after the order execution. For example, while
transferring a patient between the emergency department
and ward, orders could not be transferred or new orders
could not be entered in the system because the patient was
not yet ‗‗in the system‖.
In the case of urgent medication orders, nurses can give a
medication before the physician formally activates the
order. During nightly routine medication administration,
nurses can initiate distribution without waking up the
junior doctor who is formally responsible for signing the
order. Within this same grey zone, there could lay many
practices that would contribute to unsafe medication
routines such as doctors actively discouraging nurses to
call them for medication requests or nurses taking too
many liberties with dosing.5
All of these practices exist
within the current paper medication systems, but many
CPOE systems do not leave room for such practices.
Inexperienced computer users can face issues like a slip
of the mouse on a data entry form leading to an order for
the right medication for the wrong patient. Such errors
due to inexperience lead to arguments that pen and paper
are simpler and better. However expert level alerts in
CPOE systems are expected to take care of such issues to
some extent.
Conclusion
The Institute of Medicine‘s report has had its desired
effect. Formation of The Leapfrog Group and coming out
with the CPOE standards is a right step towards patient
safety.
CPOE systems can reduce unnecessary repetitive orders
and also significantly cut down the delays between
writing and completing orders. They can also cut staff
costs directly by reducing the time spent by nursing,
pharmacy, and other ancillary services on callbacks to
clarify orders and by eliminating the personnel time of
transcribing orders. So, health care institutions have much
to gain in efficiency and cost savings from CPOE
systems.
In the late 1980s and 1990s, some people criticized that
no one else used or ever would use CPOE. Whereas more
than 13% of U.S. hospitals have CPOE today.6
To derive the true benefits of CPOE the challenge is to
create user-friendly, seamless systems that integrate all
critical disparate systems throughout the enterprise-
including patient records, order entry, pharmacy,
radiology and Lab.
To completely replace legacy clinical systems with a
single-vendor, monolithic solution would be expensive
and cumbersome. As an alternative, taking the application
integration approach to meet CPOE requirements will
typically cost less in terms of time and material.
Large Healthcare-IT vendors should focus on larger
benefits by integrating the health delivery industry rather
than competing with each other for the same piece of the
pie.
Acknowledgements
I wish to thank FCG for giving me the opportunity to
design and develop the CPOE evaluation application. I
am thankful to my wife Dr Savita for putting on the
editor‘s cap and editing the content of this paper. Dan
Coate and Vaishali Bhinde gave me valuable inputs to
improve the presentation of the content in the paper. Like
always, Vishal Kirplani helped me in putting the images
and formatting as per specifications.
References:
[1] LT Kohn, JM Corrigan, MS Donaldson, To err is
human: building a safer health system (Committee on
Quality of Health Care in America, Institute of Medicine
Washington DC, USA: National Academy Press, 1999).
[2] Robert G. Berger, JP Kichak, Computerized Physician
order Entry: Helpful or Harmful?, Journal of American
Medical Informatics Association, 11, 2004, 100-103.
[3] Fact Sheet: Computerized Physician Order Entry
(CPOE), The Leapfrog Group for Patient Safety,
Available at:
http://www.leapfroggroup.org/media/file/Leapfrog-
Computer_Physician_Order_Entry_Fact_Sheet.pdf.
Accessed at 14 Jan 05.
[4] DW Bates, LL Leape, DJ Cullen, N Laird, et al. Effect
of computerized physician order entry and a team
intervention on prevention of serious medication errors,
Journal of American Medical Association, 280, 1998,
1311-1316.
[5] JS Ash, M Berger, E Coiera. Some Unintended
Consequences of Information Technology in Healthcare:
The Nature of Patient Care Information Systems-related
Errors, Journal of American Medical Informatics
Association, 11, 2004, 104-112.
[6] CJ McDonald, JM Overhage, BW Mamlin, PD
Dexter, WM Tierney. Physicians, Information
Technology and Healthcare Systems: A Journey, Not a
Destination, Journal of American Medical Informatics
Association, 11, 2004, 121-124.

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