1. A White Paper
Computerized Physician Order Entry
Weighing the benefits and challenges of implementation
Rhonda Joyner
HMIA 5060
Final Examination

2. TABLE OF CONTENTS
 Explore Purpose of Health Information
Technologies
 Statement of Issue
 Background/History
 Benefits
 Negative impacts
 Strategies
 Conclusion
 References

4. PURPOSE OF HITS
 The national health care expenditure was
approximately $2.6 trillion with an anticipated
growth rate of 5.8% over the next 10 years.
 Health care expenditures have grown at a faster
rate than the national gross domestic product rate. 1
 Health Information Technologies can
increase efficiency and effectiveness

5. WHAT IS COMPUTERIZED PHYSICIAN ORDER
ENTRY (CPOE)?
 A mechanism for physicians
and medical professionals to
order medications electronically
through computers or smart
phones.
 This order is then recorded for
patient records and dispersal of
medication and may facilitate
the exchange of information
amongst other providers. 8

7. The Government Has Stepped In To Ensure That The
Healthcare Industry Increase Its Utilization Of
Technology.
THE HEALTH INFORMATION TECHNOLOGY
2009 AMERICAN RECOVERY AND
REINVESTMENT ACT (ARRA) FOR ECONOMIC AND CLINICAL HEALTH
(HITECH) ACT
 Provided $19 billion to
encourage healthcare  Included a provision worth $560 million
to provide states with funding to increase
providers to adopt and
their Health Information Exchanges
use health information (HIEs).
technologies (HITs) and  $17 billion to provide increased Medicare
electronic health payments to hospitals and physician in
records (EHR) within exchange for usage of certified EHR
their organizations. systems, known as “meaningful use”. 1
 Key element is the implementation of
Computerized Physician Order Entry
(CPOE).
WHAT ACTS?

8. WHY IS CPOE IMPORTANT?
 CPOE is considered to be Stage 1 of the
meaningful use criteria, and provides health
care providers with the qualification for the
HITECH incentives.
 Providers that meet the meaningful use
guidelines by 2014 will qualify for incentive
payments. Others will be penalized if
implementation is not achieved by 2014. 8

9. MEANINGFUL USE DEFINED
 Meaningful use (MU), as defined by
SearchHealthIT, is “the use of electronic
health records (EHR) and related technology
within a healthcare organization.” 7
 Qualifies healthcare organizations for
financial incentives from Medicare and
Medicaid EHR Incentive Programs. 6

11. FEW TAKERS….
 Study conducted in 2009 indicated:
 1.5% of hospitals in the U.S. utilized an
electronic record system within all clinical units.
 7.6% of the hospitals had at least one clinical
unit utilizing a system.1, 4
 4% of physicians indicated having extensive
systems
 13% only reporting a basic electronic system. 1,5

12. CHALLENGES
 High Operating Costs
 Interruption of work flow
 May increase errors
 Lack of technical capabilities
 Physician Buy In and Trust

14. BENEFITS
 CPOE is an effort to reduce medication, and
paper errors and increase proficiency within
healthcare organizations and results in
overall cost savings if implemented correctly.
 It is estimated that medication errors
results in a national cost of $2 billion
annually. 9

15. 2009 STUDY RESULTS RELEASED BY THE MASSACHUSETTS TECHNOLOGY
COLLABORATIVE AND THE NEW ENGLAND HEALTHCARE INSTITUTE
 Stated that cost of  Indicated that CPOE
CPOE implementation could reduce the 770,000
could provide annual hospital deaths and
savings of $2.7 million injurers that are caused
for a hospital. 9 , by adverse drug events
 Relative to the cost
(ADEs).
 Preventable ADEs incidents
of approximately cost each hospital $5.6 million
$2.1 million and annually
$435,000 for yearly  Considered the leading cause
of death (excluding death by
maintenance motor vehicle, Aids, and
breast cancer). 9
 98,000 deaths occur annually
due to medical errors.10

16. ADDITIONAL BENEFITS
 “Free of handwriting identification problems
 Faster to reach the pharmacy
 Less subject to error associated with similar drug names
 More easily integrated into medical records and decision-support
systems
 Less subject to errors caused by use of apothecary measures
 Easily linked to drug-drug interaction warnings
 More likely to identify the prescribing physician
 Able to link to ADE reporting systems
 Able to avoid specification errors, such as trailing zeros
 Available and appropriate for training and education
 Available for immediate data analysis, including post marketing reporting
 Claimed to generate significant economic savings
 With online prompts, CPOE systems can
 Link to algorithms to emphasize cost-effective medications
 Reduce under prescribing and overprescribing
 Reduce incorrect drug choices” 12

18. A CLOSER LOOK AT TWO STUDIES

19. ERRORS CAUSED BY CPOE
 “Role of computerized physician order entry
systems in facilitating medication errors” article
by Koppel et al., discusses a study conducted at
“a major urban tertiary-care teaching hospital
with 750 beds, 39, 000 annual discharges, and
a widely used CPOE system (TDS) operational
there from 1997 to 2004.”
 This study uncovered 22 types of medication
errors that occurred as a result of the CPOE
system.

20. CPOE ERRORS AS IDENTIFIED BY STUDY
Information Errors Human-Machine Interface
Flaws
 Assumed Dose Information  Patient Selection
 Medication Discontinuation  Wrong Medication Selection
Failures  Unclear Log On/Log Off
 Procedure-Linked Medication  Failure to Provide Medications
Discontinuation Faults After Surgery
 Immediate Orders and Give-as-  Postsurgery “Suspended”
Needed Medication Medications
Discontinuation Faults
 Loss of Data, Time, and Focus
 Antibiotic Renewal Failure When CPOE Is Nonfunctional
 Diluent Options and Errors  Sending Medications to Wrong
 Allergy Information Delay Rooms When the Computer
 Conflicting or Duplicative System Has Shut Down
Medications  Late-in-Day Orders Lost for 24
Hours
 Role of Charting Difficulties in
Inaccurate and Delayed
Medication Administration
 Inflexible Ordering

21. Study that compares two CPOE system implementation to determine the
pediatric mortality rate after implementation of this system in pediatric intensive
care units.
CHILDREN’S HOSPITAL OF PITTSBURG CHILDREN’S HOSPITAL AND REGIONAL MEDICAL
(CHP) CENTER (CHRMC) IN SEATTLE, WASHINGTON
 Involved 1942 children  Involved 2533 pediatric
 Conducted over a period of patients
18 months (13 pre-  Conducted for a total of 26
implementation and 5 post- months, 13 pre/ 13 post-
Implementation). implementation.
 Indicated an increased  No significant increase in
morality of 6.6% from 2.8%. the mortality rate after
CPOE implementation.
DOES COPE INCREASE MORTALITY?

22. VARIANCE IN STUDY RESULTS
 CHP study had a smaller population size due to the difference in
the period of study, 18 months (CHP) and 26 months (CHRMC).
 Demographics of population were also younger, and study
included transferred patients.
 Use and application of data mining and statistical analysis varied.
 Different approaches to implementation in terms of time
frame, training, and availability and use of subject matter experts.
 Procedural and logistical changes were implemented at the same
time as CPOE implementation at CHP which had a negative
impact on effectiveness and efficiency of care.
 CHRMC personnel had an opportunity to review the results of
CHP and visit with the staff to improve implementation errors
which provided a second mover advantage.

23. CRITICAL FLAWS IN CHP STUDY
 Short implementation period of only six days.
 Order entry could not occur until a patient was
physically in the hospital. As a result, critical
patients in transit could not have their
medications processed and ordered until arrival
to the hospital.
 ICU pharmacy moved to a centralized pharmacy
not near ICU unit.
 This pharmacy could not dispense medication
until physician ordered through the CPOE
system.
 Predetermined order sets were not established
in the CPOE system prior to implementation.

24. REASONS FOR CPOE ERRORS
 The qualitative data was an important
element that impacted the CHP
implementation.2
 Workflow changes
 Lack of Order Sets
 Lack of Sufficient Training
 Technical Capabilities

26. RESEARCHERS INPUT

27. JOAN S. ASH FROM THE OREGON HEALTH & SCIENCE UNIVERSITY AT
PORTLAND
Presents the following recommendations for
implementation:
“now the CPOE implementation success depends primarily
on
1) Time considerations (response time and user time),
2) Meeting information needs (using order sets),
3) Multidimensional integration (especially with work flow),
4) The existence of essential people (leaders and support
staff, plus involved clinicians),
5) certain foundational underpinnings (e.g. trust between
administrators and clinicians), and
6) Improvement through evaluation and learning (paying
attentions to user feedback)” 2

28. FRANK FEAR WRITES IN “GOVERNANCE FIRST, TECHNOLOGY
SECOND, TO EFFECTIVE CPOE DEPLOYMENT”
 Planning a CPOE around the actual workflow
of organization is the key to long-term
success.
 Identifying and developing order sets in
advance to implementation may lead to long
term success.
 Order steps should be broad and general,
instead of specific to allow for adjustment as
physicians learn more about their system
needs and requirements. 14

29. “A RASCH MODEL ANALYSIS OF TECHNOLOGY USAGE IN
MINNESOTA HOSPITALS” BY JOHN OLSON ET AL.
 Indicates that prior  Identifies the “human factor”
technological and as being a critical
organizational component of this process.
knowledge is a function  Gradually integrate
of technical capabilities. HIT, allowing physicians the
opportunities to develop
 Recommendation is to capabilities at a slower pace.
implement EHR prior to  Identifying physician or nurse
CPOE implementation.1 “champions” of a system can
 CPOE was identified as a also gain overall “credibility”
challenging system that of a project.
should be implemented  Providing continuous training
as capabilities of hospitals may increase effectiveness
increase. 1,15 and reduce errors.1,15

31. HITS ARE EFFECTIVE TOOLS
 HITs can provide efficiency and effectiveness
in healthcare.1,2
 CPOE meets the Stage 1 meaningful use
requirements and provides a financial
incentive for implementation.1

32. TO ENCOURAGE SUCCESSFUL INTEGRATION
 Healthcare organization must understand the
difficulty of HIT systems and consider EHR
implementation prior to CPOE
 Organizations must also analyze the workflow and
establish broad order sets that will enable change
and input from physicians.14
 The “human factor” is a critical component of this
process.1,15
 Slow implementation
 Training and developing subject matter experts who can
serve as “champions” will increase the success rate of
integration. 1,15

33. REFERENCES
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7. Meaningful Use resource page. Search HealthIT Web site http://searchhealthit.techtarget.com/definition/meaningful-use . Accessed
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