Computerized Physician Order Entry: a focus on medication prescription

1. Computerized Physician Order Entry: a focus on medication prescription Nicolette de Keizer & Saeid Eslami Dept Medical Informatics University of Amsterdam

2. Outline • Definition and context • Advantages of CPOE • Disadvantages of CPOE • Outcome measures and examples • Same system other outcome

3. What is Computerized Physician Order Entry (CPOE)? Ordering of tests, medications, and treatments for patient care using computers Involves electronic communication of the orders Often use rules-based methods for checking appropriateness of care

4. CPOE, EHR and DSS Documentation DSS Medication EHR Test reports (EKG, PFT) Radiology, lab results CPOE

5. CPOE • Has a positive influence on patients’ outcome • Has a negative influence on patients’ outcome

6. CPOE Advantages Automate ordering process Reduces Order Errors Standardized, legible complete orders DSS/Alerts Data collected on variances in practice

7. Case Example Metformin is prescribed to a patient with an elevated creatinine level. A drug-lab interaction alert warns that use of this medication could result in an increased risk of fatal lactic acidosis.

8. Case Example A physician prescribes warfarin for a patient with chronic atrial fibrillation. System: vitamin K rich food likely to interfere with the efficacy of the drug. Specific patient information

9. Example DSS in CPOE – medication prescription • Allergy • Age (check drug name and dose) • Duplicate drugs on active orders, not one-time • Severe drug interactions • Drug-drug, drug-food • Dose maximum • Drugs with opposite actions

10. CPOE Disadvantages Errors still possible Alerts Multiple steps Access

11. PubMed indexed papers on CPOE

12. CPOE • Has a positive influence on patients’ outcome • Has a negative influence on patients’ outcome • On which outcome measure?

13. Outcome measures • Adherence to guideline • Alerts - user response • Time • Safety • Medication errors • ADEs (mortality) • Cost and Efficiency • Medication costs • Pharmacists interventions • Satisfaction, usage and usability

15. Example CPOE improves adherence to guideline Teich JM et al. Arch Intern Med. 2000 Oct 9;160(18):2713-4.

16. Example CPOE reduce errors • Potts studied ADE rates in 13,828 medication orders before/after CPOE implementation at Vanderbilt Children’s PICU: Potts AL, Barr FE, et al. Pediatrics. 2004 Jan;113(1 Pt 1):59-63.

17. Example CPOE introduces errors • Brigham and Womens' Hospital, Boston introduced a CPOE • After implementation, the rate of intercepted Adverse Drug Events (ADE) doubled! • Reason: The system allowed to easily order much too large dosages of potassium chloride without clear indicating that it be given in divided doses. • Bates et al The impact of computerized physician order entry on medication error prevention. JAMIA 1999, 6(4), 313-21.

18. Example CPOE introduces errors Association with increased PICU mortality: 2.8% 14 months before CPOE 6.4% 5 months after CPOE Han YY, Carcillo JA, et al. Pediatrics. 2005 Dec;116(6):1506-12.

19. Example CPOE reduce costs Brigham and Women’s Experience: Cost-Effective • Cost: • $3.7 million implementation • $ 600,000 to $1.1 million operational costs • Results: • Decreased drug costs • ADE cost is approximately $4,700 • Kausal R et al. J Am Med Inform Assoc. 2006; 13(3): 365-7

20. CPOE and cost • Huge variation in actual costs based on hospital size and complexity of system • Hardware and Software: $1-$5 million • Staff training • Ongoing maintenance • Total costs for large, fully integrated systems could be up to $60 million • Costs will decrease when DSS is geared to cost reduction

21. Usability Problems Potential selection errors Similar medication names Similar patient names Overly trust default values Influence workflow and communication Physician resistance Frequent data entry required Must not require additional time Most decision-support steps must be turned off to encourage use “Not-invented-here” syndrome

22. CPOE as a Sociotechnical intervention • Health information systems has to deal with the actors, the artefacts, and their interaction. CPOE =socio-technical systems

23. Same system other outcome • Upperman vs. Han • same hospital: Pittsburgh Childrens Hospital • other outcome measure: ADE vs mortality • Han vs. Del Beccaro • Same CPOE • Different hospitals • Same outcome measure (mortality) Upperman et al. J Pediar Surg. 2005;40:57–59; Han et al. Pediatrics. 2005 Dec;116(6):1506-12; Del Beccaro. Pediatrics 2006;118;290-295.

24. Upperman et al * p<0.05

25. Han et al * p<0.05

26. Del Becarro et al • Same results for: • transported patients • congenital cardiovascular disease patients

27. Upperman vs Han • Surrogate outcome measures such as medication errors and ADEs are not sufficient • More studies on mortality are necessary

28. Han vs. Del Beccaro • Methodological differences: • Han used unbalanced before after periods • Del Beccaro did not correct for case mix differences in before vs after period • Populations Han vs. Del Beccaro were not comparable

29. Han vs. Del Beccaro • Pittsburgh implemented too fast without pilot and usability testing: • Order entry only allowed when patient physically entered hospital • All medication in central pharmacy • Pharmacy processed order only after complete activation by nurse • Go live without necessary order sets

30. Han vs. Del Beccaro • Seattle hospital learned from Pittsburgh • Factors influencing successful implementation: • response time and user time • meeting information needs (e.g.using order sets) • multidimensional integration with workflow • Involvement leaders, support staff, clinicians • training • improvement through evaluation and learning

31. Will a CPOE improve quality of care? Yes if you implement it the right way!!

32. Successful CPOE implementation • Technical Infrastructure: • EHR • Drug information database • DSS • Sociotechnical implementation strategy • Usability pilots • Teams of informaticians, physicians, nurses, clerks, therapists • Strong leader and good project management • Training and support • R. Gardner: “implementation is 90% organizational and political and 10% technical”