While CPOE is a wonderful tool to help reduce medical errors (medication and non-medication orders) and improve efficiency, it poses several technical and business clinical process re-engineering challenges. While I think it’s important to share issues, it’s also important to look at creative solutions and workarounds to these challenges. The following represent some of the solutions that proved useful to Adept clients facing problems with CPOE implementation.
Medication standardizing – ‘Out of Scope’ medications and all medication will require ‘standard’ units of measurement to be defined (i.e. titrates, chemotherapy medication, creams, IV’s, etc.). The challenge here is defining a standard unit of measurement and incorporating that into the system, then adjusting the intake and other processes to accommodate.
Take the following case: a man is brought into the ER with 2nd degree burns. In a non-CPOE environment, the attending would write a script for burn cream. This would include the necessary information on the amount of cream required, etc. Within the CPOE system, however, this becomes a challenge.
You do not want use ad hoc notes for defining any type of vital information, volume or statistics. You want these to be separate fields with appropriate algorithms to allow the system to determine the amounts to dispense using standardized doses. *Note: If you plan to use any type of inventory control, automated ordering and/or ERP/SAP this will be vital. Additionally, it gives you better information for data mining, trending information, valuating outcomes, interaction (drug/allergy) systems and clinical decision support systems.
Second, you will want to ensure all relevant data is captured in the system to enable it to determine the appropriate doses. Therefore, you will want to review your intake process and system functionality (at the point of intake) to ensure the necessary information is being collected.
From the CPOE side, this is what that same case might look like: For the man who came in with burns, the intake process notes his height, weight, body fat index, burn percentage on the body, meds/creams provided by EMT (for interaction evaluation and inclusion in their electronic record), along with a host of other information. These need to be entered in the system prior to any “ordering.” Once in the system, algorithms will use the intake information to determine appropriate amounts for dosing and will allow automation for inventory control, eMAR and other backend system functions for a fully integrated system.
Clinical Pharmacists – Physician participation and acceptance is always an issue with CPOE systems and the workflow modifications. We have found that the use of Clinical Pharmacists often reduces physician resistance toward CPOE systems. Clinical pharmacists undergo training in drug therapy management and clinical pharmacotherapy through a six-year doctoral program and are often trained through general residency programs and, sometimes, specialized fellowships. This expertise in alternate therapies and modern techniques plus the benefit of having another set of eyes double check for medical errors and drug interactions helps balance the inconvenience of CPOE. You can utilize the expertise of a clinical pharmacist in a few different ways. Our next two solutions offer two distinct approaches; before deciding on one (or combining them), be sure to consider the pros and cons of each.
Pharmacist/Physician Interaction and Communication Planning – The current drug-use process begins with physician prescribing followed by pharmacy review, dispensing, distribution, actual drug administration, and charting. However, we recommend that pharmacists accompany physicians during their hospital rounds in order to discuss appropriate medication use for individual patients and then enter the orders electronically. By entering the prescribing order directly into the electronic system, the system provides a secondary review of prescription orders sooner and could reduce some medication errors. *Note: the clinical pharmacist will enter the order and the dispensing pharmacist will fill it.
CphOE (Computer-Aided Pharmacist Order Entry) – This expands the traditional role of pharmacists (especially Clinical Pharmacists) and enables the physicians to focus on diagnosis and patient care. In this scenario, physicians do not have to focus on alerts for drug allergy and drug-drug interactions and other potential therapies—this job is left to the pharmacists, who now have to execute a second review of the prescription. This process reduces the amount of communication required between physicians and pharmacists which has traditionally been a challenge. The Vanderbilt University Medical Center utilizes this approach.
eMAR/Bar-coding vs. CPOE – Another major point of concern is making certain the staff understands the difference between using bar-coding and eMAR versus CPOE. Many executives and administrators don’t recognize that these are separate systems and focus on different functions. Both of these tools reduce errors in different ways; bar-coding/eMAR is a great tool for reducing errors associated with memory lapses or mental slips while CPOE is more likely to prevent errors resulting from bad judgment, insufficient knowledge or incomplete clinical information. While this distinction may seem arbitrary, not highlighting these distinctions within the design and workflow development could negatively affect the productivity of the system.
Physician & Clinician Involvement and Adoption – Getting physicians, pharmacists, and nurses involved early in the process is fundamental to system success. Develop focus groups early in the design process, as strong clinician involvement will help make this an organization initiative and not an IT/business function.
Understand the Reality – CPOE should be designed as a custom extension of clinical and operational philosophies, not the other way around. The objective is to create processes and tools that support and enhance clinical “Best Practices”. CPOE is a vital set of processes that cross various modules and applications within an organization. Studies indicate most organizations that have implemented CPOE failed to recognize all the possible benefits and extensions of a good CPOE process.
CPOE Strategy – It is crucial that your CPOE strategy fits your clinical and operational strategies. Identify any potential changes that may affect the CPOE process. For instance, you may want to design the system in anticipation of future HIE and ICD (10) implementation by defining the points of integration. Healthcare organizations have numerous options for combating potential issues: upgrading relevant applications (remediate existing systems), rolling the HIPAA 5010 and ICD-10 work into a single EHR implementation, or relying on clearinghouses. Combining two or more of those avenues is a legitimate option as well.
ICD-10 & HIPAA 5010 –Due to the significant transaction differences and coding redevelopment, these need to be defined and planned before you initiate your detailed planning for CPOE.
Integrated Initiatives – While we all understand CPOE, ICD-10 and HIPAA 5010 and revenue cycle optimizations are distinct initiatives with different goals and objectives, they are interconnected and need to be treated accordingly. If you decide to have discrete implementations, be careful to plan effectively and utilize strong change controls for the best integration.
Test Your Design – It is critical to ensure you have a sound design and strategy for your CPOE. There are a few ways you can accomplish this efficiently and effectively.
Again, these are just a few of the challenges and considerations for CPOE. Every organization is unique in its systems, people, and structure; consequently every organization requires a well-planned, customized system and process. Remember: just because CPOE is implemented and running does not mean it is operating at its full potential. In order to overcome these challenges and more, it is important to make sure your team is backed with experience in the planning and execution of CPOE.