WEEK 3: Computerized Provider Order Entry (CPOE)

1. Early adoption in 1980s-1990s

2. Renewed attention after IOM reports

3. Patient safety focus

4. Supported by Leapfrog Group

5. Financial & Quality Benefits

Introduction & Background of CPOE

Early adoption in 1980s-1990s

Introduction & Background of CPOE

CPOE has historically been associated with early adopters at academic medical centers such as Brigham and Women’s Hospital which were able to implement such systems

Renewed attention after IOM reports

Introduction & Background of CPOE

• Turning Point: In 2000-2001, through the publications of the Institute of Medicine’s To Err is Human and Crossing the Quality Chasm

  • These reports shocked the industry by revealing thousands of patients died from preventable medical errors, many of which were related to medication ordering and communication failures

  • Because of these findings hc orgs and policy makers began promoting CPOE as a patient safety tool

• To Err is Human

• Crossing the Quality Chasm

What IOM reports led to increased promotion of CPOE?

Patient Safety Focus

Introduction & Background of CPOE

• Because of findings hc orgs and policy makers began promoting CPOE as a patient safety tool

Supported by Leapfrog Group

Introduction & Background of CPOE

• The ___ ____, an org that focus on hc quality also recommended CPOE as a standard for safe hospitals because it provides a clear return on investment through quality care

Financial & Quality Benefits

Introduction & Background of CPOE

• Gov’t programs like the HITECH and ARRA allowed hospitals to adopt CPOE by providing hospitals financial incentives if showed Meaningful Use for these systems and penalties for those who did not

Computerized Provider Order Entry (CPOE)

A system that requires end-users to electronically enter patient care orders and requests

True

True or False: Provider: includes Physicians, NPs, PAs any hc provider who are allowed to give medical orders

1. Provider enter orders directly into EHR

2. Removes transcript step

3. Supports order management

What is CPOE:

Provider enter orders directly into EHR

What is CPOE

• A system where ___ directly enter px orders, inc ___

Removes transcript step

What is CPOE

• By eliminating ___ the system reduces interpretation of handwriting, incorrect orders, delayed treatments, communication errors

Support order management

What is CPOE

• Data not only inputted once but continuously reviewed updated and monitored throughout px care

  • Unlike traditional charts when once written that is final and unable to be edited

  • CPOE can be edited and co-managers/consultants may also edit

  • Continuous, review, updated

Clinical Decision Support (CDS)

• The component in CPOE that assists healthcare providers in making safe and evidence-based clinical decisions when entering orders.

• Brain of CPOE

• Provides built in rules that check for drug-drug interactions, dose limits, and allergies in real time

Transcription of handwritten notes

Identify Entry Method of Traditional Systems

Direct entry by authorized provider

Identify Entry Method of Modern CPOE

Limited or no rules checking

Identify Decision Support of Traditional Systems

Built-in Clinical Decision Support

Identify Decision Support of Modern CPOE

“Once and done” entry

Identify Interaction of Traditional Systems

Ongoing review and management

Identify Interaction of Modern CPOE

• Illegible handwriting

• Missing information

• Late order processing

• Wrong medication or dose

Problems of Traditional Systems regarding transcription

1. Basic

2. Intermediate

3. Advanced

3 Levels of CPOE

Basic

Level of CPOE

• Simple CDS

• Simple order entries with basic checks, like allergies and D-D interactions, include electronic order entry with simple safety alerts, such as allergy warnings and D-D check

• Foundation of electronic ordering

Intermediate

Level of CPOE

• Results display, preferences

• Allows providers to view lab results, V/S, previous meds when ordering

• Providers can also save order sets and preference lists

Advanced

Level of CPOE

• Offer guided or mentored ordering

• Evidence based treatments based on diagnosis, patient conditions, and clinical guidelines 

• Helps standardize care and improve treatment consistency

• Acts as a meddler, giving context guidance for difficult clinical decisions

Basic to Intermediate

Most common level of CPOE in the Philippines

1. Financial

2. Resource Limitations

3. Human Factor

4. Workflow Disruption

5. Digital Divide

5 Barriers to CPOE Adoption

Financial

Barriers to CPOE Adoption

• Cost & Affordability

  • Are expensive to purchase, customize, and maintain

  • Small hospitals and clinics often lack funding

  • Only few private hospitals adopted CPOE since funds are allocated to other facilities, rather than CPOE

Resource Limitations

Barriers to CPOE Adoption

• Facilities may lack trained IT staff to manage system

Human Factor

Barriers to CPOE Adoption

• Provider Resistance

  • Some providers feel uncomfy using computers and fear computers will slow them down

  • Some doctors often feel typing takes longer than writing which leads to their frustration

Workflow Disruption

Barriers to CPOE Adoption

• CPOE changes how nurses and doctors work in the area

• Requiring new routines and skills

• Changes mental and physical way clinicians do their job

• Isn’t just about the computer but changing human behavior

Digital Divide

Barriers to CPOE Adoption

• Small practices and rural hospitals often __ due to limited resources and funds

1. Executive Leadership Support

2. Physician Involvement

3. Multidisciplinary Collaborating

4. Flexible Training

5. Realistic Goals

6. Sustainable Support model

6 Strategies for Sucess

Executive Leadership Support

Strategy for Success

• Top ranks must be supportive, leaders must provide funding, direction, and motivation

Physician Involvement

Strategy for Success

• Doctors should participate in system design to ensure it works for them

Multidisciplinary Collaborating

Strategy for Success

• Nurses, pharmacists, IT staff, and administrators must work together.

  • Teamwork is needed

Flexible Training

Strategy for Success

• Training should be continuous and adaptive to different learning styles

• You need a help desk and superusers available all the time—in case something happens to the system and avoid delay in work

Realistic Goals

Strategy for Success

• Done in phases

Sustainable Support Model

Strategy for Success

• Ongoing technical and clinical support is essential

patient safety advocate; system usability expert

As a Nurse Informaticist, you are the ____ ____ ____ and ____ ____ ____.

• You don't just fix computers, you ensure tech actually helps the patient

• You serve as a bridge between clinical practice and information technology

1. Domain Knowledge & Expertise

2. Change Management

3. Patient Safety Advocacy

4. System Usability Expert

4 Roles of Nurse Informaticist

Domain Knowledge & Expertise

Roles of Nurse Informaticist

• Understand how a nurse normally and actually moves and thinks on the floor or the ward

• Contribute clinical expertise to the system design, ensuring that nursing workflows are properly represented

Change Management

Roles of Nurse Informaticist

• Manage the organizational readiness, the psychological and structural factors of change

• You can staff through change management processes

• And adjust your systems and anxieties related to technology use

Patient Safety Advocate

Roles of Nurse Informaticist

• Evaluate based on their learnability, efficiency, error prevention, satisfaction and utility

  • Advocate for patient safety by identifying potential risks and unintended consequences of system design

System Usability Expert

Roles of Nurse Informaticist

• Evaluate system usability to ensure that the interface is efficient, safe, and easy to learn

• Bc nurses interact with the patients orders more frequently than any other

1. Organizational Readiness

2. Psychological & Structural Factors

3. Communication Planning

4. Provider Support Post-Implementation

Change Management

Organizational Readiness

Change Management

• Include both:

  • Willingness to change

  • Capacity to support change

Psychological & Structural Factors

Change Management

• ___ factors involve:

  • Staff attitudes, 

  • motivation, and 

  • confidence using tech

• __ factors include:

  • Availability of comps

  • Internet access

  • Training programs

  • Technical support

1. Staff attitudes, 

2. motivation, and 

3. confidence using tech

Psychological Factors

1. Availability of computers

2. Internet access

3. Training programs

4. Technical support

Structural Factors

Communication Planning

Change Management

• Should merely explain why the change is needed, how it benefits px, and what support is available

Provider Support Post-Implementation

Change Management

• Improve long term system use

  • is needed to reduce stress, maintain job satisfaction, and long term system use

Usability

Refers to how easily users can interact with the system

1. Learnability

2. Efficiency

3. Error Prevention

4. Satisfaction

5. Utility

5 Key Components of Usability & Patient Safety

Learnability

Key Component of Usability & Patient Safety

• How fast users understand the system

Efficiency

Key Component of Usability & Patient Safety

• How quickly tasks can be completed

Error Prevention

Key Component of Usability & Patient Safety

• How we prevent mistakes

Satisfaction

Key Component of Usability & Patient Safety

• How comfortable users feel using the system

Utility

Key Component of Usability & Patient Safety

• How useful the system is for daily tasks

Process Improvement (PDSA)

A structured method used to improve the healthcare system continuously while maintaining patient safety.

• This cycle allows healthcare institutions to refine CPOE systems gradually well, maintaining px safety

• Use this cycle to positively fix and improve the system for continuous optimization

1. Plan

2. Do

3. Study

4. Act

Process Improvement

Plan

Process Improvement

• Identify problems and decide solutions

Do

Process Improvement

• Implement changes on a small scale

Study

Process Improvement

• Evaluate outcomes and identify improvements

Act

Process Improvement

• Apply successful changes

1. Application Knowledge

2. Workflow Design

3. Change Leadership

4. Usability Testing

5. Healthcare Policy Awareness

5 Core Competencies of a Nurse Informaticist

1. Expanded Interdisciplinary Collaboration

2. Patient Engagement

3. Smarter System

4. New Hardware Platforms

5. Improved Interoperability

5 Future Directions

Expanded Interdisciplinary Collaboration

Future Direction

• Will increase allowing nurses and pharmacists to contribute to order suggestions and care planning

Patient Engagement

Future Direction

• Px will be more involved—verifying meds, treatment plans through px portals

Smarter System

Future Direction

• System will become this by predicting provider needs and offering more personalized clinical decision support

New Hardware Platforms

Future Direction

• ___ ____, such as tablets and mobile devices will make order entry more flexible and accessible

Improved Interoperability

Future Direction

• Seamless sharing of patient data across the HC institutions