Computerized Physician Order Entry: Has the Time Come?

Jacob Reider, MD

Disclosures
In This Article

Decision Support Boosts CPOE Potential

If we consider a physician order for a medication in a legacy environment, we could track the progress of the order from the physician's pen in the chart to the nurse or floor clerk who retrieves the order, and then conveys it to the pharmacy either by entering it into a computer or by calling, "tube-ing," or faxing. Let's now consider that the physician makes an error in the order, either in dosing, legibility, or perhaps simply by ordering a nonformulary medication. With a legacy system, there is no good method for a computer system to assist the physician in any way.

Unlike a legacy system, however, CPOE can aid a physician in decision support, providing benefits to patients and healthcare organizations in these important areas:

Patient safety. There are compelling data[3] that medication errors can be significantly reduced. A physician entering a medication into a CPOE system would be presented with options that would guide her or him toward better decisions. For example, to prescribe ciprofloxacin, a physician may type in the first few letters of the medication, click "search," and would then be presented with the appropriate dosage forms for ciprofloxacin, with common indications and suggested dosages for these indications.

Yet what if the patient has community-acquired pneumonia? The prescribing screen (like many paper antibiotic order sheets) may request a diagnosis and/or suspected pathogen. If the physician selects "community-acquired pneumonia," the CPOE system could alert the physician to reconsider the antibiotic choice, and could even suggest a hospital protocol for community-acquired pneumonia based on regional epidemiology and/or best practice guidelines.

The advantages of such a scenario are clear: Outcomes could improve, physicians could be instantly prompted to avoid prescribing medications that their patients are allergic to, and turn-around times between physician ordering and patient receipt of treatments could decrease due to the reduced number of humans involved in the processing of the order.[4]

Cost. While some studies suggest that cost is significantly lower with CPOE,[5] others have not replicated such significant results, suggesting that reduced costs are not universal.[6]

Quality of care. With standardization of order sets and the improved formulary compliance that CPOE offers, the variability of care will diminish, and compliance with hospital guidelines and protocols will improve.[7]

Process improvements. By linking automated processes, a CPOE system could significantly improve hospital workflow. An "NPO" (nothing by mouth) order in the system could, for example, automatically generate a message to the kitchen to hold a patient's dinner tray, or an order for a contrasted CT scan could automatically generate an additional order for oral contrast material.

With all of these potential and demonstrated benefits, why don't all physicians use CPOE?

Physician acceptance. If your blood pressure went up as you read the paragraph about the ciprofloxacin dosage, you're not alone. Clinical decision support is a very tricky business. On the one hand, physicians appreciate gentle guidance. Showing the available dosage forms for ciprofloxacin -- and even suggested doses for certain conditions -- may be welcome to most physicians. But if a system asks too many questions, or places too many demands on physicians during the course of their day, they simply won't tolerate such intrusions on their clinical decision-making and their valuable time.

Some physicians simply don't like using computers. In an academic setting, where many of the physicians are residents or employed faculty physicians, CPOE has been easier to implement because the majority of physicians in such an environment are employees, and therefore cannot direct their patients elsewhere. ("Where I don't have to use that computer thing!") Yet in community practice, where physicians work in private hospitals and hospitals often find themselves courting physicians to admit patients, CPOE is much more challenging.

Cost. The financial commitment that a hospital must make to install such a system is enormous, as is the risk. Choosing a CPOE system, and making the investment of time and money to make it work right within a hospital culture, is no small task. Cedars-Sinai Medical Center in Los Angeles recently shut down its CPOE system after years of work, and millions of dollars of investment, after physicians complained that it was too difficult to use.

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