Enhancing Medication CPOE Safety and Quality by Indications-Based Prescribing

Research shows that incorporation of medication indications-–defined as the notation of a medication’s purpose-–into the prescribing process has the potential to prevent medication errors and patient harm, as well as make prescribing more efficient. However, current computerized prescriber order entry (CPOE) systems do not effectively support adding indications to prescriptions. This project sought to address this limitation by convening six stakeholder panels to achieve consensus on the rationale, needs, requirements, and implications of incorporating medication indication into CPOE. Applying a user-centered design process and incorporating the recommendations from the panels, the researchers designed a prototype that incorporates drug indication into the prescription and ordering workflow. In addition, they interviewed patients and pharmacists to obtain feedback on sample medication lists and bottles with indications. The prototype was compared to two leading commercial CPOE systems. The team hypothesized that the new system would significantly improve ordering speed, error rate, and prescribers’ experience and satisfaction.

The specific aims of the project were as follows:

• Convene six stakeholder expert panels to achieve consensus and buy-in on the rationale, multi-user needs, operational and interoperability requirements, interface design principles, limitations and barriers, and policy implications of incorporating medication indication into CPOE. 
• Design and build a working prototype of an indications-enabled CPOE system, informed by the recommendations from the first aim. 
• Formally test and compare this indications-based prototype to two widely deployed CPOE systems using eight pre-defined use-case clinical scenarios. 

The project convened six 90-minute webinars with more than 300 individuals from 75 organizations to define requirements, discuss implications, and create model features of an innovative CPOE system that incorporated medication indications into the prescription. The topics for the six webinars, along with the PowerPoint slides and recordings are available online at: https://www.ahrq.gov/chain/research-tools/featured-certs/improving-hit-prescribing-safety-year-1.html.

The team used the lessons and key insights learned from the stakeholder panels to design a working prototype for indications-based prescribing. Development of the prototype included expert input, contextual inquiry sessions, participatory design sessions, usability roundtables, and formative usability testing. Usability testing was conducted on the final prototype to compare performance of the prototype to two existing leading commercial vendor electronic health records and found that the prototype CPOE system outperformed the commercial systems for all scenarios in terms of participants’ efficiency, effectiveness, and provider satisfaction. The research team concluded that it is imperative to design CPOE systems to efficiently and effectively incorporate indications into prescriber workflows and optimize ways this can best be accomplished.