Computerized Provider Order Entry

Computerized provider order entry (CPOE) is an application that allows health care providers to use a computer to directly enter medical orders electronically in inpatient and ambulatory settings, replacing the more traditional order methods of paper, verbal, telephone, and fax. CPOE systems can allow providers to electronically enter medication orders as well as laboratory, admission, radiology, referral, and procedure orders. Strictly defined, it is the process by which providers directly enter medical orders into a computer application.

While CPOE on its own has an impact on safety by ensuring legible orders, it is the addition of clinical decision support systems (CDSS) that drives the value of this functionality. This key component gives providers real-time support on a range of diagnosis- and treatment-related information as well as tools aimed at improving patient care and reducing medical errors and costs. In addition, decision support may add rules to check for drug-drug interactions, allergies, medication contraindications, and renal- and weight-based dosing.

CPOE systems with clinical decision support systems can improve medication safety and quality of care as well as compliance with guidelines and the efficiency of hospital workflow; they can also reduce the cost of care.

Evaluation of CPOE Systems

CPOE is one of the most studied technologies in all of health IT and has been evaluated in many settings.

• ICUs
  • Medication errors: a prospective cohort study of hand-written and computerized physician order entry in the intensive care unit
  • Evaluating the Safety and Efficiency of a CPOE System for Continuous Medication Infusions in a Pediatric ICU
  • A comparison of medication administrations errors using CPOE orders vs. handwritten orders for pediatric continuous drug infusions
• Ambulatory settings
  • Ambulatory Computerized Provider Order Entry (CPOE): Findings from the AHRQ Health IT Portfolio (PDF, 152 KB)

CPOE systems have emerged as a key technology for reducing medical errors. Of note, most institutions reporting significant benefits from CPOE implementation have been large academic institutions that have the resources to develop and periodically update their CPOE systems in response to the evolving nature of medicine and the needs of their organizations. Far fewer studies have demonstrated the benefits of off-the-shelf, vendor-supplied CPOE systems like those available to most medium- to small-sized hospitals and clinics in the United States.

While CPOE can improve patient care and increase efficiency, it is one of the most difficult to implement because of the impact on the culture and workflow of the organization. In addition, recent research suggests CPOE implementation can introduce various adverse unintended consequences. In order to identify and address potential unintended consequences, Sittig and colleagues have suggested a set of monitoring and evaluation recommendations (PDF, 51 KB ) for organizations to consider when implementing CPOE.

AHRQ has also documented emerging lessons from AHRQ-funded CPOE projects. More detail on the successes, failures, and lessons learned from the grantees that implemented CPOE in outpatient settings can be found in AHRQ's CPOE report (PDF, 192 KB) .

The following resources were selected from the Health IT Bibliography and represent peer-reviewed articles that describe best practices for the implementation and use of inpatient CPOE systems.

The Anatomy of Decision Support During Inpatient Care Provider Order Entry (CPOE): Empirical Observations from a Decade of CPOE Experience at Vanderbilt
Author(s): Miller RA, Waitman LR, Chen S, Rosenbloom ST
Source: J Biomed Inform 2005 Dec;38(6):469-85 Epub 2005 Oct 21.
Summary: The authors describe a pragmatic approach to the introduction of clinical decision support at the point of care, based on a decade of experience in developing and evolving Vanderbilt's inpatient "WizOrder" care provider order entry (CPOE) system. The inpatient care setting provides a unique opportunity to interject CPOE-based decision support features that restructure clinical workflows, deliver focused relevant educational materials, and influence how care is delivered to patients. The specific approach to implementing a given clinical decision support feature within a CPOE system should involve evaluation along three axes: what type of intervention to create; when to introduce the intervention into the user's workflow; and how disruptive, during use of the system, the intervention might be to end-users' workflows. Framing decision support in this manner may help both developers and clinical end-users plan future alterations to their systems when needs for new decision support features arise.

Computer Physician Order Entry: Benefits, Costs, and Issues
Author(s): Kuperman GJ, Gibson RF
Source: Ann Intern Med. 2003 Jul 1;139(1):31-39.
Summary: Information technology has consistently been identified as an important component for improvement throughout the health care system. Computerized physician order entry (CPOE) is a relatively new technology that allows physicians to enter orders into a computer instead of handwriting them; however, there is no consensus on the best approaches to the challenges it presents. CPOE fundamentally changes the ordering process, which can lead to: a substantial decrease in the overuse, underuse, and misuse of health care services; decrease in costs; shorten length of stay; decrease in medical errors; and improvement of compliance with several types of guidelines. The costs of implementing CPOE are substantial both in terms of technology and organizational process analysis and redesign, system implementation, and user training and support. This technology can yield many significant benefits and is an important platform for future changes to the health care system. Organizational leaders must advocate for CPOE as a critical tool in improving health care quality.

A Consensus Statement on Considerations for a Successful CPOE Implementation
Author(s): Ash JS, Starvi PZ, Kuperman GJ
Source: J Am Med Inform Assoc (JAMIA). 2003 May-Jun;10(3):229-34.
Summary: In May of 2001, 13 experts on computerized provider order entry (CPOE) from around the world gathered at a 2-day conference to develop a consensus statement on successful CPOE implementation.  A qualitative research approach, including activities before, during, and after the conference, was used to generate and validate a list of categories and considerations to guide CPOE implementation.  Preconference activities included prior reading for participants to establish a shared knowledge base.  During the conference, participants shared success factors they had discovered during their implementation of CPOE, developed lists of success factors, and prioritized main discussion points.  Postconference activities included creating a "themes document" that reflected participants' consensus on CPOE implementation.  The general considerations before CPOE implementation include: motivation for implementation; CPOE vision, leadership, and personnel; financial costs; integration: workflow, health care process; value to users/decision support systems; project management and staging of implementation; technology; training and support 24x7; learning/evaluation/improvement.

Evaluation and Certification of Computerized Provider Order Entry Systems
Author(s): Classen DC, Avery AJ, Bates DW
Source: J Am Med Inform Assoc (JAMIA). 2007 Jan-Feb;14(1):48-55 Epub 2006 Oct 31.
Summary: Computerized physician order entry (CPOE) is an application that is used to electronically write physician orders either in the hospital or in the outpatient setting. With the increasing implementation of commercial CPOE systems in various settings of care has come evidence that some implementation approaches may not achieve previously published results or may actually cause new errors or even harm. This has led to new initiatives to evaluate CPOE systems, which have been undertaken by vendors and other groups that evaluate vendors. Large employers have also joined this focus by developing flight simulation tools to evaluate the capabilities of these CPOE systems once implemented, potentially linking the results of such programs to reimbursement through pay-for-performance programs. The increasing role of CPOE systems in health care has invited much more scrutiny about the effectiveness of these systems in actual practice, which has the potential to improve their ultimate performance.

Evaluation of Outpatient Computerized Physician Medication Order Entry Systems: A Systematic Review
Author(s): Eslami S, Abu-Hanna A, de Keizer NF
Source: J Am Med Inform Assoc (JAMIA). 2007 Jul-Aug;14(4):400-6 Epub 2007 Apr 25.
Summary: This paper provides a systematic literature review of CPOE evaluation studies in the outpatient setting on safety; cost and efficiency; adherence to guideline; alerts; time; and satisfaction, usage, and usability. Thirty articles with original data (randomized clinical trial, non-randomized clinical trial, or observational study designs) met the inclusion criteria. Only four studies assessed the effect of CPOE on safety. The effect was not significant on the number of adverse drug events. Only one study showed a significant reduction of the number of medication errors. Three studies showed significant reductions in medication costs; five other studies could not support this. Most studies on adherence to guidelines showed a significant positive effect. The relatively small number of evaluation studies published to date does not provide adequate evidence that CPOE systems enhance safety and reduce cost in the outpatient settings. There is, however, evidence for (a) increasing adherence to guidelines, (b) increasing total prescribing time, and (c) high frequency of ignored alerts.

Key Attributes of a Successful Physician Order Entry System Implementation in a Multi-hospital Environment
Author(s): Ahmad A, Teater P, Bentley TD, Kuehn L, Kumar RR, Thomas A, Mekhjian HS
Source: J Am Med Inform Assoc (JAMIA). 2002 Jan-Feb;9(1):16-24.
Summary: The benefits of computerized physician order entry have been widely recognized, although few institutions have successfully installed these systems. Obstacles to successful implementation are organizational as well as technical. In the spring of 2000, following a four-year period of planning and customization, a 9-month pilot project, and a 14-month hiatus for year 2000, the Ohio State University Health System extensively implemented physician order entry across inpatient units. On implemented units, all orders are processed through the system, with 80 percent entered by physicians and the rest by nursing or other licensed care providers. The system is deployable across diverse clinical environments, focused on physicians as the primary users, and accepted by clinicians. They believe that the availability of specialty-specific order sets, the engagement of physician leadership, and a large-scale system implementation were key strategic factors that enabled physician-users to accept a physician order entry system, despite significant changes in workflow.

High Rates of Adverse Drug Events in a Highly Computerized Hospital
Author(s): Nebeker JR, Hoffman JM, Weir CR, Bennett CL, Hurdle JF
Source: Arch Intern Med 2005 May 23;165(10):1111-16.
Summary: Numerous studies have shown that specific computerized interventions may reduce medication errors, but few have examined adverse drug events (ADEs) across all stages of the computerized medication process. We describe the frequency and type of inpatient ADEs that occurred following the adoption of multiple computerized medication ordering and administration systems, including computerized physician order entry (CPOE). Pharmacists classified inpatient ADEs from prospective daily reviews of electronic medical records from a random sample of admissions at a Veterans Administration hospital. Of all ADEs, 9 percent resulted in serious harm, 22 percent in additional monitoring and interventions, 32 percent in interventions alone, and 11 percent in monitoring alone; 27 percent should have resulted in additional interventions or monitoring. Medication errors associated with ADEs occurred in the following stages: 61 percent ordering, 25 percent monitoring, 13 percent administration, 1 percent dispensing, and 0 percent transcription. High rates of ADEs may continue to occur after implementation of CPOE and related computerized medication systems that lack decision support for drug selection, dosing, and monitoring.

Overcoming Barriers to Adopting and Implementing Computerized Physician Order Entry Systems in U.S. Hospitals
Author(s): Poon EG, Blumenthal D, Jaggi T, Honour MM, Bates DW, Kaushal R
Source: Health Aff (Project Hope). 2004 Jul-Aug;23(4):184-90.
Summary: Few U.S. hospitals have implemented computerized physician order entry (CPOE) in spite of its effectiveness at preventing serious medication errors. We conducted in-depth interviews with senior management at 26 hospitals to identify ways to overcome barriers to adopting and implementing CPOE. Within the hospital, strong leadership, identifying physician champions of CPOE, leveraging the knowledge of younger physicians exposed to CPOE in medical school, and addressing workflow concerns were critical for successful implementation.  Additionally, hospitals that placed a high priority on patient safety and showed CPOE's impact on hospital efficiency could more easily justify the cost of CPOE. Outside the hospital, financial incentives and public pressures encouraged CPOE adoption. Disseminating data standards and providing third-party payer incentives would accelerate the maturation of vendors and lower CPOE costs. These findings highlight several policy levers to speed the adoption of this important patient safety technology.

Return on Investment for a Computerized Physician Order Entry System
Author(s): Kaushal R, Jha AK, Franz C, Glaser J, Shetty KD, Jaggi T, Middleton B, Kuperman GJ, Khorasani R, Tanasijevic M, Bates DW; Brigham and Women's Hospital CPOE Working Group
Source: J Am Med Inform Assoc (JAMIA). 2006 May-Jun;13(3):261-6 Epub 2006 Feb 24.
Summary: Although computerized physician order entry (CPOE) may decrease errors andimprove quality, hospital adoption has been slow. The high costs and limited data on financial benefits of CPOE systems are a major barrier to adoption. The authors assessed the costs and financial benefits of the CPOE system at Brigham and Women's Hospital (BWH), a 720-adult bed, tertiary care, academic hospital in Boston, over 10 years. Benefits were determined from published studies of the BWH CPOE system, interviews with hospital experts, and relevant internal documents. The culture at BWH is very supportive of informatics. Over 10 years, the system saved BWH $28.5 million for cumulative net savings of $16.7 million and net operating budget savings of $9.5 million, given the institutional 80 percent percent prospective reimbursement rate. The CPOE system at BWH has resulted in substantial savings, including operating budget savings, to the institution over 10 years. Other hospitals may be able to save money and improve patient safety by investing in CPOE systems.

Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors
Author(s): Ash JS, Berg M, Coiera E
Source: J Am Med Inform Assoc (JAMIA). 2004 Mar-Apr;11(2):104-12.
Summary: Medical error reduction is an international issue, as is the implementation of patient care information systems (PCISs) as a potential means of achieving it. As researchers conducting separate studies in the United States, the Netherlands, and Australia, using similar qualitative methods to investigate implementing PCISs, the authors have encountered many instances in which PCIS applications seem to foster errors rather than reduce their likelihood. The authors describe the kinds of silent errors they have witnessed and, from their disciplines (information science, sociology, and cognitive science), they interpret the nature of these errors. The errors fall into two main categories: those in the process of entering and retrieving information, and those in the communication and coordination process that the PCIS is supposed to support. The authors believe that with a heightened awareness of these issues, informaticians can educate, design systems, implement, and conduct research in such a way that they might be able to avoid the unintended consequences of these subtle silent errors.

The following AHRQ-funded projects were funded under the Transforming Healthcare Quality through Health Information Technology (THQIT) program.

1. CCHS-East Huron Hospital CPOE Project (Michael Waggoner; East Cleveland, OH)
2. CPOE Implementation in ICUs (Pascale Carayon; Madison, WI)
3. Comprehensive IT Solution for Quality and Patient Safety (Jim Jose; Atlanta, GA)
4. Implementing an Ambulatory Electronic Medical Record and Improving Shared Access (Michael Deluca; Mattoon, IL)
5. Improving Health Care through HIT (Deb Aders; Martinsville, IN)
6. Medication Management: A Closed Computerized Loop (Mark Hetz; Grants Pass, OR)
7. Project InfoCare (Peggy Esch; Bolivar, MO)
8. Regional Approach for THQIT in Rural Settings (Francis Richards; Danville, PA)
9. Rural Iowa Redesign of Care Delivery with EHR Functions (Don Crandall; Mason City, IA)