August 2, 2007

Ordering CPOEs

Two studies in the current issue of Journal of the American Medical Informatics Association (JAMIA) highlight the current frustration with, and potential importance of, computerized physician (provider) order entry (CPOE) systems. The electronic entry of physician instructions for patient care has been touted by the government as a way to reduce medication errors and improve safety, although studies to date have shown mixed results. CPOE has the potential to change patient care, for better or worse, particularly when the ordering process is linked to clinical decision support software, clinical guidelines, and alerts.

Joan Ash, PhD, Department of Medical Informatics and Clinical Epidemiology at Oregon Health & Science University’s School of Medicine, and colleagues followed up their earlier work on unintended consequences of CPOE use at five selected hospitals, with this current study, The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry. Here, they sought to measure the extent and importance of eight of these previously identified types of unintended consequences at every US hospitals with a CPOE system. A total of 176 hospitals completed the telephone survey, a response rate of 47%. Six of the eight types of unintended consequences previously identified by the five hospitals were also considered important by the majority of these 176 hospitals: workflow issues; communications issues; overdependence on technology; never-ending system demands; emotions (usually negative); and more/new work issues. The remaining two types—changes in power structure, and new kinds of errors—identified as important in the preliminary study were not regarded as important with the majority of these hospitals. The authors note an important limitation of their study: they queried individuals who “might have given answers biased in a positive way because they believe in CPOE’s benefits. This might help explain why the two categories of power shifts and new kinds of errors did not rank highly…” The authors’ recommend that hospital leaders charged with implementing CPOE consider each of the eight types of unintended adverse consequences carefully during their planning. “Implementation success depends on managing the unintended, as well as the intended, consequences of CPOE…Unless we make a concerted effort to avoid, manage, and/or overcome unintended consequences, the implementation of clinical information systems may lead to detrimental results.”

Evaluation of Outpatient Computerized Physician Medication Order Entry Systems: A Systematic Review provides a literature review of outpatient CPOE evaluation studies to determine if outcomes exist related to improved patient care. The authors identified 30 such studies, a relatively small number with few if any of them deemed to be well designed. The study’s main finding was that the available evidence does not demostrate that CPOE enhances safety or reduces medication costs, although they did find an increased adherence to clinical guidelines. The outpatient setting presents challenges to CPOE research because inpatient orders tend to be more easily collected and reviewed due to centralized hospital information systems.

As technology advances and the applied research aspects of medical informatics matures, we can hope for better, more clinically relevant studies on software and best-of-breed applications directed at evidence-based practices.

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