The successful implementation of computerized prescriber order entry (CPOE) in health care settings is a project that both relies on and affects numerous departments and practitioners. In order to reach its potential as a workflow and patient safety tool, the development and installation of a CPOE system must be a multidepartmental initiative that seeks and gains input from all relevant parties.
The goal of the clinical laboratory is to perform the right test for the right patient at the right time in order to positively impact patient care and enable the lab to become a true physician’s aid at the bedside. Therefore, medical laboratories should play a pivotal role in the development and adoption of CPOE. While simply advocating for and using CPOE is important, in order to fully realize the benefits of CPOE, the laboratory must gain a specific understanding of its role and take an ownership stake in the project. Crucial to this process is the creation of evidence-based order sets that the laboratory can manage and prescribers can use to process patient treatment orders in the most efficient way possible.
Common Non-CPOE Issues
MedCentral Health System in Mansfield, Ohio, is a 351-bed system comprising two hospitals with laboratories that process 1.4 million tests annually. Before CPOE and evidence-based order sets were implemented at our health system, four types of commonly reoccurring problems were identified: testing overutilization, testing underutilization, wrong orders, and off label use. Among these, overutilization seems to be the issue bearing most concern among laboratorians.
Undoubtedly, every laboratorian in this country has encountered this problem at some point and CPOE can be an effective tool to help control it. However, it is important to keep in mind that a truly advantageous CPOE enterprise must be based on medical evidence, bringing about positive change due to the soundness of its protocols; it is not simply a means to an end of limiting testing overutilization. Therefore, when our physician advisory group (PAG) [see SIDEBAR] began working on developing order sets for laboratory tests, they focused the bulk of their attention on evidence-based medicine (EBM). Of course, the PAG was well aware of the potential for overutilization of lab tests, procedures, and medications, based on experience and past research.
For a short publication that addresses this issue from the laboratory point of view, see Impact of CPOE Order Sets on Lab Orders from the 2003 AMIA Symposium Proceedings.1 The authors found an increase in lab test utilization when the CPOE order sets were derived from best practices (except in surgical diagnosis-related groups, where test utilization decreased). This tells us that in addition to overutilization, there is also underutilization of tests. To properly address these issues from the onset, MedCentral’s PAG decided to implement EBM order sets and then analyze utilization patterns. As expected, what we are now seeing is that when order sets are built based on true EBM, problems of overutilization, underutilization, wrong order, and improper off-label use dwindle because every test request must be made within the confines of established evidence. This fulfills the laboratory’s mission of helping physicians order the right test, at the right time, for the right patient according to the evidence.
Essential CPOE Elements
In theory, the use of CPOE should not affect the way orders are received and processed in the lab. However, when poorly designed, recently implemented, or loosely controlled, use of CPOE can introduce new problems. For example, even when a physician’s laboratory orders are integrated and documented with the patient’s clinical information and automatically checked for errors like duplication, the physician might be able to overrule it and keep the initial orders entered, even if they are unnecessary or redundant.
With this in mind, the following elements are critical for the initial CPOE adoption to flourish:
The most basic functions of CPOE—entering and processing orders via computer (as opposed to handwritten paper orders), integrating patient information, and error review—benefit all departments and staff involved in direct patient care. Proper use of CPOE systems and evidence-based order sets provide improved communication between the ordering prescriber and the laboratory department, which inherently improves physician satisfaction because laboratorians or nurses rarely need to contact them for clarification. CPOE also leads directly to decreased transcription errors, decreased order duplications, the elimination of standing orders, and a decrease in the number of patient blood draws (iatrogenic anemia). As these operational improvements benefit all health care practitioners, CPOE and evidence-based order sets have the potential to improve efficiencies, reduce health care costs, and increase patient safety.
Integration with Information Systems
Integrating CPOE into a hospital’s technology platform can be done via the hospital information system (HIS), as is the case for MedCentral, or it can be done using a middleware specifically for CPOE. In MedCentral’s IT architecture, the HIS is fully integrated with the LIS. Therefore, an entered order for laboratory services is automatically sent from the HIS to the LIS with the patient’s entire demographic, the ordering physician’s information, date and time of ordering, physician’s comment (if present), and any other information that allows traceability of the transaction.
In addition, and perhaps most important, our HIS/CPOE system is set up to check for duplicate orders. The laboratory department has defined a minimum frequency requirement for several tests—eg, urine culture no sooner than 24 hours; CBC with differential no sooner than 24 hours; influenza, rotavirus, respiratory syncytial virus Ag (RSV) no sooner than 24 hours. If a physician orders one or more of these tests more frequently than what is established by the CPOE PAG, the HIS/CPOE system will alert the physician of the possibility of duplicated orders at the moment the physician is signing the orders. If the physician chooses to keep the orders because of a clinical indication that supports more frequent testing, such as diabetes ketoacidosis, hypovolemic shock, or severe sepsis with multiple organ failure, he or she will have to input a reason for the deviation. Enabling duplicate checking and documenting any physician overruling of the attendant alert allows the lab to analyze these trends and improve lab test utilization.
Development of Order Sets
In general, CPOE systems seek to create a standardized, electronic network to process patient treatment information, including medication and laboratory testing orders, in order to address a number of deficiencies in paper-based systems (see FIGURE 1). Within a CPOE system, orders for services are best handled using predetermined, evidence-based order sets to enable this standardization. An order set is a group of patient care orders organized along a common theme such as signs or symptoms, diagnoses, procedure, treatment, etc.
Thus, there are significant, system-wide benefits to developing standardized order sets:
Converting Paper Order Sets
At MedCentral, we developed our order sets in two ways: by using evidence-based order set templates and by adapting and improving previously used paper order sets, the latter of which is done more frequently when the order set is intended for specialists. When working with order set templates, the first step is prioritization. After the PAG selects the appropriate order sets, the laboratory and pharmacy departments are the first services to edit and make suggestions for improvement. By way of example, when reviewing the order set for acute myocardial infarction, the initial order set template might indicate that the associated diagnostic test can be Troponin-I, Troponin-T, or CK-MB, but in your laboratory, only Troponin-I is performed. In this case, the laboratory representative would edit the order set to reflect actual test menu options.
After the lab and the pharmacy review the order sets, physicians add their comments and then the sets are returned to the PAG to evaluate all previous alterations, discuss and determine any further modifications, and then begin educating all associated staff based on PAG approvals. This step is critical because it involves the creation of standards of practice that ideally will lead to improved utilization of procedures, medications, and laboratory tests. Lastly, the facility’s Medical Executive Board must grant their approval of all order sets.
Managing the transition of paper order sets to electronic, CPOE-friendly versions is less time and labor intensive than customizing templates, as the paper order set has previously been reviewed and approved. In order to convert a paper order set to CPOE, it simply needs to be converted to an electronic format; a process that includes linking evidence-based guidelines and quality measures, as well as making any improvements deemed necessary since the paper order set was developed or last updated.
The Laboratory’s Checklist
Use of a basic checklist can be quite beneficial when reviewing and approving order sets from the laboratory perspective. This checklist should include the following basic precepts:
After CPOE implementation and after prescribers and order recipients become comfortable using the system, overall communication between ordering physicians and the laboratory will become more lean and efficient. The fundamental concept is that the forced functions of CPOE based on evidence will mitigateoverutilization, underutilization, wrong ordering, and off label use. When choices are limited based on evidence, these issues become less refutable. For example, after implementing one of the American Society for Microbiology’s Clostridium difficile testing algorithms through CPOE, utilization of this test has decreased by 60% in the inpatient population. Likewise, underutilization of testing has been remedied through EBM-based CPOE; in 2009, 57% of blood cultures performed in the emergency department were single blood cultures. Ordering a single blood culture generally constitutes a substandard of care and should never be done for adult patients in particular, as this practice results in an inadequate volume of blood cultured, and the results of a single blood culture are more difficult to interpret. According to the present Clinical and Laboratory Standard Institute (CLSI) guideline, collecting two or three sets of blood cultures per episode (each set from a different site) is appropriate. After adopting this test to CPOE through a medical executive board-approved protocol, 100% of the blood culture orders in the emergency department are now within the CLSI guideline.
Regardless, the laboratory’s role in perpetuating proper CPOE and order set use does not end there. Ongoing analysis of CPOE and order set utilization patterns makes effective use of physician and user feedback and allows the lab to offer further education when necessary.
As with any process change of the scale presented by the transition to CPOE, we faced the multifaceted challenge of reengineering the entire workflow related to placing, executing, and resolving orders for testing and medications, as well as overcoming the general resistance to change that accompanies such initiatives. However, the same elements that enable CPOE to be properly adopted—interdisciplinary teamwork and open communication—tend to be among the pillars of most health care organizations. The success of CPOE depends on aligning it with the overall goals of the institution, and this is something that must be emphasized throughout the process.
With this in mind, it is important not to underestimate the effects of CPOE on the entire order process. The functionality of CPOE is not simply the placing of orders on a computer as opposed to paper. Rather, it should be seen as a proxy for how all health care providers interact with each other in a health system. Therefore, such an initiative should always have a clearly designated CPOE champion and include a governing body, such as a physician advisory group. Of particular benefit to the PAG is inclusion of non-physician representatives of the various services affected by CPOE. While training and supporting physicians and other prescribers is imperative to decrease frustration, that same education must be developed and applied to the laboratory staff that process testing orders. In our case, the solution was to create a medical staff educator position for CPOE and ensure we had robust IT support when we took the system live for the first time. At MedCentral, the medical staff educator is a full-time position currently filled by a registered nurse. Keep in mind, a wide-ranging and heavily technology-dependent initiative such as CPOE is bound to encounter a few system issues at the beginning.
The creation of evidence-based order sets as a form of clinical decision support is the foundation of CPOE. When EBM is used to develop the order sets, it unleashes the potential for quality improvement, error reduction, clinical variability reduction, and improved patient and physician satisfaction. Many of the inherent problems of a paper-based system will be resolved through the adoption of order set rules. Ultimately, CPOE enables a health care facility to provide the right test, medication, and procedure for the right patient at the right time. Although these are benefits in and of themselves, the journey of process improvement never ends. As long as open communication, education, and troubleshooting are acknowledged as necessary to program maintenance, CPOE will help improve patient safety.
Eugenio H. Zabaleta, PhD, is a clinical chemist at MedCentral Health System in Mansfield, Ohio. He is also a part-time lecturer at Cleveland State University’s graduate clinical chemistry program. Dr. Zabaleta graduated from the Catholic University of Cordoba (Argentina) with a degree in biochemistry and received his PhD in chemistry from the University of Akron.
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