Q&A with with
Gregorio Ramos,
BSMT, (AMT)
 

MedicalLab Management: Are CPOE systems integral to proper laboratory service requisitions? 
Gregorio Ramos: From its earliest stages, there has always been positive acceptance in medical laboratories with regard to the implementation of CPOE systems due to the direct benefits such systems provide to lab services. For the lab, CPOE adoption results in faster testing turn around, as orders are submitted in real time, directly by the prescriber (as opposed to a unit secretary or other support personnel), resulting in fewer errors due to incomplete information or mistranscription.

Minimizing the time required for activities that support clinical lab testing processes is an ongoing initiative for healthcare facilities. Without CPOE, orders for lab services are usually hand-written by prescribers on a chart, and depending on how busy the unit clerks are, there can be a delay (sometimes lengthy) between when the prescriber orders the testing and when that order actually arrives in the lab. Furthermore, because this process relies on clear and flawless communication between the prescriber and any staff member responsible for transcribing and delivering the order to the lab, any mistakes can easily lead to error. 

MLM: How have the requirements of the Meaningful Use mandate affected laboratory’s adoption of CPOE?
Ramos: The basic construct of the Meaningful Use mandate is to ensure healthcare providers are using an electronic medical record (EMR) as a quantitatively effective tool in their practices. Accordingly, most clinical laboratories are eager for their facilities to adopt CPOE to allow the lab to participate in this effort. However, as with any healthcare initiative that requires the adoption of computer hardware and software technology, those that engage in proper planning and establish realistic guidelines are the most likely to be successful in conforming to the criteria of Meaningful Use. 

To give an idea of the importance of CPOE in affecting Meaningful Use adherence, it is listed as the first eligible core objective of Stage 1. So, while the objective of this measure refers directly to the concept of entering a minimum percentage of medication orders via CPOE (30%), clearly the adoption of CPOE affects other aspects of patient care attendant to medication orders, including lab testing. In fact, the certification criteria for establishing a computerized provider order is such that it enables a user to electronically record, store, retrieve, and modify, at a minimum, the following order types: Medications, laboratory, and radiology/imaging.1 Thus, the lab has much to gain from successful CPOE adoption. Lastly, the mandate also has given vendors in the lab market the opportunity to present themselves as a solution for CPOE adoption.



MLM: What are some of the traditional roadblocks for CPOE integration with laboratory information systems and how can these challenges be addressed?
Ramos: There are a number of roadblocks to CPOE integration with laboratory information systems and each requires a unique approach to overcome.

• Prescriber Acceptance:CPOE adoption will only be successful if prescribers commit to using it properly. If prescribers feel entrenched in the traditional manner of placing orders manually on patient charts or through the transcription of verbal orders, and will not commit to this change and its requirements, it will be very hard for the organization to adopt CPOE effectively. In order to address this, the organization should designate a physician or prescriber champion who will lead the effort to bring his or her colleagues on board with CPOE adoption. The facility should follow this up with thorough dissemination of relevant information and provide ample training to all affected disciplines. This process should certainly include a review of technology interoperability within the lab, as well as pharmacy and radiology.
• Project Planning and Timeline: As mentioned above, a tenable plan and timeline for CPOE adoption is critical for successful integration into lab workflow. In order to create realistic goals, logistical factors must be addressed. Among these is determining a sufficient number of computer terminals needed, hardwiring the system into the facility, and providing continual technical support.
• Improper Order Set Development: As a significant stakeholder in the success of a CPOE and LIS integration, lab administration should insist on a timely review of any established order sets well before implementation. Just as pharmacy and radiology should weigh in, the lab also is responsible for contributing a vetted order catalogue to the CPOE build team in a timely manner.
• Non-standardization of Order Sets: Many prescribers have strong opinions as to how lab order sets should be formatted, and these opinions can vary wildly. In order to make the CPOE process truly efficient, prescribers must find a common ground in creating a minimal standard order set for facility use. As always, this determination should largely hinge on evidence-based medicine.
• Differing Platforms: If the CPOE system is not of the same platform as the laboratory information system, this is an obvious roadblock. Although there are ways to bridge differing platforms, each product is different and has a different integration protocol. Therefore, it is important to establish a credible reason (usually financial) for acquiring a CPOE system that differs from an established LIS and vice versa. While a bridge may be built, the cost may overcome any savings gained by the initial purchase. Furthermore, if the platforms differ, a process will need to be developed by which to test the veracity of integration (or bridging) of the two systems. 

MLM: When adopting a new CPOE system into laboratory workflow, what are the main integration points to consider?
Ramos: The source of evidence for test codes needs to be identified from the outset and this usually is a function of the laboratory order catalog. Timely review of the proposed, standardized CPOE order set from a laboratory-needs perspective is also important. There is the potential of instances where certain order options found on established order sets are not actually provided by the lab or which require specific instructions from the lab that are not included. If these issues are not resolved prior to adoption, more significant problems will arise. To assist with this, make sure the lab order catalog is made available to the CPOE team as early as possible, preferably before standardized order sets are defined. Lastly, the concept of CPOE and LIS integration is simply that—a translatable interface between two information systems. Therefore, ensuring the integrity of information passed between these two systems is paramount.

Reference

1. Centers for Medicare & Medicaid Services. Eligible Professional Meaningful Use Core Measures, Measure 1 of 14, Stage 1. Last updated: July 2013. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/1_CPOE_for_Medication_Orders.pdf

Gregorio Ramos, BSMT, (AMT), is currently a consultant for a multi-hospital system working on hospital information system conversions. In 22 years of healthcare experience, he served 12 years on the laboratory bench, as well as 10 years combined experience in laboratory administration and healthcare information technology. Greg received both his BS in medical technology and doctor of medicine degrees at Manila Central University in the Philippines.