Computerized Provider Order Entry
To replace paper, computerized provider order entry (CPOE) systems allow providers such as physicians, nurse practitioners, or other ordering authorities to electronically order medications, tests, or other medical procedures for an individual patient (Taieb-Maimon et al. 2018). In hospital setting, this term tends to be used instead of e-prescribing which usually refers to electronic prescription of medications, because the scope of CPOE is broader than e-prescribing. It may also include other types of medical orders (Ahmed et al. 2016).
Globally, CPOE has been taken up by many countries such as the USA, Australia, Canada, and England (Samadbeik et al. 2017; Scott et al. 2018), with majority of research evidence from the USA (Scott et al. 2018). In the USA, 77% of all prescriptions were completed electronically in 2017 (Surescripts 2017).
Due to comorbidities and physiological changes, older people commonly use a large number of medications (Qian et al. 2016), have greater healthcare demands, and need long-term treatments (Tommelein et al. 2016). Thus, they are more vulnerable to potentially inappropriate prescriptions (Dalton et al. 2018). It is estimated that at least one potentially inappropriate prescription occurs in about 25–56% of hospitalized older people (Hamilton et al. 2011), nearly 30% of older people living in community (Morgan et al. 2016), and almost 50% in residential aged care homes (Stafford et al. 2011). Computerized provider order entry systems have been shown to reduce inappropriate prescriptions and aid in the prevention of adverse drug events for older people (Dalton et al. 2018). These beneficial effects on care quality have become one of the key driving forces for the introduction of CPOE, in addition to efficiency and cost saving.
Key Research Findings
In 1971, the first CPOE system was developed in the USA with rudimentary functions which allowed physicians to quickly order medications with a few clicks (OHSU 2015). In the 1980s, additional features were added to CPOE systems, including simple decision support, e.g., alerts for known adverse interactions and automatic reordering (OHSU 2015). The 1990s saw the rapid development of commercial CPOE systems; however, the uptake was slow with less than 10% of the US hospitals had fully operational CPOE systems in 2002 (Ash et al. 2004). Since CPOE became a core requirement in the Meaningful Use of Electronic Health Records, the usage rate of CPOE in the US hospitals has increased significantly from 14% in 2010 to 64% in 2016 (Castlight and Leapfrog 2016).
E-prescribing is a unique type of CPOE. While CPOE systems allow orders to be transmitted to a pharmacy information system and nursing services within a hospital, e-prescribing allows an outpatient department (e.g., emergency department), clinic, or other health services outside of a hospital to transmit prescriptions to retail pharmacies (StratisHealth 2009).
The development of e-prescribing includes four overlapping phases: adoption, utilization, quality, and optimization (HealthTechZone 2018). Beginning in 2005, the US health industry was focused on the adoption of e-prescribing (HealthTechZone 2018). To encourage the use of a qualified e-prescribing system, in 2009 the US government established an Electronic Prescribing Incentive Program (Centers for Medicare and Medicaid Services 2018). Although the program has ended in 2013, e-prescribing continues with the meaningful use (Centers for Medicare and Medicaid Services 2018). The development of CPOE has entered the third phase, focusing on improving the quality of prescription (HealthTechZone 2018).
Research on CPOE
There are an increasing number of research on CPOE. Much of the research was conducted in the USA, and a small number of studies were conducted in residential aged care homes. Scott et al. (2018) conducted a systematic review of 20 studies involving the use of CPOE to reduce potentially inappropriate medication prescriptions. Their review showed that 14 (70%) of these studies were conducted in the USA, 4 (20%) in Canada, 1 (5%) in Italy, and 1 (5%) in the Netherlands. Eight (40%) of these studies were conducted in hospitals, nine (45%) in primary care, and only three (15%) in residential aged care homes.
Dalton et al. (2018) also conducted systematic review on the effectiveness of CPOE to reduce potentially inappropriate prescription. Their review included eight controlled trial studies. Except for one study that was conducted in Italy, all the other studies were conducted in the USA (87.5%) in hospital settings.
In an earlier review conducted by Clyne et al. (2012), 14 studies on using CPOE to reduce inappropriate medication use and polypharmacy in older people were included. Of these studies, 12 (85.7%) were conducted in the USA, and 2 (14.3%) were in Canada. Six studies (42.8%) were conducted in ambulatory care, four (28.6%) in hospitals, and four (28.6%) in residential aged care homes.
Barriers to Implementation
Although the world is embracing CPOE, the implementation of CPOE is still a daunting task. Research has identified barriers to implementation including disruptive changes in the workflow during the implementation (Adams et al. 2008), low training support (Elliott et al. 2016), lack of integration with other systems (Elliott et al. 2016), poor user interface (Graber et al. 2015; Taieb-Maimon et al. 2018), and physician resistance due to perception of loss of autonomy (Kruse and Goetz 2015). Among these, disruptive changes and low training support are the top two barriers (Kruse and Goetz 2015).
The benefits of CPOE include reduced number of errors, reduced number of inappropriate orders of medications, decreased adverse drug events (ADEs), improved patient safety, improved efficiency, enhanced physician-patient communication, and cost saving.
Reduced Number of Errors Related to Poor Handwriting
Reduced Number of Inappropriate Orders of Medications
With specific alerts embedded into a CPOE system, the number of orders of potentially inappropriate medications for hospitalized older people decreased quickly (Mattison et al. 2010).
Decreased Adverse Drug Events
Adverse drug events are harms caused by inappropriate medications (Bhavsar et al. 2017). Due to high chance of multiple chronic conditions, older people are at high risk of experiencing ADEs, nearly seven times more often than the other population groups (Lucado et al. 2006). It is estimated that over half of the ADEs are preventable (Von Laue et al. 2003) and up to 60% of ADEs identified during hospitalization actually occur at the time of ordering (Nebeker et al. 2005); therefore, the CPOE systems play a critical role to prevent ADEs.
A systematic literature review of 50 studies found that the CPOE systems were capable of preventing ADEs (Charles et al. 2014). A more recent study has also found that higher e-prescribing usage rate was linked to lower ADE rate (Bhavsar et al. 2017), because it can help overcome common risk factors of ADEs, such as the lack of communication between concurrent prescribers (Green et al. 2007) and inappropriate medication orders (Mattison et al. 2010).
Improved Patient Safety
Safety benefits of CPOE have been perceived by physicians, nurses, and pharmacists. A study conducted in an Australian residential aged care home found that the physicians perceived e-prescribing as beneficial to the safety of older people because the changes they made to prescriptions could be synchronized to the system used in the residential aged care home, ensuring that nurses had access to correct medication list (Elliott et al. 2016). Nurses who worked in the residential aged care home also felt that e-prescribing had safety benefits because it helped to avoid transcription errors and delays associated with a hybrid paper-electronic medication management system (Elliott et al. 2016). As the pharmacists did not have to interpret handwritten orders, they also saw the safety benefits that e-prescribing had to offer (Elliott et al. 2016).
Computerized provider order entry has shown efficiency gain in residential aged care homes (Elliott et al. 2016; Subramanian et al. 2007), because no paper-based prescription forms need to be faxed among nurses, physicians, and pharmacists who work in different locations (Elliott et al. 2016).
Enhanced Physician-Patient Communication
In a survey study investigating older people’s perception of e-prescribing, more than 80% of them preferred e-prescribing, and more than 90% were satisfied with their physicians, because the system had led them to enjoy an increased communication with their physicians regarding medication-related topics (Schleiden et al. 2015).
A study conducted in six hospitals in Massachusetts in the USA found that a CPOE system could save a hospital up to US $2.7 million per year, despite the onetime implementation cost of US $2.1 million and the annual maintenance cost of US $ 435,000 (Adams et al. 2008). An average hospital could expect full payback in about 26 months (Adams et al. 2008).
Unintended Adverse Consequences
It is now well recognized that health information technology including CPOE may introduce unintended adverse consequences (Vélez-Díaz-Pallarés et al. 2017), with more than 60% of the technology-based medication incidents related to CPOE (Samaranayake et al. 2012). A study investigated prescription errors associated with CPOE among hospitalized older people in Spain (Vélez-Díaz-Pallarés et al. 2017). It found that during the 6 months of using the CPOE system, 107 errors were introduced by the system (Vélez-Díaz-Pallarés et al. 2017). Almost all these errors were related to human-machine interactions due to wrong or partial entries (Vélez-Díaz-Pallarés et al. 2017).
Due to a lack of attention in human-computer interaction, use errors such as selection of a wrong patient by slipping off a dropdown list may occur (Graber et al. 2015; Taieb-Maimon et al. 2018). Research has found that improvements in human-computer interface design such as highlighting selected patient and adding patient photo can draw the attention of users and significantly improve the recognition of wrong patient error (Graber et al. 2015).
Out of the intention to improve patient safety, a growing number of alerts have been built in CPOE systems to alert providers for drug-drug interactions, dose check, allergy, laboratory test value, etc. (Vanderman et al. 2017). However, these alerts caused fatigue to providers and were overridden 49–96% of the time (Van Der Sijs et al. 2006). Alert fatigue has become the most common complaints about CPOE (Ash et al. 2007).
To reduce alert fatigue, mitigation strategies have been developed. Riedmann et al. (2011) developed a context model for prioritizing drug safety alerts. This model contains 20 factors grouped into 3 categories: characteristics of the patient or case (e.g., diagnosis), characteristics of the organizational unit or user (e.g., experienced users may receive less intrusive alerts regarding certain drugs), and characteristics of the alert (e.g., less serious ADEs may be presented in a less intrusive way) (Riedmann et al. 2011). Vanderman et al. (2017) implemented a simple, non-interruptive, age-specific alert function to identify inappropriate prescription at the point of CPOE in an ambulatory care setting. They found a significant decrease in the incidence of the most frequently prescribed inappropriate medications for older patients receiving care (Vanderman et al. 2017).
Due to lack of system interoperability, use of hybrid paper-electronic systems, and legal requirements, end users have experienced inefficiency with CPOE systems. As physicians usually look after older people living in different residential aged care homes, they may have to learn to use different information systems for medication prescription when visiting each residential aged care home (Elliott et al. 2016). This impedes work efficiency.
If e-prescribing is in place but medication administration records are still on paper, nurses would have to print out the electronic prescriptions for transcribing into paper-based medication administration records (Rochon et al. 2005). Even though the medication administration records are in electronic systems, manual transcription may still be required because of a lack of interoperability between the e-prescribing system used in a physician’s office and the electronic system used in a residential aged care home (Bollen et al. 2005).
The legal requirement may also impede work efficiency. One study conducted in an Australian residential aged care home identified that physicians had to wait for nurses to print out paper copy and sign on it, because electronic signature was not acceptable by law (Elliott et al. 2016).
Future Directions of Research
Despite the increasing adoption and implementation of CPOE systems in healthcare, the relevant research of CPOE use in residential aged care homes is still limited. More research needs to be conducted in this setting where more vulnerable older people were concentrated. Although improvements have been made in CPOE systems to mitigate the unintended adverse consequences, ongoing monitoring is required as newer systems may introduce new types of unintended adverse consequences. Prospective studies need to be conducted to analyze in detail how these unintended adverse consequences occur and to establish strategies to prevent them (Vélez-Díaz-Pallarés et al. 2017). As the true impact of CPOE on care outcomes is still unclear, large-scale multicenter randomized controlled trials are needed (Dalton et al. 2018).
Computerized provider order entry systems allow orders of medications, tests, or other medical procedures to be made electronically. Due to comorbidities and physiological changes, older people are particularly at risk of inappropriate prescriptions; therefore, they are the major beneficiaries of the CPOE systems. Despite the ample benefits of CPOE, unintended adverse consequences including use errors, alert fatigue, and inefficiency may also occur, hindering the benefits it promised. Therefore, ongoing monitoring and responding mechanisms need to be in place to prevent the unintended adverse consequences and maximize the benefits of CPOE.
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