Experts offer lessons learned on CPOE

Despite all the hoopla about computerized prescriber order entry, CPOE systems are installed in only 5%-7% of healthcare systems throughout the country, prompting researchers to describe the technology as still in its infancy.

At a CPOE conference sponsored by ASHP and the Institute for Safe Medication Practices, held in Dallas last month, David Classen, M.D., associate professor of medicine, University of Utah, Salt Lake City, and VP, First Consulting Group, Long Beach, Calif., suggested that the addition of an audit system for CPOE might help to raise awareness about safety issues and track efficacy. "Just putting in CPOE does not guarantee an impact on safety," he cautioned. However, he said, the future might see Web-based tests and diagnostic tools that would enable each clinical facility to monitor the efficacy of its CPOE intervention.

As well as clinical concerns, there are organizational challenges facing CPOE implementation. "It is one of the biggest changes an organization will go through," said Classen. Implementing a CPOE program presents a big challenge for physicians, he said, particularly in a community hospital setting, and it requires a training and learning curve on the part of all personnel. "CPOE does work in community hospitals," he assured the audience, adding that the systems are moving from inpatient to outpatient settings.

The findings of a nationwide study of 10 sites by Classen and his colleagues suggest the importance of devising a CPOE system that is both highly responsive and highly accessible. A responsive system acknowledges orders as they are requested, ideally within a few seconds. And in some settings, the use of rolling laptops or tablet PCs makes the CPOE system more accessible. Successful programs also allowed remote access by physicians, increasing the potential that physicians would utilize the technology. Classen recommended, however, that program managers conduct testing to ensure a smooth electronic order entry process before involving physicians, thereby enhancing utilization rates among the medical staff.

System implementation varies from setting to setting. Alicia Miller, M.S., R.Ph., associate director of pharmacy and clinical assistant, Ohio State University Medical Center (OSUMC), Columbus, spoke about her hospital's implementation of a CPOE system. At OSUMC, the CPOE system has been highly successful, and all orders are now submitted electronically. She estimated that at least 80%-85% of orders are entered into the system directly by physicians, indicating a high degree of physician involvement.

Miller attributes a successful CPOE implementation to flexible physician training and a knowledgeable support staff. In addition, she noted, the final program should be quick, efficient, and logical, with few screen flips and minimal downtime. Prior to implementation, it's important to set realistic expectations, Miller emphasized. "Your problems will not be resolved on day one," she said. She underscored the need to develop a partnering relationship with the vendor as well, and review other products offered by the vendor for possible future upgrades.

"Build a vision of what the future will look like before you start the project," urged Classen.

The use of technology as a tool for enhancing the safety and efficacy of the clinical process can go only so far. Miller said, "The pharmacist is the final clinical decision support of CPOE."

Classen and Miller believe in the need to have physician champions to ensure program success. Miller noted that success depends upon endorsement by key medical staff as well as other key decision makers. "Pharmacy needs to become a player on the CPOE team," she stressed.