Computerized physician order entry in the critical care and general inpatient setting: A narrative review

doi:10.1016/j.jcrc.2004.08.006

Journal of Critical Care

Volume 19, Issue 4, December 2004, Pages 271-278

https://doi.org/10.1016/j.jcrc.2004.08.006 Get rights and content

Abstract

Computerized physician order entry (CPOE) is an increasingly used technologic tool for entering clinician orders, especially for medications and laboratory and diagnostic tests. Studies in hospitalized patients, including critically ill patients, have demonstrated that CPOE, especially with decision support, improves several outcomes. These improved outcomes include clinical measures such as reductions in serious medication errors and enhanced antimicrobial management of critically ill patients resulting in reduced length of stay. Additionally, several process outcomes have improved with CPOE such as increased compliance with evidence-based practices, reductions in unnecessary laboratory tests and cost savings in pharmacotherapeutics. Future studies are needed to demonstrate the benefits of more patient specific decision support interventions and the seamless integration of CPOE into a wireless, computerized medication administration system.

Section snippets

Methods

The citation search strategy was restricted to English language peer-reviewed journals and included several approaches. Electronic database searches were conducted in October 2003 and included Ovid MEDLINE from dates January 1, 1966 to September 1, 2003, Premedline, EMBASE, and All EBM Reviews (which includes the Cochrane Database of Systematic Reviews, the American College of Physicians [ACP] Journal Club, the Database of Abstracts of Reviews, and Effects and the Cochrane Central Registry of

Study identification and selection

Studies of CPOE included for this review were conducted on hospitalized patients and categorized to general care units and critical care units. Studies conducted in ambulatory settings, including emergency departments, were excluded from analysis. Study designs acceptable for this review were prospective randomized controlled trials (RCTs) including quasi-randomized processes such as alternate allocation and prospective observational studies with controls such as interrupted time series.

Results

A total of 18 articles satisfied the selection criteria, including 2 studies of CPOE in critical care settings,13, 14 8 studies of CPOE in general inpatient care settings15, 16, 17, 18, 19, 20, 21, 22 and 8 studies conducted in both critical care and general inpatient care settings.23, 24, 25, 26, 27, 28, 29, 30 With the exception of a single pediatric study,14 the remaining studies were only conducted in adult patient settings. The pediatric study was included because it satisfied our

Discussion

While the number of well-conducted trials of CPOE in the general care and especially critical care settings are still small, there is a growing accumulation of data supporting the beneficial effects of CPOE and CDSS. Many of these studies include both general and critical care units; more critical care data would be valuable. Nevertheless, the findings summarized in this review are examples of ongoing research efforts that are building the groundwork to validate Reed Gardner’s predictions from

Acknowledgements

The author thanks Ms. Tiffany Wang for her assistance in preparing the manuscript, and Dr. David W. Bates for his thoughtful review and mentorship.

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Cited by (45)

Computerized physician order entry in the cardiac intensive care unit: Effects on prescription errors and workflow conditions
2014, Journal of Critical Care
Citation Excerpt :
Patients admitted to the intensive care unit (ICU) are particularly vulnerable to prescription errors (PEs) because of the presence of multiple risk factors [4]. However, the use of CPOE in ICUs is still limited for several reasons: the complexity and variability of the patient's clinical status, which requires frequent changes in treatment orders; the possibility of committing new medication errors by misuse of computer media; and the workflow disruptions [5,6]. Although there have been several publications regarding its use in the pediatric intensive care setting [7], only few authors have specifically evaluated the effects of CPOE among adult patients admitted to the ICU [8–10].
To evaluate the effects of a computerized physician order entry (CPOE) system in the cardiac intensive care unit by detecting prescription errors (PEs) and also to assess the impact on working conditions.
A longitudinal, prospective, before-after study was conducted during the periods before and after the implementation of the CPOE system. Clinical pharmacists were responsible for the registration, description and classification of PEs, and their causes and severity, according to an international taxonomy. Professionals were also surveyed for their opinion, concerns, and level of satisfaction.
A total of 470 treatment orders containing 5729 prescriptions were evaluated. The CPOE resulted in a marked reduction in the number of PEs: error rate was 44.8% (819 errors among 1829 prescriptions) with handwritten orders and 0.8% (16 among 2094 prescriptions) at the final electronic phase (P < .001). Lapses were the main cause of error in both prescription methods. Most errors did not reach the patients. Errors related with the computerized system were scarce. Most users were satisfied with many aspects of this technology, although a higher workload was reported.
Computerized physician order entry in the cardiac intensive care unit proved to be a safe and effective strategy in reducing PEs and was globally well received by professionals.
Effects of a short text message reminder system on emergency department length of stay
2012, International Journal of Medical Informatics
Citation Excerpt :
These factors all together made it difficult to reduce disposition time of the multiple-consultation group. There is accumulating evidence that CPOE has beneficial roles in critical and emergency care through improvements in ambiguous workflow, compliance with practice guidelines, and decision support [20–26]. CPOE enables a vast number of SMS messages to be automatically transmitted at an accurate time point to the responsible faculty.
Specialty consultations and waiting for admission to a hospital bed are major contributors to increased length of stay and overcrowding in the emergency department. We implemented a computerized short messaging service to inform care providers of patient delay in order to reduce length of stay. The purpose of this study was to evaluate the effects of this strategy on length of stay in the emergency department.
This was a before-and-after observational study. Prior to this study, we registered the mobile phone numbers of all board certified specialists into a computerized physician order entry database and developed an auto-sending short messaging program linked to consultation orders. The short message was transmitted at 2 and 4 h after consultation, when a disposition was not yet established, and at 8 h after the admission order if the patient was still waiting. The length of stay of consulted patients and intervals such as consultation time (registration–consultation), disposition time (consultation–admission decision), and boarding time (admission decision–hospitalization) of admitted patients were compared between the pre-implementation (September 2009) and post-implementation period (November 2009). Subgroup analyses of disposition time were performed according to time of consultation and the number of consultations.
A total of 7518 patients visited the emergency department during the pre-periods and post-periods. Among them, 3335 patients required specialty consultations. The median length of stay of consulted patients decreased significantly after implementation of the messaging system (pre-207 min vs. post-193 min, p < 0.001). Among admitted patients, the median length of stay decreased by 36 min from 294 min to 258 min (p < 0.001). In the subgroup analysis, times for establishing patient dispositions decreased significantly when the consultation was performed at night and when there was only one department consulted. The numbers of patients with disposition times within 2 and 4 h and boarding times within 8 h were all increased after implementation of the short message service program.
This study suggested that the computerized physician order entry-based short messaging service program, used to inform decision-makers of patient delay, could reduce the length of stay for consulted patients in the emergency department.
Reviewing the impact of computerized provider order entry on clinical outcomes: The quality of systematic reviews
2012, International Journal of Medical Informatics
Computerized provider order entry (CPOE) is central to current efforts at improving clinical care. Understanding the quality of the evidence for CPOE is important to the practical decision of implementation, patient safety and future design efforts. This paper presents the results of a systematic analysis of the quality of systematic reviews of empirical CPOE research.
The systematic search process included PubMed, CINAHL, Scopus, Cochrane, INSPEC, and PsychInfo databases from the years 1987–mid 2010 in English only. All reviews with a focus on CPOE, electronic ordering, Electronic Health Record, or Health Information Technology were included. Studies were excluded if they did not mention a systematic review in the title or text, report a formal search process, report results of the search, or specifically include a separate section on CPOE in the results. Quality was assessed using systematic criteria developed by Oxman and Guyatt, QUOROM, and PRISMA. All three authors conducted the reviews independently. Disagreements were resolved through discussion. Descriptive data was extracted.
The search process yielded 185 initial unique references with 13 final reviews meeting the inclusion criteria. The rating of overall quality in the Oxman and Guyatt scale averaged 4.9 out of a possible 7 and the average mean of the sum of the other questions was 5.69. The overall QUOROM/PRISMA ratings averaged 63% completion and ranging from 45% to 81%.
The quality of these reviews were moderate. Only one study conducted a full quantitative synthesis, and overall heterogeneity was reported as very high in the 3 studies that measured it. Recommendations emphasize clarifying the phenomenon of CPOE by avoiding reporting conclusions across sub-group analyses, increasing emphasis on the development of theoretical models, including more quantitative assessments, and increasing breadth of outcomes.
Does Computerized Provider Order Entry Reduce Prescribing Errors for Hospital Inpatients? A Systematic Review
2009, Journal of the American Medical Informatics Association
Citation Excerpt :
Identifying errors post-CPOE has specific challenges. It may be more difficult to identify emergent new error types that are specific to electronic prescribing, such as entering orders in the wrong patient's record, incorrect default dosing, or inappropriate use of decision support.37,50,51 Further, the need to scroll across or down a page, or to view multiple screens sequentially may make duplicated, discontinued, or not ordered prescriptions and the patient's medication history less noticeable.22
Previous reviews have examined evidence of the impact of CPOE on medication errors, but have used highly variable definitions of “error”. We attempted to answer a very focused question, namely, what evidence exists that CPOE systems reduce prescribing errors among hospital inpatients? We identified 13 papers (reporting 12 studies) published between 1998 and 2007. Nine demonstrated a significant reduction in prescribing error rates for all or some drug types. Few studies examined changes in error severity, but minor errors were most often reported as decreasing. Several studies reported increases in the rate of duplicate orders and failures to discontinue drugs, often attributed to inappropriate selection from a dropdown menu or to an inability to view all active medication orders concurrently. The evidence-base reporting the effectiveness of CPOE to reduce prescribing errors is not compelling and is limited by modest study sample sizes and designs. Future studies should include larger samples including multiple sites, controlled study designs, and standardized error and severity reporting. The role of decision support in minimizing severe prescribing error rates also requires investigation.
Computerized physician order entry in critical care
2009, Best Practice and Research: Clinical Anaesthesiology
Computerized physician order entry means prescribing of medication and ordering laboratory tests or radiology examinations in an electronic way instead of using paper forms. In itself, it offers advantages such as legible orders, faster order completion, inventory management and automatic billing. If combined with clinical decision support, the real benefits of CPOE become apparent in the first place by prevention of medication errors and adverse drug events. On the contrary, if CPOE configuration is not done carefully, adverse drug events can be facilitated. Therefore, and for reasons of end-user acceptance, implementation is challenging. CPOE has the potential for significant economic saving. However, the initial implementation cost is high.
The impact of pharmacists’ interventions within the Closed Loop Medication Management process on medication safety: An analysis in a German university hospital
2022, Frontiers in Pharmacology

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Computerized physician order entry in the critical care and general inpatient setting: A narrative review

Abstract

Section snippets

Methods

Study identification and selection

Results

Discussion

Acknowledgements

Am J Med

Am J Med

J Am Med Inform Assoc

Patient safetyImproving safety with information technology

N Engl J Med

To Err is Human. Building a Safer Health System. Institute of Medicine

Crossing the Quality ChasmA New Health System for the 21st Century

The Institute of Medicine Report on the Quality of Healthcare

Computer-based physician order entrythe state of the art

JAMA

Will electronic order entry reduce health carecosts?

Effective Clin Pract

Computer physician order entrybenefits, costs, and issues

Ann Int Med

Users’ Guides to the Medical Literature: XVIII. How to use an article evaluating the clinical impact of a computer-based clinical decision support system

JAMA

Improved perioperative antibiotic use and reduced surgical wound infections through use of computer decision analysis

Infection Control Hospital Epidemiol

Linking guideline to regular feedback to increase appropriate requests for clinical testsblood gas analysis in intensive care

BMJ

Efficacy of computerized decisionsupport for mechanical ventilationResults of a prospective multi-center randomized trial

Proc AMIA Symp

Making Health Care SaferA Critical Analysis of Patient Safety Practices

A computer-assisted management program for antibiotics and other antiinfective agents

N Engl J Med

Development and impact of a computerized pediatric antiinfective decision support program

Pediatrics

A randomized trial of “corollary orders” to prevent errors of omission

J Am Med Inform Assoc

A computerized reminder system to increase the use of preventive care for hospitalized patients

N Engl J Med

A clinical decision support system for prevention of venous thromboembolismEffect on physician behavior

JAMA

Computer reminders to implement preventive care guidelines for hospitalized patients

Arch Int Med

Computer-generated informational messages directed to physicianseffect on length of hospital stay

J Am Med Inform Assoc