The Office of the National Coordinator for Health Information Technology (ONC) is quite adamant about the role of computerized physician order entry (CPOE) in ensuring the delivery of evidence-based, high-quality, and most importantly safe care to patients using EMR and health IT systems.
Between Stage 1 and Stage 2 Meaningful Use, the requirements for CPOE jump from more than 30 percent of all unique patients with at least one medication to more than 60 percent of medication, 30 percent of laboratory, and 30 percent of radiology orders created by the eligible providers during the reporting period.
Despite the increased importance of CPOE established by the EHR Incentive Programs, the use of electronic order sets and related capabilities has its detractors. “When we were starting order entry, a pediatrician colleague of mine said, ‘We couldn’t just be doing these order sets. It’s rote. How will the residents ever learn? It is cookbook medicine,’” recalls Carol Steltenkamp, CMIO at University of Kentucky HealthCare.
This view of CPOE, however, is not one shared by the CMIO and her experience at the academic medical center that has worked to implement CPOE into its Allscripts EMR and the workflows of its clinicians and residents in medicine, nursing, pharmacy, dentistry, and other specialties:
You walk the ideal space with that sweet spot as having them do the right thing as part of their regular workflows. The other side of that coin (and something that most folks don’t talk about) is making sure they don’t do the wrong thing. When you start to embed evidence behind it, that’s where it becomes even more important and more apparent. You remove it from the perception of a straight cookbook. I don’t disagree that that’s a knock on CPOE and order sets, but it falls down pretty quickly.
The implementation of CPOE has spanned more than a decade. Over that time, UK HealthCare’s CMIO has come to appreciate the real benefit of using CPOE when those training to care for patients are free to consider more about the care they’re providing.
“We had always had a what mentality — what should I do for this patient,” she explains. “But now they need to be asking why. Why am I doing this? Why are we doing it this way? Why are we ordering this test and not that test? What are we using that antibiotic and not this antibiotic?”
In short, the learning experience is taken to another level. “When they’re in this system and able to hit a button and see why we’re doing it this way, it is very important. If you develop your order appropriately as well as discern and get down to what you feel is going on with that patient, then that’s pretty much laid out there for them,” notes Steltenkamp.
CPOE starts with managing your order sets
Although Steltenkamp and UK HealthCare have more than ten years of experience with CPOE and order sets, the process has not been without its challenges. “We’re still implementing because when you’re an organization that had over 2,500 order sets that allowed us to be ‘fraught with opportunity,’” she says.
The current goal of the academic medical center is to pare this number down to something more manageable, somewhere in the range of 1,000 order sets. But how did an organization with levels of CPOE adoption around 100 percent end up with so many order sets? The answer comes down to getting clinician buy-in.
“When we were going live back in the mid 2000s, we didn’t allow order sets beyond the divisional range, so we didn’t allow personal order sets,” reveals Steltenkamp. “But one of the ways to catch people’s attention and get their buy-in to use computerized physician order entry was to try and do some things from a convenience order set way such as daily rounding orders and that kind of thing.”
Thus explain the current predicament of having to reduce the number of order sets in order to get the most of CPOE. If clinicians are faced with too many choices, they run the risk of having their workflows negatively impacted by a tool destined to streamline care delivery.
Working with Elsevier and its InOrder product, UK HealthCare is in the process of taking its order catalogues, cleaning them up, and shipping them back into their EMR. “We had too much and found out that we became a challenge for IT for upkeep,” adds Steltenkamp.
What the situation at UK HealthCare highlights is the importance of optimization, namely of anything that connects to or is a part of the EMR.
“This is the consummate optimization project. We are optimizing our CPOE and what we are able to do with it,” Steltenkamp believes. “That thinking you can start taking to other parts of your EMR. Have you optimized your documentation for physicians and nurses? Have you optimized your problem list, which is going to be fascinating as we move into the ICD-10 world? There are lots of opportunities. That’s what has really encouraged us: It’s an opportunity for optimization.”
In the end, the adoption and optimization of CPOE at UK HealthCare proves the point that health IT can be a blessing or a curse if not properly implemented. “IT should never be a barrier. It should facilitate,” she says.
