Computerized Physician Order Entry (CPOE) – Using IT to Decrease Adverse Drug Events

Let’s imagine a situation where a doctor prescribes certain drugs and tests to a patient on paper. Filling out papers and entering in various kinds of journals and reports takes the doctor’s time, and the patient needs to walk with documents to different offices to make an appointment, and then undergo the necessary tests, etc. In health matters, time can be a decisive factor in a patient’s life.

Approximately 70% of hospitals in the United States have moved or are in the process of transitioning to administering prescriptions, testing, etc. electronic. Computerized Supplier Order Entry (CPOE) systems are recognized as essential tools for improving healthcare providers’ efficiency and effectiveness. The potential of these systems has revolutionized the workflow and has had a profound impact on patient safety. As a result, the introduction of CPOE systems into the clinical workflow is imperative. However, research has shown that such integration can be tricky. In this article, we will look at the software that eliminates paperwork and solutions to various problems posed by technology.

1. What is CPOE, and how is it used in healthcare?
2. Building a CPOE workflow and its primary integrations
3. CPOE benefits
4. How to use CPOE effectively and make it EPCS compliant?
5. Issues of implementing CPOE

What is CPOE, and how is it used in healthcare?

Computerized order entry for doctors is when doctors can place orders for patient care through an electronic system that transmits them to various departments. These typically include pharmacy orders for drugs, laboratory blood tests, radiology orders, and other patient-specific instructions, rather than manual prescriptions.

The essential function of the CPOE is to enable the physician to provide the right care to the patient and make it almost impossible to do the wrong thing for the patient. Most CPOE systems use preventive measures. These include checks:

• Drug interactions
• Drug interactions (e.g., warning when prescribing a blood thinner in a patient with an active diagnosis of upper gastrointestinal (GI) bleeding)
• Age of Medicines (a list of alcohol-based medicines to help physicians order medication for the geriatric population or pediatric patients, many dosages differ).

The development team decides which features are needed and which are not to avoid overloading the system. Each security feature has several alert levels (low, medium, high). It would be a mistake to use only high or medium. There are many strategies for configuring the system, and you must choose which works best for your organization.

Work on this kind of system began about 40 years ago. The first attempt to implement it was in one of the hospitals in California. Still, then such a decision was negatively received by the staff, which can be explained by the lack of computer literacy at that time. It wasn’t until the late 1990s that CPOE was appreciated and began to bring real benefits to hospitals due to technological advances, lower development costs, and the ever-increasing computer literacy of healthcare professionals.

Building a CPOE workflow and its primary integrations

Modern CPOE systems are one of the components of the healthcare IT infrastructure. These systems can run as extended functionality of Electronic Health Record (EHR) systems and use a clinical decision support module to check drug-drug and allergy drug interactions, check the dosage, and avoid duplicate therapy.

The CPOE solution can also be pre-integrated with the medical practice management platform to flag orders that require prior approval in the insurance plan. In this way, you can minimize the number of rejected claims for reimbursement of hospital insurance costs.

Now we will try to represent the hospital workflow using CPOE:

1. The user (doctor) logs into the EHR system.
2. The EHR system confirms that the user is authorized and initiates the ordering process through the CPOE system.
3. The doctor creates or edits the order for medicines, various kinds of research.
4. The order is validated against the patient’s medical history, a knowledge base of a clinical decision support system, and the health insurance plan stored in the practice management system.
5. After all checks, the order goes to the supplier system of the product or service (pharmacy, laboratory, etc.).
6. The order is recorded in the patient’s medical history in the EHR system.

This approach makes prescribing drugs more transparent, which eliminates errors and fraud. We’ll talk more about the benefits later in the article.

CPOE benefits

Electronic prescriptions and test prescriptions can significantly improve patient efficiency and safety. Most users point out the following advantages of using CPOE:

• it is almost impossible to lose an order with this system;
• eliminates errors due to illegible handwriting;
• prevention of mistakes when taking medications. According to statistics, the side effects of drugs cause 7000 deaths annually. The CPOE module combined with the clinical decision support component can reduce medication errors by about 65%;
• reduction of the length of stay in the hospital of the patient, as well as the cost of 13%;
• optimization of reimbursement rates through automatic notification of orders that require prior approval from insurance companies;
• transparency of the ordering process;
• improved administration. The system helps pharmacies and laboratories receive orders faster. At the same time, patients receive the right drugs and services in the correct dosage or order.

This kind of approach is desirable for hospitals but is becoming mandatory in the US with new regulations.

How to use CPOE effectively and make it EPCS compliant?

Through the Promoting Interoperability (PI) program in the United States, the introduction of electronic prescription software has been well stimulated. PI requires hospitals to register more than 60 percent of drug orders, as well as referrals for tests and radiology examinations using CPOE. Also, more than half of all prescriptions must be automatically verified against the drug formulary (the range of drugs managed by the health plan) and electronically submitted to pharmacies.

Likewise, the Patient and Community Support Act, which aims to combat opioid addiction, will accelerate the adoption of eRx technologies. According to this law

From January 2021, healthcare organizations are required to use electronic prescriptions for controlled substances (EPCS).

For example, in some states, all health care providers in California will be required to make all prescriptions electronically from January 1, 2022, due to legislative changes.

The traditional electronic assignment workflow will not be drastically changed when new laws come into force. Comply with EPCS requirements, CPOE systems must meet several essential requirements of the Drug Enforcement Agency (DEA).

Two-factor authentication. The system can use two of the following options:

• password or answer to a personal question;
• biometric identifier (fingerprint or scan of the iris of the eye);
• PKI (Public Key Infrastructure) smart cards;
• an OTP (One Time Password) token generated by the app, or hard token;

Two-stage control. Two specialists must approve each controlled drug prescription. The first confirms that the doctor has the authority to sign the order. The second, in turn, verifies his identity using a two-factor authentication process.

Integration with the government PDMP database. For pharmacies, when dispensing controlled drugs to patients, pharmacies must add the order to the Prescription Drug Monitoring Program (PDMP), a network of independent electronic databases created to track controlled substance prescriptions in each state.

Issues of implementing CPOE

Despite the advantages of the organization, it is worth weighing the pros and cons of implementing a CPOE system due to the high costs of monetary and technological resources. Order entry systems for large hospitals can perform a thorough analysis of organizational processes. The most common barriers to technology adoption in healthcare organizations are:

#1 Complex integration

Unfortunately, even ready-made solutions cannot be quickly implemented into the workflow since it is necessary to accurately customize all system processes for the requirements of each hospital, laboratory, or another healthcare provider. Things can get complicated if the healthcare organization uses software from different vendors.

Recommendation. If possible, work with one software vendor, namely the one who created and configured the EHR system. Alternatively, you can ask for advice on whether the new solution will be compatible with your existing platform. The best way out is to create a customized solution that more closely matches your needs. While custom development takes time, in most cases, the effort pays off in the future.

#2 Gaps in the process

The introduction of new things, such as software, often disrupts the standard workflow and can lead to a drop in productivity, through employee frustration or even mistakes that pose a risk to patients. How quickly the CPOE implementation will occur is influenced by the experience of staff with various kinds of programs, the number of new functions that need to be mastered, and so on.

Recommendation. You should not rush from one extreme to another and try to implement everything at once. Experience shows that deliberately slowing down the introduction of software allows employees to get used to innovations. By connecting functions, one by one, minimizing doctors’ resistance to change and preventing performance degradation. It is worth noting that this approach allows you to test every feature of the system and identify software errors during the training period.

#3 System update and support

Hospitals and clinics need to maintain and update their e-prescription software to ensure it always meets all industry requirements, as well as new business trends and current clinical guidelines. It is essential for working with patients and observing orders and laws in the field of health care.

Recommendation.  It is optimal to review the CPOE order sets every six months to guarantee their relevance. When choosing a system, it is essential to check with the supplier whether there will be an opportunity for technical support at the required level after the system is implemented. A third-party company may provide regular updates and technical support.

#4 Introducing new errors

Unfortunately, when some types of errors are eliminated, CPOE systems can introduce new ones. For example, the auto-fill feature increases the risk of missing the right drug and choosing the wrong one.

Recommendation. Regular testing of medical software will allow hospitals to assess the percentage of errors in drug ordering, identify sources of problems, and take measures to prevent them. In the United States, testing is carried out by a non-profit organization that aims to improve the safety of American health care.

CPOE systems make a considerable contribution by integrating with other organizations’ applications, such as electronic medical records, practice management tools, and electronic prescription modules. Interoperability, privacy, and security issues, as well as the ability to exchange data between different medical software, are the primary concerns and implementation of CPOE. Despite these persistent challenges, most healthcare providers have already implemented it in part because of its benefits and upcoming changes in health laws.

Tech Side and the Development Team

Let’s dive into more technical aspects of health solution development. Based on our experience in health technologies, we’ve singled out an approximate tech stack.

Technology stack:

• Fron-end development: Angular or React
• Back-end development: PHP/ Python/Node.js
• Programming languages for mobile development: Kotlin (Android) and Swift (iOS)/Flutter for both platforms

This list of technologies is not final and is provided for your information. It can differ from application to application depending on business goals, features, and platforms.

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Development team:

• Project Manager
• Business Analyst
• System Administrator
• UI/UX designer
• HTML/CSS Slicer
• Android engineer
• iOS engineer 
• Front-end developer
• Back-end developer
• QA engineer

When developing a healthcare solution for work in the United States or Europe, be sure that such a project meets government requirements for their functions and information security.

Conclusion

There is a forecast that thanks to government initiatives and the active implementation of information technology in healthcare, the computerized physician order entry (CPOE) market will grow significantly – from 6 to 10% over the next five years.

Investments in healthcare are increasing every year, and healthcare IT is becoming more common. Implementation and use of Electronic Health Records (EHR) and other Health Information Technologies (HIT) transform primary health care practices and assist in implementing IT systems and software in clinics and hospitals.

It is also assumed that increased investment by leading IT companies in healthcare will accelerate adoption. Patient orientation is the most significant trend in the market these days. Besides, the growing popularity of wireless and cloud technologies is also driving the market growth.

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