Computerized physician order entry systems are continuing to evolve in a direction intended to make the workflow process smoother for physicians. In other words, for CPOE, the emphasis is being taken off the “C” and placed on the “P”, system vendors say.
“Our system should be thought of less as software and more as an agent of cultural change,” said Graham Hughes, MD, vice president and general manager of product strategy for Waukesha, WI-based GE Healthcare’s IT division. “The system is designed to help, not hinder the physician.”
A renal specialist, Hughes has 20 years’ experience working with CPOE systems and drew upon his physician background to help design GE’s “third wave” system. He describes the first wave as having a clerical component that physicians weren’t ready for, followed by a model that offered clinical decision support and was “more physician friendly.” The latest generation contains all the elements physicians need to do their jobs effectively, he said.
“The third wave is really designed as clinician focused, with a huge emphasis on workflow and user experience,” Hughes said. “What we’ve done is focus less on feature sets and more on the ability to measure specific improvement in cost, quality and access. It drives and measures quantifiable improvement in cost quality.”
Thomas Jefferson University Hospital in Philadelphia deployed GE’s second generation system in 2001 and by 2004 the 900-bed hospital had all inpatient units on CPOE. Mary McNichol, senior director of information systems, says it made an immediate impact.
“Two basic benefits were clear right way – one being legible orders,” she said. “The other thing is once you have automated orders, you don’t have to go to a specific unit – you can access it from anywhere. The system provides a great capability for rules, taking data, vital signs and meds to create alerts and reminders.”
Roughly 1,500 physicians (900 attending and 600 residents) use the system, along with thousands of nurses. The system employs two sets of alerts – for drug interaction and formulary grading. Users are instructed to be judicious in order to avoid the “alert fatigue” common with CPOE systems.
For GE’s third wave, Hughes said finer alerting distinctions have been built into the system based on clinician feedback.
“We asked our customers what they thought would be the most intelligent alerting method,” he said. “Whether in provision around correct dosage or drug interactions, they said there were different levels of alerting they wanted to control at the organizational level. So we built a utility with various grades – some are informational pop-ups, others are passive while urgent messages interrupt workflow. It differentiates between different specialties and levels of knowledge.”
Of the three new features added to Atlanta-based Eclipsys’ systems, new alert functions are at the top of the list, said Rick Mansour, MD, chief medical information officer.
“If you have too many, you don’t have any,” he said about the reason for alert fatigue. “We have dramatically strengthened the system so that alerts can be exquisitely fine tuned to exactly which drug interactions will spring an alert. It amounts to less than 1 percent of what is in commercial databases.”
To complement that, the company developed analytic tools designed to let system users examine any time period to see which clinicians are getting which alerts, volumes of frequency and response rates, Mansour said.
Linda Gleespen, RN, lead quality and clinical analyst for Summa Health System and St. Thomas Hospitals in Akron, OH, says her organization uses Eclipsys alert functions for drug interaction, allergy and duplicate checking and that staff are on guard against alert fatigue.
“We’re very much of the philosophy of proactive design versus reactive alerts,” she said. “Clinical decision support features are ingrained in the technology – if a patient comes in for surgery and the allergy information is not entered, the physician cannot enter an order. The right meds are ingrained in the order sets, so it follows the correct standards of care.”
Los Angeles-based Zynx Health focuses on the best practices aspect of CPOE, an aspect that aligns doctors’ decisions with the highest standards of care, said COO Greg Dorn, MD.
“The most exciting thing about CPOE is making decisions in a dynamic computer environment,” he said. “We do two things – digest those best practices and create ways of interlacing them into the electronic environment with software technology. It is a finite set of best choices that helps to guide decision-making on the fly, eliminating errors of omission. It has a beneficial impact on clinical care.”
