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Weir, Charlene R., and Cynthia A. McCarthy. "Using Implementation Safety Indicators for CPOE Implementation." Joint Commission Journal on Quality and Patient Safety 35, no. 1 (January 2009): 21–28. http://dx.doi.org/10.1016/s1553-7250(09)35004-7.
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Bradley, Victoria. "Implementation, CPOE, and Medication Errors." CIN: Computers, Informatics, Nursing 23, no. 3 (May 2005): 113–14. http://dx.doi.org/10.1097/00024665-200505000-00001.
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Allenet, Benoît, Pierrick Bedouch, Stéphanie Bourget, Magalie Baudrant, Luc Foroni, Jean Calop, and Jean-Luc Bosson. "Physicians’ perception of CPOE implementation." International Journal of Clinical Pharmacy 33, no. 4 (May 13, 2011): 656–64. http://dx.doi.org/10.1007/s11096-011-9521-2.
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Hoffman, James M., Donald K. Baker, Scott C. Howard, Joseph H. Laver, and Jerry L. Shenep. "Safe and Successful Implementation of CPOE for Chemotherapy at a Children's Cancer Center." Journal of the National Comprehensive Cancer Network 9, Suppl_3 (February 2011): S—36—S—50. http://dx.doi.org/10.6004/jnccn.2011.0131.
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Computerized prescriber order entry (CPOE) for medications has been implemented in only approximately 1 in 6 United States hospitals, with CPOE for chemotherapy lagging behind that for nonchemotherapy medications. The high risks associated with chemotherapy combined with other aspects of cancer care present unique challenges for the safe and appropriate use of CPOE. This article describes the process for safe and successful implementation of CPOE for chemotherapy at a children's cancer center. A core principle throughout the development and implementation of this system was that it must be as safe (and eventually safer) as existing paper systems and processes. The history of requiring standardized, regimen-specific, preprinted paper order forms served as the foundation for safe implementation of CPOE for chemotherapy. Extensive use of electronic order sets with advanced functionality; formal process redesign and system analysis; automated clinical decision support; and a phased implementation approach were essential strategies for safe implementation of CPOE. With careful planning and adequate resources, CPOE for chemotherapy can be safely implemented.
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Webber, E. C., and A. R. Shriner. "Attitudes and Perceptions of Pediatric Residents on Transitioning to CPOE." Applied Clinical Informatics 05, no. 03 (2014): 721–30. http://dx.doi.org/10.4338/aci-2014-04-ra-0045.
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SummaryBackground: Many resident physicians have experienced transitioning from traditional paper documentation and ordering to an electronic process during their training.Objective: We sought to investigate the attitudes and perceptions of residents related to implementation of computer provider order entry (CPOE) and clinical decision support (CDS).Methods: Pediatric residents completed web-based surveys prior to CPOE implementation and at 6 months and 12 months after implementation. The survey assessed resident attitudes and perceptions related to CPOE and the use of CDS tools. Additionally, at 6 and 12 months, residents were asked how electronic medical record (EMR) resources might impact future career decisions.Results: Prior to CPOE implementation, 70% of residents were looking forward to CPOE, but 28% did not want to transition from paper ordering. At 12 months post-implementation, 80% of residents favored CPOE over paper ordering and only 3.33% wished to revert to paper ordering. Residents reported an increase in time needed to enter admission orders 6-months after CPOE implementation. By 12 months post-implementation, there was no significant difference in perceived time to complete admission orders when compared to pre-CPOE responses. Most residents (91.67%) identified that overall EMR resources were an important factor when considering future employment opportunities. The most important factors included the degree of EMR implementation, technology resources and the amount of support staff. The least important factors included patient portal access and which EMR product is used.Conclusions: Overall, residents demonstrated a preference for CPOE compared to traditional paper order entry. Many residents remained unaware of CDS tools embedded within CPOE at the 12 month follow-up, but a majority of residents did find them helpful and felt more knowledgeable about current guidelines. EMR resources, including degree of EMR implementation, technology resources and support staff are likely to be important factors as residents take future employment opportunities into consideration.Citation: Shriner AR, Webber EC. Attitudes and perceptions of pediatric residents on transitioning to CPOE. Appl Clin Inf 2014; 5: 721–730http://dx.doi.org/10.4338/ACI-2014-04-RA-0045
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Miller, Alicia S. "The Implementation Process (Part 1)." Hospital Pharmacy 37, no. 10 (October 2002): 1104–6. http://dx.doi.org/10.1177/001857870203701003.
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This continuing feature will inform readers about the process of implementing, maintaining, and supporting computerized prescriber order entry (CPOE) at the Ohio State University Medical Center. (By “prescribers,” we refer to health care professionals authorized to prescribe medications by their states.) Practical information on what worked and what failed will be provided, along with current updates on the status of CPOE at the Medical Center.
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Miller, Alicia S. "The Implementation Process (Part 2)." Hospital Pharmacy 37, no. 11 (November 2002): 1218–21. http://dx.doi.org/10.1177/001857870203701104.
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This continuing feature will inform readers about the process of implementing, maintaining, and supporting computerized prescriber order entry (CPOE) at the Ohio State University Medical Center. (By “prescribers,” we refer to health care professionals authorized to prescribe medications by their states.) Practical information on what worked and what failed will be provided, along with current updates on the status of CPOE at the Medical Center.
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Miller, Alicia S. "The Implementation Process (Part 3)." Hospital Pharmacy 37, no. 12 (December 2002): 1343–47. http://dx.doi.org/10.1177/001857870203701204.
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This continuing feature will inform readers about the process of implementing, maintaining, and supporting computerized prescriber order entry (CPOE) at the Ohio State University Medical Center. (By “prescribers,” we refer to health care professionals authorized to prescribe medications by their states.) Practical information on what worked and what failed will be provided, along with current updates on the status of CPOE at the Medical Center.
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Miller, R. A., and A. Ozdas. "Care Provider Order Entry (CPOE): A Perspective on Factors Leading to Success or to Failure." Yearbook of Medical Informatics 16, no. 01 (August 2007): 128–37. http://dx.doi.org/10.1055/s-0038-1638536.
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SummaryAuthors provide a perspective on factors leading to successful care provider order entry (CPOE) implementations.Viewpoint of authors supported by background literature review.Authors review both benefits and challenges related to CPOE implementation using three guiding principles: (1) a clinical approach to clinical systems, which claims that CPOE implementation is analogous to a “good” clinician delivering care to a patient; (2) a commitment to quality, which advocates that no compromises should be made in implementing system functionality and clinical system content – the highest objective for CPOE implementation is to provide better quality of care and increased safety for patients; (3) a commitment to fairness, as evidenced by respect for individuals and support of local autonomy, which advocates for minimizing disruptions to clinician-users’ workflows, and adequate local control over CPOE system design and evolution, including clinical content management.Past experiences with CPOE implementation can inform future installation attempts. Sociocultural factors dominate in determining the success of implementation, and should govern technical factors.
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Beam, Kristyn, Megan Cardoso, Megan Sweeney, Geoff Binney, and Saul Weingart. "Examining Perceptions of Computerized Physician Order Entry in a Neonatal Intensive Care Unit." Applied Clinical Informatics 08, no. 02 (April 2017): 337–47. http://dx.doi.org/10.4338/aci-2016-09-ra-0153.
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SummaryBackground: Computerized provider order entry (CPOE) is a technology with potential to transform care delivery. While CPOE systems have been studied in adult populations, less is known about the implementation of CPOE in the neonatal intensive care unit (NICU) and perceptions of nurses and physicians using the system.Objective: To examine perceptions of clinicians before and after CPOE implementation in the NICU of a pediatric hospital.Methods: A cross-sectional survey of clinicians working in a Level III NICU was conducted. The survey was distributed before and after CPOE implementation. Participants were asked about their perception of CPOE on patient care delivery, implementation of the system, and effect on job satisfaction. A qualitative section inquired about additional concerns surrounding implementation. Responses were tabulated and analyzed using the Chi-square test.Results: The survey was distributed to 158 clinicians with a 47% response rate for pre-implementation and 45% for post-implementation. Clinicians understood why CPOE was implemented, but felt there was incomplete technical training. The expectation for increased job satisfaction and ability to recruit high-quality staff was high. However, there was concern about the ability to deliver appropriate treatments before and after implementation. Physicians were more optimistic about CPOE implementation than nurses who remained concerned that workflow may be altered.Conclusions: Introducing CPOE is a potentially risky endeavor and must be done carefully to mitigate harm. Although high expectations of the system can be met, it is important to attend to differing expectations among clinicians with varied levels of comfort with technology. Interdisciplinary collaboration is critical in planning a functioning CPOE to ensure that efficient workflow is maintained and appropriate supports for individuals with a lower degree of technical literacy is available.Citation: Beam KS, Cardoso M, Sweeney M, Binney G, Weingart SN. Examining perceptions of computerized physician order entry in a neonatal intensive care unit. Appl Clin Inform 2017; 8: 337–347 https://doi.org/10.4338/ACI-2016-09-RA-0153
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Lyons, Ann M., Katherine A. Sward, Vikrant G. Deshmukh, Marjorie A. Pett, Gary W. Donaldson, and Jim Turnbull. "Impact of computerized provider order entry (CPOE) on length of stay and mortality." Journal of the American Medical Informatics Association 24, no. 2 (July 8, 2016): 303–9. http://dx.doi.org/10.1093/jamia/ocw091.
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Objective: To examine changes in patient outcome variables, length of stay (LOS), and mortality after implementation of computerized provider order entry (CPOE). Materials and Methods: A 5-year retrospective pre-post study evaluated 66 186 patients and 104 153 admissions (49 683 pre-CPOE, 54 470 post-CPOE) at an academic medical center. Generalized linear mixed statistical tests controlled for 17 potential confounders with 2 models per outcome. Results: After controlling for covariates, CPOE remained a significant statistical predictor of decreased LOS and mortality. LOS decreased by 0.90 days, P < .0001. Mortality decrease varied by model: 1 death per 1000 admissions (pre = 0.006, post = 0.0005, P < .001) or 3 deaths (pre = 0.008, post = 0.005, P < .01). Mortality and LOS decreased in medical and surgical units but increased in intensive care units. Discussion: This study examined CPOE at multiple levels. Given the inability to randomize CPOE assignment, these results may only be applicable to the local setting. Temporal trends found in this study suggest that hospital-wide implementations may have impacted nursing staff and new residents. Differences in the results were noted at the patient care unit and room levels. These differences may partly explain the mixed results from previous studies. Conclusion: Controlling for confounders, CPOE implementation remained a statistically significant predictor of LOS and mortality at this site. Mortality appears to be a sensitive outcome indicator with regard to hospital-wide implementations and should be further studied.
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Warhurst, H. M., S. S. Smith, E. G. Cox, A. S. Crumby, K. R. Nichols, and E. C. Webber. "Conversion of a single-facility pediatric antimicrobial stewardship program to multi-facility application with computerized provider order entry and clinical decision support." Applied Clinical Informatics 04, no. 04 (2013): 556–68. http://dx.doi.org/10.4338/aci-2013-07-ra-0054.
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SummaryObjective: Antimicrobial stewardship programs (ASPs) help meet quality and safety goals with regard to antimicrobial use. Prior to CPOE implementation, the ASP at our pediatric tertiary hospital developed a paper-based order set containing recommendations for optimization of dosing. In adapting our ASP for CPOE, we aimed to preserve consistency in our ASP recommendations and expand ASP expertise to other hospitals in our health system.Methods: Nine hospitals in our health system adopted pediatric CPOE and share a common domain (Cerner Millenium™). ASP clinicians developed sixty individual electronic order sets (vendor reference PowerPlans™) to be used independently or as part of larger electronic order sets. Analysis of incidents reported during CPOE implementation and medication variances reports was used to determine the effectiveness of the ASP adaptation.Results: 769 unique PowerPlans™ were used 15,889 times in the first 30 days after CPOE implementation. Of these, 43 were PowerPlans™ included in the ASP design and were used a total of 1149 times (7.2% of all orders). During CPOE implementation, 437 incidents were documented, 1.1% of which were associated with ASP content or workflow. Additionally, analysis of medication variance following CPOE implementation showed that ASP errors accounted for 2.9% of total medication variances.Discussion: ASP content and workflow accounted for proportionally fewer incidents than expected as compared to equally complex and frequently used CPOE content.Conclusions: Well-defined ASP recommendations and modular design strengthened successful CPOE implementation, as well as the adoption of specialized pediatric ASP expertise with other facilities.Citation: Webber EC, Warhurst HM, Smith SS, Cox EG, Crumby AS, Nichols KR. Conversion of a single-facility pediatric antimicrobial stewardship program to multifacility application with computerized provider order entry and clinical decision support. Appl Clin Inf 2013; 4: 556–568 http://dx.doi.org/10.4338/ACI-2013-07-RA-0054
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York, Jaclyn B., Megan Z. Cardoso, Dara S. Azuma, Kristyn S. Beam, Geoffrey G. Binney, and Saul N. Weingart. "Computerized Physician Order Entry in the Neonatal Intensive Care Unit: A Narrative Review." Applied Clinical Informatics 10, no. 03 (May 2019): 487–94. http://dx.doi.org/10.1055/s-0039-1692475.
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Background Computerized physician order entry (CPOE) has grown since the early 1990s. While many systems serve adult patients, systems for pediatric and neonatal populations have lagged. Adapting adult CPOE systems for pediatric use may require significant modifications to address complexities associated with pediatric care such as daily weight changes and small medication doses. Objective This article aims to review the neonatal intensive care unit (NICU) CPOE literature to characterize trends in the introduction of this technology and to identify potential areas for further research. Methods Articles pertaining to NICU CPOE were identified in MEDLINE using MeSH terms “medical order entry systems,” “drug therapy,” “intensive care unit, neonatal,” “infant, newborn,” etc. Two physician reviewers evaluated each article for inclusion and exclusion criteria. Consensus judgments were used to classify the articles into five categories: medication safety, usability/alerts, clinical practice, clinical decision Support (CDS), and implementation. Articles addressing pediatric (nonneonatal) CPOE were included if they were applicable to the NICU setting. Results Sixty-nine articles were identified using MeSH search criteria. Twenty-two additional articles were identified by hand-searching bibliographies and 6 articles were added after the review process. Fifty-five articles met exclusion criteria, for a final set of 42 articles. Medication safety was the focus of 22 articles, followed by clinical practice (10), CDS (10), implementation (11), and usability/alerts (4). Several addressed more than one category. No study showed a decrease in medication safety post-CPOE implementation. Within clinical practice articles, CPOE implementation showed no effect on blood glucose levels or time to antibiotic administration but showed conflicting results on mortality rates. Implementation studies were largely descriptive of single-hospital experiences. Conclusion CPOE implementation within the NICU has demonstrated improvement in medication safety, with the most consistent benefit involving a reduction in medication errors and wrong-time administration errors. Additional research is needed to understand the potential limitations of CPOE systems in neonatal intensive care and how CPOE affects mortality.
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Kaemingk, D., D. Frieze, P. Hendrie, T. H. Payne, and D. B. Martin. "Safe Implementation of Computerized Provider Order Entry for Adult Oncology." Applied Clinical Informatics 06, no. 04 (2015): 638–49. http://dx.doi.org/10.4338/aci-2015-03-ra-0027.
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Summary Background: Oncology has lagged in CPOE adoption due to the narrow therapeutic index of chemotherapy drugs, individualized dosing based on weight and height, regimen complexity, and workflows that include hard stops where safety checks are performed and documented. Objectives: We sought to establish CPOE for chemotherapy ordering and administration in an academic teaching institution using a commercially available CPOE system. Methods: A commercially available CPOE system was implemented throughout the hospital. A multidisciplinary team identified key safety gaps that required the development of a customized complex order display and a verification documentation workflow. Staff reported safety events were monitored for two years and compared to the year prior to go live. Results: A workflow was enabled to capture real-time provider verification status during the time from ordering to the administration of chemotherapy. A customized display system was embedded in the EMR to provide a single screen view of the relevant parameters of chemotherapy doses including current and previous patient measurements of height and weight, dose adjustments, provider verifications, prior chemotherapy regimens, and a synopsis of the standard regimen for reference. Our system went live with 127 chemotherapy plans and has been expanded to 189. Staff reported safety events decreased following implementation, particularly in the area of prescribing and transcribing by the second year of use. Conclusions: We observed reduced staff reported safety events following implementation of CPOE for inpatient chemotherapy using an electronic verification workflow and an embedded custom clinical decision support page. This implementation demonstrates that CPOE can be safely used for inpatient chemotherapy, even in an extremely complex environment.
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Bazhenova, Lyudmila, and Patricia A. DeMoor. "Impact of computerized provider order entry on medication errors in outpatient chemotherapy administration." Journal of Clinical Oncology 30, no. 34_suppl (December 1, 2012): 295. http://dx.doi.org/10.1200/jco.2012.30.34_suppl.295.
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295 Background: Computerized provider order entry (CPOE) reduces medication errors (ME) in ambulatory and hospital settings. We conducted a study to assess the effect of CPOE on ME in an outpatient NCI designated infusion center (IC). Methods: Both actual and prevented ME were prospectively reported by clinical staff as part of IC Standard Operating Procedure using the electronic Quality Variance Reporting (eQVR, Incident Reporting 2.0, University of California) system. Reported ME from 10/2007 to 03/2011 were reviewed by 2 investigators and classified into categories by consensus: wrong medication given (WM), medication missed (MM), wrong timing/rate (T/R), wrong dose (WD), unmet chemotherapy parameters (UP) and other (O). Classifications were further categorized by preventable or facilitated by CPOE. We compared ME 18 mo. pre and post implementation. The 6 month go live period was reviewed separately to examine ME related to a learning curve (LC). Results: 40,366 patients were seen pre-implementation, 47,460 post, and 14,343 during go live. The total ME per pt was similar pre and post (see table). There were dramatic rate differences in WM and MM, but no effect on T/R, WD, UP. In the pre period 66% of ME were felt preventable by CPOE. In turn 35% of ME were facilitated by CPOE. Preventability rates differed between categories. During go live 100% of CPOE facilitated ME were related to user and designer LC. Post implementation 58% of CPOE facilitated ME were still accounted by LC with the rest felt related to the complexity of CPOE. Conclusions: ME are rare in our outpatient IC. CPOE did not change the total number of ME but significantly decreased the rate of WM. Complexities of CPOE resulted in increased MM. LC related errors still occur 24 mo. after implementation of CPOE and require constant monitoring and education. CPOE increased the rate of serious ME felt due to the change in workflow and adding an extra layer of complexity. Human errors cannot be fixed with CPOE and generally encompassed the ME in T/R, WD, and UP classifications [Table: see text]
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DeMoor, Patricia A., and Lyudmila Bazhenova. "Impact of computerized provider order entry on medication errors in chemotherapy administration." Journal of Clinical Oncology 30, no. 15_suppl (May 20, 2012): e16535-e16535. http://dx.doi.org/10.1200/jco.2012.30.15_suppl.e16535.
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e16535 Background: Computerized provider order entry (CPOE) reduces medication errors (ME) in ambulatory prescriber and hospital settings. We conducted a study to assess the effect of CPOE on ME in an outpatient NCI designated academic infusion center (IC). Methods: Both actual and prevented ME were reported by clinical staff as part of IC Standard Operating Procedure using the electronic Quality Variance Reporting (eQVR, Incident Reporting 2.0, University of California) system. Reported ME from 10/2007 to 03/2011 were reviewed by 2 investigators and classified into categories by consensus: wrong medication given (WM), medication missed (MM), wrong timing/rate (T/R), wrong dose (WD), unmet chemotherapy parameters (UP) and other (O). Classifications were further categorized by preventable or facilitated by CPOE. We compared ME 18 mo. pre and post implementation. The 6 month go live period was reviewed separately to examine ME related to a learning curve (LC). Results: 40,366 patients were seen pre-implementation, 47,460 post, and 14,343 during go live. The total ME per pt was similar pre and post (see table). There were dramatic rate differences in WM and MM, but no effect on T/R, WD, UP. In the pre period 66% of ME were felt preventable by CPOE. In turn 35% of ME were facilitated by CPOE. Preventability rates differed between categories. During go live 100% of CPOE facilitated ME were related to user and designer LC. Post implementation 58% of CPOE facilitated ME were still accounted by LC with the rest felt related to the complexity of CPOE. Conclusions: ME are rare in our outpatient oncology IC. CPOE did not change the total number of ME but significantly decreased the rate of WM. Complexities of CPOE resulted in increased MM. LC related errors still occur 24 mo. after implementation of CPOE and require constant monitoring and education. CPOE increased the rate of serious ME felt due to the change in workflow and adding an extra layer of complexity. Human errors cannot be fixed with CPOE and generally encompassed the ME in T/R, WD, and UP classifications. [Table: see text]
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Coustasse, Alberto, Joseph Shaffer, David Conley, Julia Coliflower, Stacie Deslich, and Andrew Sikula. "Computer Physician Order Entry (CPOE)." Journal of Information Technology Research 6, no. 3 (July 2013): 16–31. http://dx.doi.org/10.4018/jitr.2013070102.
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In an effort to reduce Adverse Drug Events (ADEs) and to improve patient safety, funding has been earmarked to improve the rate of adoption of Computerized Physician Order Entry (CPOE) among healthcare providers. It has been shown that the ordering stage of medications is where most medication errors and preventable ADEs occur. The purpose of this study was to examine the implementation CPOE systems in hospitals to determine benefits and concerns of this technology in the United States healthcare system. A review of the literature published in the last 13 years (since 2000) in the English language was performed to complete this investigation. CPOE has emerged as a valuable tool to improve medical efficiency and to decrease medication errors and ADEs. Efficiencies were found to reduce the overall workload of nurses, clerical workers and pharmacists. CPOE has proven to be a secure way of transferring physician orders electronically thus helping hospitals and physicians practice a more effective and better quality of care with less medical errors which has led to decreased operating expenses. While barriers such as lack of professional buy in, and cost of implementation have hindered the widespread use and growth of CPOE systems, these barriers are being overcome with the financial incentives from the HITECH Act, and with the increased savings of CPOE implementation, which may motivate more healthcare systems to adopt CPOE.
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Srinivasamurthy, Suresh Kumar, Ramkumar Ashokkumar, Sunitha Kodidela, Scott C. Howard, Caroline Flora Samer, and Uppugunduri Satyanarayana Chakradhara Rao. "Impact of computerised physician order entry (CPOE) on the incidence of chemotherapy-related medication errors: a systematic review." European Journal of Clinical Pharmacology 77, no. 8 (February 23, 2021): 1123–31. http://dx.doi.org/10.1007/s00228-021-03099-9.
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Abstract Purpose Computerised prescriber (or physician) order entry (CPOE) implementation is one of the strategies to reduce medication errors. The extent to which CPOE influences the incidence of chemotherapy-related medication errors (CMEs) was not previously collated and systematically reviewed. Hence, this study was designed to collect, collate, and systematically review studies to evaluate the effect of CPOE on the incidence of CMEs. Methods A search was performed of four databases from 1 January 1995 until 1 August 2019. English-language studies evaluating the effect of CPOE on CMEs were selected as per inclusion and exclusion criteria. The total CMEs normalised to total prescriptions pre- and post-CPOE were extracted and collated to perform a meta-analysis using the ‘meta’ package in R. The systematic review was registered with PROSPERO CRD42018104220. Results The database search identified 1621 studies. After screening, 19 studies were selected for full-text review, of which 11 studies fulfilled the selection criteria. The meta-analysis of eight studies with a random effects model showed a risk ratio of 0.19 (95% confidence interval: 0.08–0.44) favouring CPOE (I2 = 99%). Conclusion The studies have shown consistent reduction in CMEs after CPOE implementation, except one study that showed an increase in CMEs. The random effects model in the meta-analysis of eight studies showed that CPOE implementation reduced CMEs by 81%.
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Pontefract, Sarah K., James Hodson, Ann Slee, Sonal Shah, Alan J. Girling, Robin Williams, Aziz Sheikh, and Jamie J. Coleman. "Impact of a commercial order entry system on prescribing errors amenable to computerised decision support in the hospital setting: a prospective pre-post study." BMJ Quality & Safety 27, no. 9 (March 23, 2018): 725–36. http://dx.doi.org/10.1136/bmjqs-2017-007135.
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BackgroundIn this UK study, we investigated the impact of computerised physician order entry (CPOE) and clinical decision support (CDS) implementation on the rate of 78 high-risk prescribing errors amenable to CDS.MethodsWe conducted a preintervention/postintervention study in three acute hospitals in England. A predefined list of prescribing errors was incorporated into an audit tool. At each site, approximately 4000 prescriptions were reviewed both pre-CPOE and 6 months post-CPOE implementation. The number of opportunities for error and the number of errors that occurred were collated. Error rates were then calculated and compared between periods, as well as by the level of CDS.ResultsThe prescriptions of 1244 patients were audited pre-CPOE and 1178 post-CPOE implementation. A total of 28 526 prescriptions were reviewed, with 21 138 opportunities for error identified based on 78 defined errors. Across the three sites, for those prescriptions where opportunities for error were identified, the error rate was found to reduce significantly post-CPOE implementation, from 5.0% to 4.0% (P<0.001). CDS implementation by error type was found to differ significantly between sites, ranging from 0% to 88% across clinical contraindication, dose/frequency, drug interactions and other error types (P<0.001). Overall, 43/78 (55%) of the errors had some degree of CDS implemented in at least one of the hospitals.ConclusionsImplementation of CPOE with CDS was associated with clinically important reductions in the rate of high-risk prescribing errors. Given the pre-post design, these findings however need to be interpreted with caution. The occurrence of errors was found to be highly dependent on the level of restriction of CDS presented to the prescriber, with the effect that different configurations of the same CPOE system can produce very different results.
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Dinora, Devin R., Joshua J. Elder, and Kyle A. Harwood. "Design, Implementation, and Evaluation of Compliance With Pharmacy Workflow During a Pediatric Oncology Computerized Provider Order Entry (CPOE) Launch." Journal of Pediatric Pharmacology and Therapeutics 26, no. 5 (June 28, 2021): 491–96. http://dx.doi.org/10.5863/1551-6776-26.5.491.
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OBJECTIVE There is a lack of published literature detailing how computerized physician order entry (CPOE) pharmacy workflow is designed and implemented. The intent of this project was to design, implement, and assess compliance with the pharmacy workflow required for launching CPOE to improve the safety and efficiency of chemotherapy order entry for pediatric patients. METHODS This process implementation project took place in 2 phases, which included the design and implementation of pharmacy workflow education, and retrospective chart review of patients who received chemotherapy ordered through CPOE. An anonymous survey was also distributed to pharmacy staff, nurses, and physicians, and an assessment of any CPOE-related safety reports was completed. RESULTS Eighty-three patients received intravenous and/or intrathecal chemotherapy ordered via the CPOE software, Beacon, within the electronic medical record system, Epic, in the first 30 days post-launch across both the inpatient and outpatient settings. Overall compliance with the CPOE workflow for entering chemotherapy plans was 77% and >66% compliance with the order preparation process. Pharmacists provided an average of 1.6 interventions per review. The pharmacy was able to prepare chemotherapy within the allotted institutional time benchmarks in most cases. An overall combined multidisciplinary survey response rate of 30.6% was achieved. Twenty-eight Beacon-related patient safety reports were filed in the first 2 weeks post-launch. CONCLUSIONS The Beacon launch at this single pediatric institution was successful, and the pharmacy workflow was shown to greatly affect the overall success of the launch of CPOE. The careful prospective design, education, implementation, and retrospective review of the pharmacy workflow is key to process implementation related to chemotherapy CPOE.
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Hill, V., K. Bruner, G. Maciaz, L. Saucedo, L. Catzoela, R. Ramirez, W. J. Jacobs, et al. "Successful Implementation of Clinical Information Technology." Applied Clinical Informatics 06, no. 04 (2015): 698–715. http://dx.doi.org/10.4338/aci-2015-06-soa-0067.
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SummaryObjectives: To identify and describe the most critical strategic and operational contributors to the successful implementation of clinical information technologies, as deployed within a moderate sized system of U.S. community hospitals.Background and Setting: CHRISTUS Health is a multi-state system comprised of more than 350 services and 60 hospitals with over 9 000 physicians. The Santa Rosa region of CHRISTUS Health, located in greater San Antonio, Texas is comprised of three adult community hospital facilities and one Children’s hospital each with bed capacities of 142–180. Computerized Patient Order Entry (CPOE) was first implemented in 2012 within a complex market environment. The Santa Rosa region has 2 417 credentialed physicians and 263 mid-level allied health professionals.Methods: This report focuses on the seven most valuable strategies deployed by the Health Informatics team in a large four hospital CHRISTUS region to achieve strong CPOE adoption and critical success lessons learned. The findings are placed within the context of the literature describing best practices in health information technology implementation.Results: While the elements described involved discrete de novo process generation to support implementation and operations, collectively they represent the creation of a new customer-centric service culture in our Health Informatics team, which has served as a foundation for ensuring strong clinical information technology adoption beyond CPOE.Conclusion: The seven success factors described are not limited in their value to and impact on CPOE adoption, but generalize to – and can advance success in – varied other clinical information technology implementations across diverse hospitals. A number of these factors are supported by reports in the literature of other institutions’ successful implementations of CPOE and other clinical information technologies, and while not prescriptive to other settings, may be adapted to yield value elsewhere.
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Meslin, S., W. Zheng, R. Day, E. Tay, and M. Baysari. "Evaluation of Clinical Relevance of Drug–Drug Interaction Alerts Prior to Implementation." Applied Clinical Informatics 09, no. 04 (October 2018): 849–55. http://dx.doi.org/10.1055/s-0038-1676039.
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Introduction Drug–drug interaction (DDI) alerts are often implemented in the hospital computerized provider order entry (CPOE) systems with limited evaluation. This increases the risk of prescribers experiencing too many irrelevant alerts, resulting in alert fatigue. In this study, we aimed to evaluate clinical relevance of alerts prior to implementation in CPOE using two common approaches: compendia and expert panel review. Methods After generating a list of hypothetical DDI alerts, that is, alerts that would have been triggered if DDI alerts were operational in the CPOE, we calculated the agreement between multiple drug interaction compendia with regards to the severity of these alerts. A subset of DDI alerts (n = 13), with associated patient information, were presented to an expert panel to reach a consensus on whether each alert should be included in the CPOE. Results There was poor agreement between compendia in their classifications of DDI severity (Krippendorff's α: 0.03; 95% confidence interval: –0.07 to 0.14). Only 10% of DDI alerts were classed as severe by all compendia. On the other hand, the panel reached consensus on 12 of the 13 alerts that were presented to them regarding whether they should be included in the CPOE. Conclusion Using an expert panel and allowing them to discuss their views openly likely resulted in high agreement on what alerts should be included in a CPOE system. Presenting alerts in the context of patient cases allowed panelists to identify the conditions under which alerts were clinically relevant. The poor agreement between compendia suggests that this methodology may not be ideal for the evaluation of DDI alerts. Performing preimplementation review of DDI alerts before they are enabled provides an opportunity to minimize the risk of alert fatigue before prescribers are exposed to false-positive alerts.
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Marken, P. A., S. D. Simon, J. L. Hackman, R. S. Schaefer, and M. E. Patterson. "Associations between the concurrent use of clinical decision support and computerized provider order entry and the rates of appropriate prescribing at discharge." Applied Clinical Informatics 03, no. 02 (2012): 186–96. http://dx.doi.org/10.4338/aci-2011-11-ra-0068.
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SummaryIntroduction: Electronic health record systems used in conjunction with clinical decision support (CDS) or computerized provider order entry (CPOE) have shown potential in improving quality of care, yet less is known about the effects of combination use of CDS and CPOE on prescribing rates at discharge.Objectives: This study investigates the effectiveness of combination use of CDS and CPOE on appropriate drug prescribing rates at discharge for AMI or HF patients.Methods: Combination use of CDS and CPOE is defined as hospitals self-reporting full implementation across all hospital units of CDS reminders, CDS guidelines, and CPOE. Appropriate prescribing rates of aspirin, ACEI/ARBs, or beta blockers are defined using quality measures from Hospital Compare. Multivariate linear regressions are used to test for differences in mean appropriate prescribing rates between hospitals reporting combination use of CDS and CPOE, compared to those reporting the singular use of one or the other, or the absence of both. Covariates include hospital size, region, and ownership status.Results: Approximately 10% of the sample reported full implementation of both CDS and CPOE, while 7% and 17% reported full use of only CPOE or only CDS, respectively. Hospitals reporting full use of CDS only reported between 0.2% (95% CI 0.04 – 1.0) and 1.6% (95% CI 0.6 – 2.6) higher appropriate prescribing rates compared to hospitals reporting use of neither system. Rates of prescribing by hospitals reporting full use of both CPOE and CDS did not significantly differ from the control group.Conclusions: Although associations found between full implementation of CDS and appropriate prescribing rates suggest that clinical decision tools are sufficient compared to basic EHR systems in improving prescribing at discharge, the modest differences raise doubt about the clinical relevance of the findings. Future studies need to continue investigating the causal nature and clinical relevance of these associations.
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Hanauer, David A., Sung W. Choi, Robert W. Beasley, Ronald B. Hirschl, and Douglas W. Blayney. "Implementation of Computerized Provider Order Entry (CPOE) Does Not Impact Provider Work Time in An Inpatient Malignant Hematology Service." Blood 112, no. 11 (November 16, 2008): 4704. http://dx.doi.org/10.1182/blood.v112.11.4704.4704.
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Abstract No data are available concerning the impact of CPOE on inpatient leukemia and lymphoma care. CPOE may improve patient safety, reduce time between order entry and medication administration, and reduce medication and transcription errors. However, concerns have arisen about potential increased time required to enter electronic orders compared to handwritten orders. Our hypothesis was that CPOE would require more order-related time from caregivers, and reduce the amount of time for direct patient care. We studied the work patterns of three Physician Assistants (PAs) who worked under the supervision of faculty physicians, and were the exclusive inpatient care providers. The PA-staffed hematology service was chosen to minimize the impact of rotating house staff on our results. Faculty, who were not studied, entered the few chemotherapy orders necessary, while PAs entered orders for hydration, antibiotics, supportive care and other medications, and for consultations and diagnostic tests. The UMHS Institutional Review Board reviewed the study protocol and waived the requirement for patient informed consent. We performed a direct observation time and motion study pre- and post-implementation of a commercial CPOE system (Sunrise Clinical Manager™ 4.5, Eclipsys, Boca Raton, Florida) on one inpatient hematology service at the UMHS University Hospital. The same three PAs were shadowed pre- and post-implementation. We also closely matched morning and afternoon observation times in order to reduce variability in activities taking place at different times of the day. Prior to CPOE implementation the PAs had a 4 hour general training session and a 1 hour chemotherapy training session. Pre-built order sets were routinely used by the PAs. A portable tablet computer was used by an independent observer to record data, using a data entry interface containing 63 individual activity categories modified from the Time and Motion database under “IT Tools” at http://www.ahrq.gov. Data were grouped into subcategories for analysis. We grouped 12 activities as ordering-related (e.g. writing orders, writing forms, clarifying orders, etc.) We observed the same three PAs for 85.4 hours (over 2 weeks) pre, and for 75.8 hours (over 4 weeks) starting 3 months post-CPOE. Mean patient census was 11.3 per day pre- and 9.2 per day post implementation observation periods. Overall time for order-related activities was unchanged, requiring 7.7% of total time pre- and 8.1% of total time post-CPOE even though actual order writing took longer with CPOE compared to written (4.9% pre vs. 7.0% post). CPOE had almost no impact on direct patient care time (Figure), with PAs spending 38.2% total time on direct patient care pre-CPOE compared to 38.4% post. A minimal difference was also found with the overall total for indirect patient care activities (37.1% pre vs. 38.7% post). Our results suggest that using CPOE on a busy hematology inpatient service has minimal impact on time spent by trained PAs using standard order sets 3 months after implementation. The decision to adopt CPOE for a busy hematology service should not be based on the hypothesis that there will be a change in workflow or task organization. More study is needed to determine if CPOE for hematology patients results in a change in the quality of patient care or safety. Figure. Percentage of total time spent in 6 analysis categories both before and after implementation of a commercial CPOE system for an inpatient hematology service. These 6 categories represent 63 individual activities categories that were recorded in the time and motion study. Error bars represent 95% confidence intervals. Figure. Percentage of total time spent in 6 analysis categories both before and after implementation of a commercial CPOE system for an inpatient hematology service. These 6 categories represent 63 individual activities categories that were recorded in the time and motion study. Error bars represent 95% confidence intervals.
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Jozefczyk, Kenneth G., William Klugh Kennedy, Miranda Jackson Lin, Julie Achatz, Maresa DiMarco Glass, W. Susie Eidam, and Michael J. Melroy. "Computerized Prescriber Order Entry and Opportunities for Medication Errors." Journal of Pharmacy Practice 26, no. 4 (March 5, 2013): 434–37. http://dx.doi.org/10.1177/0897190012465982.
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Purpose: Predefined error opportunity categories were used as a surrogate for medication errors to assess the impact of computerized prescriber order entry (CPOE) on the potential for error in the prescribing and order entry phases of the medication-use process. Methods: This study was performed in a neonatal intensive care unit at a 535-bed tertiary care center. Pre- and post-CPOE implementation incidence of error opportunity was compared by evaluating 500 orders before and after implementation using 18 predefined criteria. Results: A total of 14 913 opportunities for error (OE) existed in our sample of 1000 medication orders. The number of orders with zero OE improved from 42% (n = 209) to 98% (n = 480; P < .0001), in the pre- and postgroups, respectively. The odds ratio with 95% confidence interval was 0.058 (0.036-0.094) in favor of CPOE. Conclusions: The implementation of CPOE was associated with a reduction in OEs in the prescribing phase or order entry phase of the medication-use process.
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Lewing, Benjamin D., Mark D. Hatfield, and Sujit S. Sansgiry. "Impact of Computerized Provider Order Entry Systems on hospital staff pharmacist workflow productivity: A three site comparative analysis based on level of CPOE implementation." Journal of Hospital Administration 7, no. 1 (December 21, 2017): 1. http://dx.doi.org/10.5430/jha.v7n1p1.
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Objective: Computerized Provider Order Entry (CPOE) is a system that enables physicians to send medication orders electronically rather than physically writing out the order. CPOE can reduce handwriting and transcription related medication errors and has been a major implementation goal for health systems. The objective of this study was to quantify and examine differences seen in the workflow of pharmacists at hospitals, with different levels of CPOE implementation.Methods: An observational, prospective time and motion study was conducted among three hospitals within the same health system: one classified as a non-CPOE system, one as short-term CPOE, and one as long-term CPOE. Pharmacists were observed in one-hour blocks, in which a data instrument was used to record 38 different tasks, which were grouped into four activities: clinical, distributive, administrative, and miscellaneous. The distributive category was further divided into three sub-categories. The average time associated with performing activities across the three hospitals was compared by descriptive and comparative analyses using ANOVAs and the post-hoc Tukey’s range test.Results: A total of 252 hours were collected and 235 met the inclusion criteria. The significant differences in time spent on task categories among hospitals were as follows: Non-CPOE vs. short term CPOE vs. long-term CPOE (mean ± SD in min/h) clinical tasks: (6.55 ± 6.40) vs. (4.95 ± 4.15) vs. (3.79 ± 4.91), respectively, (p < .05); order entry tasks: (29.62 ± 11.24) vs. (17.44 ± 10.73) vs. (10.27 ± 8.88) respectively, (p < .05); order verification tasks: (0.88 ± 1.77) vs. (13.93 ± 8.50) vs. (16.60 ± 9.63) respectively, (p < .05); other distributive tasks: (13.60 ± 10.04) vs. (15.86 ± 8.38) vs. (19.66 ± 8.42) respectively, (p < .05); and miscellaneous: (3.78 ± 4.64) vs. (1.54 ± 3.20) vs. (2.23 ± 3.51) respectively, (p < .05).Conclusions: The presence of a CPOE system could affect pharmacists’ workflow and time allotment on different types of pharmacy activities. Further, the time spent on certain activities was associated with the amount of time the CPOE system was implemented.
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Chaparro, Juan D., David C. Classen, Melissa Danforth, David C. Stockwell, and Christopher A. Longhurst. "National trends in safety performance of electronic health record systems in children’s hospitals." Journal of the American Medical Informatics Association 24, no. 2 (March 1, 2017): 268–74. http://dx.doi.org/10.1093/jamia/ocw134.
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Objective: To evaluate the safety of computerized physician order entry (CPOE) and associated clinical decision support (CDS) systems in electronic health record (EHR) systems at pediatric inpatient facilities in the US using the Leapfrog Group’s pediatric CPOE evaluation tool. Methods: The Leapfrog pediatric CPOE evaluation tool, a previously validated tool to assess the ability of a CPOE system to identify orders that could potentially lead to patient harm, was used to evaluate 41 pediatric hospitals over a 2-year period. Evaluation of the last available test for each institution was performed, assessing performance overall as well as by decision support category (eg, drug-drug, dosing limits). Longitudinal analysis of test performance was also carried out to assess the impact of testing and the overall trend of CPOE performance in pediatric hospitals. Results: Pediatric CPOE systems were able to identify 62% of potential medication errors in the test scenarios, but ranged widely from 23–91% in the institutions tested. The highest scoring categories included drug-allergy interactions, dosing limits (both daily and cumulative), and inappropriate routes of administration. We found that hospitals with longer periods since their CPOE implementation did not have better scores upon initial testing, but after initial testing there was a consistent improvement in testing scores of 4 percentage points per year. Conclusions: Pediatric computerized physician order entry (CPOE) systems on average are able to intercept a majority of potential medication errors, but vary widely among implementations. Prospective and repeated testing using the Leapfrog Group’s evaluation tool is associated with improved ability to intercept potential medication errors.
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Gray, Andrew, Christopher M. B. Fernandes, Kristine Van Aarsen, and Melanie Columbus. "The impact of computerized provider order entry on emergency department flow." CJEM 18, no. 4 (March 28, 2016): 264–69. http://dx.doi.org/10.1017/cem.2016.11.
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AbstractObjectivesComputerized provider order entry (CPOE) has been established as a method to improve patient safety by avoiding medication errors; however, its effect on emergency department (ED) flow remains undefined. We examined the impact of CPOE implementation on three measures of ED throughput: wait time (WT), length of stay (LOS), and the proportion of patients that left without being seen (LWBS).MethodsWe conducted a retrospective cohort study of all ED patients of 18 years and older presenting to London Health Sciences Centre during July and August 2013 and 2014, before and after implementation of a CPOE system. The three primary variables were compared between time periods. Subgroup analyses were also conducted within each Canadian Triage and Acuity Scale (CTAS) level (1–5) individually, as well as for admitted patients only.ResultsA significant increase in WT of 5 minutes (p=0.036) and LOS of 10 minutes (p=0.001), and an increase in LWBS from 7.2% to 8.1% (p=0.002) was seen after CPOE implementation. Admitted patients’ LOS increased by 63 minutes (p<0.001), the WT of CTAS 3 and 5 patients increased by 6 minutes (p=0.001) and 39 minutes (p=0.005), and LWBS proportion increased significantly for CTAS 3–5 patients, from 24.3% to 42.0% (p<0.001) for CTAS 5 patients specifically.ConclusionsCPOE implementation detrimentally impacted all patient flow throughput measures that we examined. The most striking clinically relevant result was the increase in LOS of 63 minutes for admitted patients. This raises the question as to whether the potential detrimental effects to patient safety of CPOE implementation outweigh its benefits.
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Berg, M., and J. Aarts. "Same Systems, Different Outcomes." Methods of Information in Medicine 45, no. 01 (2006): 53–61. http://dx.doi.org/10.1055/s-0038-1634037.
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Summary Objectives: To compare the outcome of the implementation of computerized physician order entry (CPOE) systems in two Dutch hospitals. Methods: Qualitative research methods, including interviews in both hospitals, observations of system in use, observations of staff meetings and document analysis were used to understand the implementation of CPOE. The transcribed texts and implementation documents were analyzed for relevant concepts.The transcripts and field notes were analyzed using a heuristic success and failure model with medical work as the primary focus. Results: Occasions that determined the outcome of the implementation were classified according to factors that may influence the success or failure of implementing systems. Conclusions: The themes and patterns that emerged from the data helped validate the concept of medical work as the primary focus of our analysis model; in addition the concept of a support base necessary to accept changes in medical work that result from introducing CPOE may help to understand the different implementation outcomes.
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Forrer, C., S. Shaha, and S. Magid. "Duplicate Orders: An Unintended Consequence of Computerized provider/physician order entry (CPOE) Implementation." Applied Clinical Informatics 03, no. 04 (2012): 377–91. http://dx.doi.org/10.4338/aci-2012-01-ra-0002.
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SummaryObjective: Computerized provider/physician order entry (CPOE) with clinical decision support (CDS) is designed to improve patient safety. However, a number of unintended consequences which include duplicate ordering have been reported. The objective of this time-series study was to characterize duplicate orders and devise strategies to minimize them.Methods: Time series design with systematic weekly sampling for 84 weeks. Each week we queried the CPOE database, downloaded all active orders onto a spreadsheet, and highlighted duplicate orders. We noted the following details for each duplicate order: time, order details (e.g. drug, dose, route and frequency), ordering prescriber, including position and role, and whether the orders originated from a single order or from an order set (and the name of the order set). This analysis led to a number of interventions, including changes in: order sets, workflow, prescriber training, pharmacy procedures, and duplicate alerts.Results: Duplicates were more likely to originate from different prescribers than from same prescribers; and from order sets than from single orders. After interventions, there was an 84.8% decrease in the duplication rate from weeks 1 to 84 and a 94.6% decrease from the highest (1) to the lowest week (75). Currently, we have negligible duplicate orders.Conclusions: Duplicate orders can be a significant unintended consequence of CPOE. By analyzing these orders, we were able to devise and implement generalizable strategies that significantly reduced them. The incidence of duplicate orders before CPOE implementation is unknown, and our data originate from a weekly snapshot of active orders, which serves as a sample of total active orders. Thus, it should be noted that this methodology likely under-reports duplicate orders.Citation: Magid S, Forrer C, Shaha S. Duplicate Orders: An unintended consequence of computerized provider/physician order entry (CPOE) implementation. Analysis and mitigation strategies. Appl Clin Inf 2012; 3: 377–391http://dx.doi.org/10.4338/ACI-2012-01-RA-0002
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Manzo, John, Mark J. Sinnett, Frank Sosnowski, Robert Begliomini, Jill Green, and Fred Pane. "Case Study: Challenges, Successes and Lessons Learned from Implementing Computerized Physician Order Entry (CPOE) at Two Distinct Health Systems: Implications of CPOE on the Pharmacy and the Medication-Use Process." Hospital Pharmacy 40, no. 5 (May 2005): 420–29. http://dx.doi.org/10.1177/001857870504000509.
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The purpose of this case study is to provide an understanding of the divergent experiences, challenges, and successes associated with implementing Computerized Physician Order Entry (CPOE) at two distinct health systems utilizing the same software vendor. Pharmacy leaders at Lehigh Valley Hospital and Health Network in Allentown, PA and Montefiore Medical Center in the Bronx, NY describe the various strategies deployed for CPOE planning and implementation, the outcomes and impacts of CPOE implementation, and valuable experience. Improvements and efficiencies in the medication management process and time savings will be described. Additionally, reductions in medication prescribing errors and enhancements in medication cost savings secondary to improved medication utilization are delineated. The authors conclude that while the challenges associated with planning and implementing CPOE for medication management and its impact on the pharmacy are great, pharmacist involvement early in the strategic planning is vital to ensure a successful and safer electronic medication management process.
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Carayon, P., J. M. Walker, and P. L. T. Hoonakker. "Measurement of CPOE end-user satisfaction among ICU physicians and nurses." Applied Clinical Informatics 01, no. 03 (2010): 268–85. http://dx.doi.org/10.4338/aci-2010-03-ra-0020.
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Summary Background: Implementation of Computerized Provider Order Entry (CPOE) can fail or meet high levels of user resistance for a variety of reasons, including lack of attention to users’ needs and the significant workflow changes induced and required by CPOE. End-user satisfaction is a critical factor in IT implementation. Objective: The goal of this study was to identify criteria to select a valid and reliable questionnaire to measure end-user satisfaction with CPOE. Methods: We developed seven criteria that can be used to select valid and reliable questionnaires. We applied the selection criteria to existing end-user satisfaction questionnaires. Results: Most of the questionnaires used to measure end-user satisfaction have been tested for reliability and validity and most of the questionnaires have reasonably reliability and some sort of validity. However, only one questionnaire, the Physician Order Entry User Satisfaction and Usage Survey (POESUS) met most of the other criteria we developed to select a questionnaire to evaluate CPOE implementation. We used the POESUS in our study and compared the results with other studies. Results show that users are moderately satisfied with CPOE. Conclusion: Using the seven criteria we developed, it is possible to select reliable and valid questionnaires. We hope that in the future this will lead to an increasing number of studies using the same questionnaires. That will improve the possibilities for comparing the results of one study to another (benchmarking).
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Valencia, Fernando S., Rossana Ruiz, Silvia P. Neciosup, Luis A. Mas, Karina M. Aliaga, Flor Huaman, Jenny Ruiz, et al. "Implementation of Computerized Physician Order Entry for Chemotherapy: A Latin American Experience." JCO Clinical Cancer Informatics, no. 2 (December 2018): 1–12. http://dx.doi.org/10.1200/cci.18.00041.
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Purpose We describe the implementation process of a computerized physician order entry (CPOE) for outpatient chemotherapy at a Latin American hospital, with the intent of providing other institutions with general guidance and insight through our experience. Methods In 2012, under the direction of the Department of Medicine of the Instituto Nacional de Enfermedades Neoplásicas, a multidisciplinary team composed of oncologists, nurses, pharmacists, and informatics engineers was formed to develop software for a CPOE for chemotherapy within a preexistent homegrown electronic medical record system in various phases. This included mapping and redesigning processes in an entirely electronic format, integrating the needs of the user for the development of electronic order sets, developing a checkpoint and a warning system to minimize prescription errors, and finally, training all the staff in implementation of the system. Results A CPOE for outpatient chemotherapy was successfully implemented in 2016. We have successfully standardized 266 chemotherapy orders, including for both solid tumors and hematologic malignancies, on the basis of appropriate guidelines. The software is linked to laboratory results and allows entry of important details for the patient's safety, such as anthropometric information for an automatic dose calculation and ranges for safe prescription. In addition, it is linked to the nursing plan sheets. Finally, it is possible to assess and continuously monitor the complex process of chemotherapy prescription. Conclusion This is the first report of implementation of a CPOE for chemotherapy in our region. The system was designed by a multidisciplinary team with its own resources. Our experience demonstrates the feasibility of computerizing the chemotherapy prescription process, constituting a tangible example for other institutions with potential impact on patient care.
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Franco, Kyle A., and Keliana O'Mara. "Impact of Computerized Provider Order Entry on Total Parenteral Nutrition in the Neonatal Intensive Care Unit." Journal of Pediatric Pharmacology and Therapeutics 21, no. 4 (July 1, 2016): 339–45. http://dx.doi.org/10.5863/1551-6776-21.4.339.
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OBJECTIVES: To determine if computerized provider order entry (CPOE) implementation impacts the time it takes for preterm neonates to reach their parenteral macronutrient goals. METHODS: Retrospective review of neonates <1750 g receiving parenteral nutrition (PN) before and after the implementation of CPOE. Primary outcome was the attainment of parenteral macronutrient goals. Secondary outcomes included time to attainment, the frequency of electrolyte abnormalities, and the incidence of required adjustments made to PN orders by verification pharmacists. RESULTS: Goal PN was achieved by 12/47 (25.5%) intervention vs. 2/44 (4.5%) control group infants (p < 0.05). This goal was attained in 10.8 ± 7.5 days in the intervention group and 10 ± 4.2 days in the control group (p = 0.90). Goal protein was reached by 74.5% of CPOE patients vs. 36.4% of controls, p < 0.05. Lipid goals were achieved by 98% vs. 100% (p = 0.33) of patients and were attained at an average of 1.5 ± 0.8 days vs. 2.0 ± 1.1 days (p < 0.05). Abnormal serum electrolyte values occurred more frequently in the control group (0.79 vs. 1.12/day PN). Adjustments by a verification pharmacist were required in 5.6% of CPOE compared with 30.4% of control group orders (p < 0.05). CONCLUSIONS: CPOE parenteral nutrition increased the proportion of preterm neonates attaining overall macronutrient goals. With CPOE, protein goals were reached by more patients and goal lipids were achieved faster. This system also decreased the number of pharmacist interventions during verification of PN orders and appeared to positively impact the incidence of serum electrolyte disturbances.
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Hanauer, D. A., R. W. Beasley, J. Schumacher, M. G. Duck, and D. W. Blayney. "Introduction of computerized provider order entry (CPOE) and time impact in an inpatient hematology/oncology service: Serial time and motion studies." Journal of Clinical Oncology 27, no. 15_suppl (May 20, 2009): e17507-e17507. http://dx.doi.org/10.1200/jco.2009.27.15_suppl.e17507.
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e17507 Background: The impact of CPOE on inpatient hematology/oncology care is not well studied. CPOE has many benefits, but concerns exist about increased time required to enter electronic orders compared to handwritten orders. We hypothesized that CPOE would require more order-related time from caregivers, and reduce the amount of time for direct patient care. Methods: Physician assistants (PAs) enter all patient orders (except those for chemotherapy) and are the dedicated and exclusive care providers on this non-house staff service at the main Hospital of the University of Michigan Health System. We chose the PA service for observation as we could eliminate potential biases introduced by rotating house staff we observed in earlier studies. PAs were directly observed at -1, +3 and +8 months post implementation of a CPOE system (Sunrise Clinical Manager, Eclypsis, Atlanta GA). Dedicated observers used a data entry tool with a modified database (available on the Health IT Tools section at healthit.ahrq.gov) on a tablet computer. For analysis, the 60 individual activities were grouped into 6 major categories, as well as an ordering category. We observed the same three PAs for 82.5 hours pre-CPOE, for 75.0 hours at 3 months post and for 70.5 hours 8 months post. Productive time was all non-personal and non-administrative time. The faculty entered chemotherapy orders and supervised the PAs, but were not studied. Results: Overall time for order-related activities was unchanged during the three observation periods, requiring 10.3, 10.6 and 11.4% of productive time, respectively. Time spent on direct patient care (as a percentage of productive time) was also unchanged once CPOE was implemented (50.7% pre vs. 49.8% and 47.8% post). Conclusions: We could not detect differences in order-entry time by well-trained PAs using standardized order sets before and after CPOE implementation on an inpatient hematology/oncology service. The decision to adopt CPOE should not be based on the hypothesis that there will be less (or more) time spent on order entry tasks. No significant financial relationships to disclose.
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Wright, Lorianne, Lemuel Russell Waitman, and Alison Grisso. "Implementation of Pediatric-Specific Decision Support in a CPOE System." Hospital Pharmacy 39, no. 4 (April 2004): 381–85. http://dx.doi.org/10.1177/001857870403900415.
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Ash, J. S. "A Consensus Statement on Considerations for a Successful CPOE Implementation." Journal of the American Medical Informatics Association 10, no. 3 (January 28, 2003): 229–34. http://dx.doi.org/10.1197/jamia.m1204.
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ten Hoopen, A. J., P. E. Zanstra, and P. F. de Vries Robbé. "Comparing the Implementation of CPOE in two Dutch Hospitals Revisited." Methods of Information in Medicine 46, no. 01 (2007): V—VI. http://dx.doi.org/10.1055/s-0038-1628142.
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Harshberger, C. A., B. Brockstein, G. Carro, W. Jiang, W. Spath, and J. Lawton. "Evaluation of outcomes before and after electronic medical record (EMR) and computerized physician order entry (CPOE) system implementation in an outpatient oncology setting." Journal of Clinical Oncology 25, no. 18_suppl (June 20, 2007): 17058. http://dx.doi.org/10.1200/jco.2007.25.18_suppl.17058.
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17058 Background: Computerized physician order entry (CPOE) in electronic medical records (EMR) has been recognized as an important tool in optimal health care provision that can reduce errors and improve safety. The objective of this study is to describe documentation completeness and user satisfaction of medical charts before and after outpatient oncology EMR/CPOE system implementation in a hospital based outpatient cancer center within three treatment sites and with sixteen physicians. Methods: A retrospective chart review was conducted on 32 randomly selected patients to date, who received one of the following regimens: FOLFOX, carboplatin-paclitaxel, CHOP-rituximab, or AC between 1999 and 2006. Charts were case matched with physician and regimen to compare documentation completeness. Completeness scores were assigned to each chart based on the number of documented data points found out of the 33 data points assessed. A user satisfaction survey of the paper chart and EMR/CPOE system was conducted among the physicians (n=16), nurses (n=43), and pharmacists (n=8) who worked with both systems. Results: The mean percentage of identified data points successfully found in the EMR/CPOE charts was 94% vs. 68% in the paper charts (p<0.001). Regimen complexity did not alter the number of data points found. The survey response rate was 64% and the results showed that satisfaction was statistically significant in favor of the EMR/CPOE system. The time required to find the data points will be assessed by having a physician, nurse, and pharmacist review the same charts. Data on 112 charts will be presented. Conclusions: Using EMR/CPOE systems improves completeness of medical record and chemotherapy order documentation and improves user satisfaction with the medical record system. No significant financial relationships to disclose.
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Russell, Rebecca A., David Triscari, Kathy Murkowski, and Matthew C. Scanlon. "Impact of Computerized Order Entry to Pharmacy Interface on Order-Infusion Pump Discrepancies." Journal of Drug Delivery 2015 (November 18, 2015): 1–6. http://dx.doi.org/10.1155/2015/686598.
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Background. The ability of safety technologies to decrease errors, harm, and risk to patients has yet to be demonstrated consistently. Objective. To compare discrepancies between medication and intravenous fluid (IVF) orders and bedside infusion pump settings within a pediatric intensive care unit (PICU) before and after implementation of an interface between computerized physician order entry (CPOE) and pharmacy systems. Methods. Within a 72-bed PICU, medication and IVF orders in the CPOE system and bedside infusion pump settings were collected. Rates of discrepancy were calculated and categorized by type. Results were compared to a study conducted prior to interface implementation. Expansion of PICU also occurred between study periods. Results. Of 455 observations, discrepancy rate decreased for IVF (p=0.01) compared to previous study. Overall discrepancy rate for medications was unchanged; however, medications infusing without an order decreased (p<0.01), and orders without corresponding infusion increased (p<0.05). Conclusions. Following implementation of an interface between CPOE and pharmacy systems, fewer discrepancies between IVF orders and infusion pump settings were observed. Discrepancies for medications did not change, and some types of discrepancies increased. In addition to interface implementation, changes in healthcare delivery and workflow related to ICU expansion contributed to observed changes.
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Hertz, Sherrie, John Gilks, Leonard Kaizer, Marta Yurcan, and Vishal Kukreti. "Concordance with best-practice guidelines for systemic treatment computerized prescriber order entry systems." Journal of Clinical Oncology 31, no. 31_suppl (November 1, 2013): 245. http://dx.doi.org/10.1200/jco.2013.31.31_suppl.245.
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245 Background: In 2012, Cancer Care Ontario, released evidence-based guidance for the key features, functionalities, and components of a Systemic Treatment Computerized Prescriber Order Entry (ST CPOE) system to ensure safe, high-quality care. Concordance measurement indicators were developed alongside the guidelines and a survey was then conducted to understand the current state in a meaningful and practical manner in the province of Ontario. Methods: A self-assessment survey was distributed to 22 hospital groups, including cancer centres and both academic and community hospitals, using four different ST CPOE systems in Ontario. 52 items were assessed on a four-point Likert scale, and descriptive hospital data was collected. Composite scores were calculated by category (regimen and protocols, functionality, useful alerts, audit logs, system integration, usability) and overall. Local and provincial results were analyzed. Results: Twenty-one (21) responses were received, with the majority (17) of surveys being completed by pharmacists. 48% had been using a ST CPOE system for more than 5 years and 38% for less than one year. 81% responded that they did not, or did not know if, they had local/institutional indicators for monitoring their systems. The mean total concordance score overall was 79% (range 65% to 92%) of a potential 208 total points. The highest mean score was in the category of audit logs (92%) and the lowest in system integration (69%). Approximately half (48%) had a multidisciplinary ST CPOE advisory group. While 16 hospitals were using the same ST CPOE system, there was distinct variability in responses from these sites, indicating the effects of tailored implementations and/or discrepancy in level of knowledge of system functionalities. Conclusions: Current concordance with best practice guidelines for ST CPOE systems in Ontario is incomplete and variable. While ST CPOE systems have potential to improve safety in the chemotherapy delivery, differences in system functionalities and their implementation have been identified. This study will be used to inform specific areas of strength, set benchmarks and potential areas for improvement.
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Georgiou, Andrew, Tony Greenfield, Joanne Callen, and Johanna I. Westbrook. "Safety and Efficiency Considerations for the Introduction of Electronic Ordering in a Blood Bank." Archives of Pathology & Laboratory Medicine 133, no. 6 (June 1, 2009): 933–37. http://dx.doi.org/10.5858/133.6.933.
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Abstract The introduction of computerized provider order entry (CPOE) systems is associated with major changes in work processes. Implementation strategies need to consider how the technology will affect and be affected by the organization in which it is being installed. The aim of this study was to examine the potential effect of the introduction of a CPOE system on key work processes in a hospital blood bank by using qualitative data from focus groups, interviews, and participant observation and quantitative data of telephone communication. We found that work practices in the blood bank are made up of a mosaic of collaborative processes underpinned by communication channels to facilitate safe and efficient work practices. The introduction of CPOE systems requires consideration of these channels and of the ways that CPOE may disrupt existing communication processes. There needs to be high levels of staff preparedness to minimize patient risk and optimize performance.
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Gradin, Sharon, Nancy Wolf, Marta Yurcan, Tim Yardley, Leonard Kaizer, and Vishal Kukreti. "Evaluating the implementation of computerized prescriber order entry (CPOE) for systemic treatment (ST) in Ontario." Journal of Clinical Oncology 32, no. 30_suppl (October 20, 2014): 54. http://dx.doi.org/10.1200/jco.2014.32.30_suppl.54.
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54 Background: A successful effort was led in Ontario to increase ST CPOE adoption from 73% to 92% to support safety of patients receiving complex systemic treatment. This work included implementation at 19 hospitals from 2011-2013. The implementation process included identification of multidisciplinary team champions, baseline workflow analysis and development of a future desired state. Findings from this project’s benefits evaluation are presented. Methods: Each hospital was required to collect pre and post implementation measurements for medication errors, transcription errors and order clarity/completeness. Six months post implementation, a semi-structured telephone interview was conducted with representative hospitals (9/19) to obtain qualitative feedback on how implementation impacted workflow, inter-professional practice and workload. Results: Hospitals that implemented showed: 1) decrease in overall medication error rates. 2) decrease in transcription error rates and 3) decrease in number of unclear or incomplete orders. Qualitative feedback from hospital leads indicated that the “future desired” workflow was achieved by all. Most hospital respondents indicated that clarity of inter-professional communication regarding orders improved and in most cases overall workload did not increase. Conclusions: The findings reinforce the benefit associated with implementation of ST CPOE in outpatient settings. Lessons learned in Ontario can be leveraged to support successful implementation of ST CPOE in other jurisdictions. Critical implementation success factors included: 1) leadership and multi-disciplinary involvement; 2) provision of funding and cost sharing; 3) facilitation of process improvement through established methodologies, 4) knowledge transfer and peer group led education and training sessions. [Table: see text]
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Braithwaite, J., J. I. Westbrook, and J. L. Callen. "The Importance of Medical and Nursing Sub-cultures in the Implementation of Clinical Information Systems." Methods of Information in Medicine 48, no. 02 (2009): 196–202. http://dx.doi.org/10.3414/me9212.
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Summary Objective: To measure doctors’ and nurses’ perceptions of organisational culture and relate this to their attitudes to, and satisfaction with, a hospital-wide mandatory computerised provider order entry (CPOE) system in order to illuminate cultural compositions in CPOE use. Methods: A cross-sectional survey design was employed. Data were collected by administering an organisational culture survey (Organisational Culture Inventory, OCI) along with a user-satisfaction survey to a population of 103 doctors and nurses from two clinical units in an Australian metropolitan teaching hospital. Clinicians from the hospital had used the CPOE system since 1991 to order and view clinical laboratory and radiology tests electronically for all patients. The OCI provides a measure of culture in terms of three general styles which distinguish between: constructive; passive/defensive, and aggressive/defensive cultures. The cluster which best describes the overall culture is the one that has the highest percentile score when the percentile scores of the four cultural norms included in the cluster are averaged. The user satisfaction survey asked questions relating to satisfaction with, and attitudes to, the system. Results: We found identifiable sub-cultures based on professional divisions where doctors perceived an aggressive-defensive culture (mean percentile score = 43.8) while nurses perceived a constructive culture (mean percentile score = 61.5). There were significant differences between doctors and nurses on three of the attitude variables with nurses expressing more positive views towards CPOE than doctors. Conclusion: The manifestation of sub-cultures within hospitals and the impact this has on attitudes towards clinical information systems should be recognized and addressed when planning for system implementation. Identification and management of the cultural characteristics of different groups of health professionals may facilitate the successful implementation and use of clinical information systems.
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Ramirez, Anne, Debra Carlson, and Carey Estes. "Computerized Physician Order Entry: Lessons Learned from the Trenches." Neonatal Network 29, no. 4 (July 2010): 235–41. http://dx.doi.org/10.1891/0730-0832.29.4.235.
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Implementation of computer physician order entry (CPOE) demands planning, teamwork, and a steep learning curve. The nurse-driven team at the hospital unit level is pivotal to a successful launch. This article describes the experience of one NICU in planning, building, training, and implementing CPOE. Pitfalls and lessons learned are described. Communication between the nurse team at the unit and the clinical informatics team needs to be ongoing. Self-paced training with realistic practice scenarios and one-on-one “view then practice” modules help ease the transition. Many issues are not apparent until after CPOE has been implemented, and it is vital to have a mechanism to fix problems quickly. We describe the experience of “going live” and the reality of day-to-day order entry.
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Hanauer, David A., Kai Zheng, Elaine L. Commiskey, Mary G. Duck, Sung W. Choi, and Douglas W. Blayney. "Computerized Prescriber Order Entry Implementation in a Physician Assistant–Managed Hematology and Oncology Inpatient Service: Effects on Workflow and Task Switching." Journal of Oncology Practice 9, no. 4 (July 2013): e103-e114. http://dx.doi.org/10.1200/jop.2012.000655.
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Mogharbel, Asra, Dawn Dowding, and John Ainsworth. "Physicians’ Use of the Computerized Physician Order Entry System for Medication Prescribing: Systematic Review." JMIR Medical Informatics 9, no. 3 (March 4, 2021): e22923. http://dx.doi.org/10.2196/22923.
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Background Computerized physician order entry (CPOE) systems in health care settings have many benefits for prescribing medication, such as improved quality of patient care and patient safety. However, to achieve their full potential, the factors influencing the usage of CPOE systems by physicians must be identified and understood. Objective The aim of this study is to identify the factors influencing the usage of CPOE systems by physicians for medication prescribing in their clinical practice. Methods We conducted a systematic search of the literature on this topic using four databases: PubMed, CINAHL, Ovid MEDLINE, and Embase. Searches were performed from September 2019 to December 2019. The retrieved papers were screened by examining the titles and abstracts of relevant studies; two reviewers screened the full text of potentially relevant papers for inclusion in the review. Qualitative, quantitative, and mixed methods studies with the aim of conducting assessments or investigations of factors influencing the use of CPOE for medication prescribing among physicians were included. The identified factors were grouped based on constructs from two models: the unified theory of acceptance and use of technology model and the Delone and McLean Information System Success Model. We used the Mixed Method Appraisal Tool to assess the quality of the included studies and narrative synthesis to report the results. Results A total of 11 articles were included in the review, and 37 factors related to the usage of CPOE systems were identified as the factors influencing how physicians used CPOE for medication prescribing. These factors represented three main themes: individual, technological, and organizational. Conclusions This study identified the common factors that influenced the usage of CPOE systems by physicians for medication prescribing regardless of the type of setting or the duration of the use of a system by participants. Our findings can be used to inform implementation and support the usage of the CPOE system by physicians.
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Talmon, J., J. S. Ash, D. W. Bates, M. C. Beuscart-Zéphir, A. Duhamel, P. L. Elkin, R. M. Gardner, A. Geissbuhler, and E. Ammenwerth. "Impact of CPOE on Mortality Rates – Contradictory Findings, Important Messages." Methods of Information in Medicine 45, no. 06 (2006): 586–94. http://dx.doi.org/10.1055/s-0038-1634123.
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Summary Objective: To analyze the seemingly contradictory results of the Han study (Pediatrics 2005) and the Del Beccaro study (Pediatrics 2006), both analyzing the effect of CPOE systems on mortality rates in pediatric intensive care settings. Methods: Seven CPOE system experts from the United States and Europe comment on these papers. Results: The two studies are not contradictory, but almost non-comparable due to differences in design and implementation. They demonstrate the range of outcomes that can be obtained from introducing informatics applications in complex health care settings. Implementing informatics applications is a socio-technical activity, which often depends more on the organizational context than on a specific technology. As health informaticians, we must not only learn from failures, but also avoid both uncritical scepticism that may arise from drawing overly general conclusions from one negative trial, as much as uncritical optimism from limited successful ones. Conclusion: The commentaries emphasize the need to promote systematic studies for assessing the socio-technical factors that influence the introduction of increasingly sophisticated informatics applications within complex organizations. The emergence of evidence-based health informatics will be based both on evaluation guidelines and implementation guidelines, both of which increase the chances of successful implementation. In addition, well-educated health informaticians are needed to manage and guide the implementation processes.
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Harshberger, Cara A., Abigail J. Harper, George W. Carro, Wayne E. Spath, Wendy C. Hui, Jessica M. Lawton, and Bruce E. Brockstein. "Outcomes of Computerized Physician Order Entry in an Electronic Health Record After Implementation in an Outpatient Oncology Setting." Journal of Oncology Practice 7, no. 4 (July 2011): 233–37. http://dx.doi.org/10.1200/jop.2011.000261.
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Prgomet, Mirela, Ling Li, Zahra Niazkhani, Andrew Georgiou, and Johanna I. Westbrook. "Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis." Journal of the American Medical Informatics Association 24, no. 2 (October 7, 2016): 413–22. http://dx.doi.org/10.1093/jamia/ocw145.
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Objective: To conduct a systematic review and meta-analysis of the impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay (LOS), and mortality in intensive care units (ICUs). Methods: We searched for English-language literature published between January 2000 and January 2016 using Medline, Embase, and CINAHL. Titles and abstracts of 586 unique citations were screened. Studies were included if they: (1) reported results for an ICU population; (2) evaluated the impact of CPOE or the addition of CDSSs to an existing CPOE system; (3) reported quantitative data on medication errors, ICU LOS, hospital LOS, ICU mortality, and/or hospital mortality; and (4) used a randomized controlled trial or quasi-experimental study design. Results: Twenty studies met our inclusion criteria. The transition from paper-based ordering to commercial CPOE systems in ICUs was associated with an 85% reduction in medication prescribing error rates and a 12% reduction in ICU mortality rates. Overall meta-analyses of LOS and hospital mortality did not demonstrate a significant change. Discussion and Conclusion: Critical care settings, both adult and pediatric, involve unique complexities, making them vulnerable to medication errors and adverse patient outcomes. The currently limited evidence base requires research that has sufficient statistical power to identify the true effect of CPOE implementation. There is also a critical need to understand the nature of errors arising post-CPOE and how the addition of CDSSs can be used to provide greater benefit to delivering safe and effective patient care.