Journal of Oncology Practice, Vol 1, No 2 (July), 2005: pp. 70
© 2005
American Society of Clinical Oncology.
DOI: 10.1200/JOP.1.2.70
Debate Over CPOE Continues
An article in the March issue of JAMA noted that rather than increasing patient safety, a computerized physician order entry (CPOE) actually facilitated errors.1 In contrast, the authors of an article in the May issue of the same journal estimated an 81% reduction in medication errors over the last 5 years, in part due to the introduction of computerized pharmacy ordering.2 These two articles represent the continuing debate over the value of CPOE systems, with some thinking that the electronic systems have not met their goal of increasing patient safety and others believing that the technology is promising. One point all would agree on is that CPOEs are far more complicated than originally expected and that a system must be planned carefully before implementation.3
The first study generated widespread media coverage that focused on the failure of CPOE systems. However, the results of the study should be interpreted with caution. The CPOE system evaluated in the single-institution study is now outdated and off the market. It included pre-Windows interfaces and monochromatic screens that are difficult to read, and it required "flipping" through as many as 20 screens to review a single patient's medication history. In addition, two points about the design of the study should be noted. First, the study addressed the probability of prescribing errors—not actual errors—and second, a comparison of a CPOE system with a paper-based ordering system would have provided more useful findings about the value of the system.
In an editorial accompanying the study, Wears and Berg point out that implementation of a CPOE requires behavioral change on the part of physicians and other health care professionals.4 This fact, more than technological flaws, may be the overriding problem. They note, "There is a long-standing, rich, and abundant literature on the problems associated with the introduction of computer technology into complex work in other domains...there is no reason to expect health care, which is from an organizational standpoint probably the most complex enterprise in modern society, to be immune to them."4
In commenting on the study, David Brailer, MD, PhD, national coordinator for Health Information Technology, said, "The findings from this study show that the particular way that computerized physician order entry products are developed and implemented makes all the difference in whether quality is improved."5
Several other factors are involved in the success—or failure—of implementing a CPOE system. All systems are not created equal and thus, not all systems will be appropriate for all sites.6 Wears and Berg note that perhaps the most important point is that problems with CPOE systems should not be framed as "not developing the systems right" but rather, that the problems demonstrate "not developing the right systems."4 In other words, when a system is being developed for a specific site, the needs of the individual institution and the workflow of the organization should be thoroughly reviewed and evaluated. In addition, a CPOE should be implemented only after other computerized clinical systems are in place, and adequate training should be provided.7
It is also possible that the expectations for the technology are too high. Shane notes that CPOE systems alone do not provide a complete solution to drug-prescribing errors.8 The integration of online decision support, point-of-care medication scanning systems, and other clinical tools and resources will help to improve safety and enhance the quality of care.3,6 Furthermore, it has been suggested that the source of medication errors at a site should be identified before a CPOE system is implemented and the system should then be customized to avoid the errors that are most likely to be harmful to patients.9 Customization of the system can also help to address some of the frequently cited disadvantages. For example, a system can be programmed to flag incorrect doses that are the result of keyboarding errors9 and alerts and alarms can be kept to a minimum so they do not needlessly interrupt the user.6 Once implemented, a CPOE system should be continually evaluated to ensure that it is meeting the needs of its users as well as fostering better patient care.
The problems that have arisen with CPOE systems should be used as lessons to develop ways to avoid repeating history. Also, as the use of such systems increases, ways to better implement them will be identified. CPOE systems are increasingly being recommended for outpatient practices. The complexity of cancer care calls for oncology practices to be especially attentive to the development and customization of the system.
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References
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- Koppel R, Metlay JP, Cohen A, et al: Role of computerized physician order entry systems in facilitating medication errors. JAMA 293:1197-1203, 2005[Abstract/Free Full Text]
- Leape LL, Berwick DM: Five years after To Err Is Human: What have we learned? JAMA 293:2384-2390, 2005[Abstract/Free Full Text]
- CPOE, bedside technology, and patient safety: A roundtable discussion. Am J Health-Syst Pharm 60:1219-1228, 2003[Free Full Text]
- Agency for Healthcare Research and Quality: New AHRQ-funded study on computerized order entry finds flaws that could lead to errors, points to opportunities for improvement. Press release, March 8, 2005. Available at: www.ahrq.gov/news/press/pr2005/cpoepr.htm. Accessed May 24, 2005
- Wears RL, Berg M: Computer technology and clinical work: Still waiting for Godot. JAMA 293:1261-1263, 2005[Free Full Text]
- Handler JA, Feied CF, Coonan K, et al: Computerized physician order entry and online decision support. Acad Emerg Med. 11:1135-1141, 2004[CrossRef][Medline]
- Kuperman GJ, Gibson RF: Computer physician order entry: Benefits, costs, and issues. Ann Intern Med. 139:31-39, 2003[Abstract/Free Full Text]
- Shane R: CPOE: The science and the art. Am J. Health-Syst Pharm. 60:1273-1276, 2003[Free Full Text]
- Traynor K: Customization key to successful CPOE. Am J Health-Syst Pharm. 61:1087, 2004 1092, 1094[Free Full Text]
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