Helping clinicians cope with CPOE systems
Laboratory information system vendors know well the
patient safety benefits of computerization, and they’re laboring to
bring the insights of the LIS world to the creation of CPOE, or computerized
physician order entry.
"Electronic ordering allows fewer errors to occur, not only in
the patient data—for example, getting the name wrong, but
also in the lab data—for example, choosing the wrong test
for a patient," says Curt Johnson, vice president of sales at Orchard
Mention patient safety and physician ordering to most LIS vendors
and you will almost certainly hear the word "alerts" in their replies.
"The givens in CPOE are an electronic ordering system, alerts
and rules, and a clinical database to fire them against," says Bernard
Kasten, MD, vice president for medical affairs at MedPlus, a Quest
When it comes to clinical alerts, the rules or algorithms can
become "as complex as the organization would like," says Floyd Eisenberg,
MD, MPH, physician executive for clinical systems at Siemens Medical
Solutions Health Services. "Our rules engine can extract data from
various locations, perform the appropriate calculations, and notify
the physician synchronously during the ordering process or asynchronously
at the occurrence of new events outside an existing order session,"
Dr. Eisenberg says.
Not long after the Institute of Medicine report "To err is human"
set off a firestorm of concern in 1999, more than 100 organizations
joined under the rubric of the Leap Frog Group for Patient Safety
to help organize an industrywide system of defining and certifying
solutions to the problem of avoidable medical errors. Like the IOM,
the Leap Frog Group named CPOE as a critical component of such solutions
and began specifying and certifying the components of a CPOE system.
The coalition determined that CPOE systems have two main features:
they encourage physicians to order electronically rather than through
handwritten or oral instructions, and they provide a high level
of information about patients by integrating clinical information
from a variety of sources, most notably the pharmacy, laboratory,
and radiology. CPOE, according to the Leap Frog Group, falls within
a larger function known as clinical decision support and should
be distinguished from the more general function of simple orders
As of August 2001, reports the Leap Frog Group, about 13 CPOE products were
on the market or slated for imminent release. The group named several vendors
supplying CPOE systems at that time: Cerner, Clinicomp, Eclipsys, IDX, Meditech,
Per Se, Siemens, VisualMed, 3M, Autros/ Epic, McKesson, and GE Medical Systems.
The art of the alert
Neither alerts nor the technology underlying them are new. The
ability to generate alerts, especially those based on the operation
of a rules engine and a clinical database, is a proven technology
in the LIS world. Nonetheless, the technology, like most, is still
a work in progress and is in many ways as much art as science.
In its fullest expression, the application of rules technology
seeks to completely replicate clinical decision-making—an
ambitious and often impractical undertaking. Rob Bush, president
of Orchard Software, recalls a project in which he worked to implement
rules to alert technologists about results requiring a second look
before being released. "We created a system that would electronically
consider everything a technologist would consider in making this
decision," he says. That meant considering a lot of variables—which
physician ordered the test, where the patient was located in the
hospital, medical history, patient age and gender, and lab-oriented
data, such as previous results, instrument flags, and delta checks.
"Our contention was that if it was something the technologist
used to screen results, and we couldn’t replicate it in the rules
system, we weren’t offering a real alternative solution," Bush says.
"If you can’t do that, you’re not really offering an alternative;
you are, in effect, asking your client to be ready to do the same
thing twice, if need be, once in an automated way and, if that isn’t
completely reliable, then once again by human beings."
Extend this experience to CPOE, he continues, and you may find
that, beyond the simplest level of alerts, you face a problem of
rapidly diminishing returns—of pouring more and more time
and energy into work that pays you fewer and fewer real gains—and
that the challenge of creating an electronic duplicate of the human
decision-making process is nearly insurmountable.
Fortunately, the alerts required to help physicians make safer
orders do not require so comprehensive an application of rules technology.
In fact, many flags, notifications, and warnings do not require
a rules system in the purest sense at all. Moreover, for alerts
of any kind, the more likely question is not whether they can duplicate
human judgment, but whether they will be so numerous and self-evident
as to annoy rather than assist.
"If every little trivial thing rings a four-star alarm, the doctor
is soon going to lose interest in any of the rules," Dr. Kasten
says. In fact, he argues, this is exactly what has happened in many
rules-based alert systems: Physicians have chosen to opt out of
them, to run them off or de-subscribe to them, because they have
been seen as cumbersome, impractical, and "riddled with false-positives,"
Dr. Kasten says. Adds Dr. Eisenberg of Siemens, "My concern is that
the system can provide many alerts, but if the number and/or quality
is more an annoyance than a benefit, clinicians of any type will
quickly learn to breeze right by them." Alerts, he says, must either
provide a clinician with significant, timely information that poses
a real, immediate risk to a patient or request information the clinician
perceives to be important in the clinical care process.
The "nuisance potential" of alerts has been acknowledged as a
serious issue by the Leap Frog Group. In a December 2001 report,
the group said that "a hospital must achieve the right balance between
useful alerting and ‘over-alerting’ or intercepting orders that
have a very low risk of ADEs [adverse drug events]. Such ‘nuisance’
alerts can seriously impair physician acceptance of CPOE and, more
important, lead users to ignore all alerts, thereby decreasing the
value of clinical decision support." (Kilbridge, et al. Overview
of the Leap Frog Group evaluation tool for computerized physician
order entry. Leap
Frog Group [in conjunction with First Consulting], December 2001,
Alerts can also have subtle political and legal implications.
Their tone must strike the right balance between obsequious and
"It’s very important that rules be presented in a way that is
not pedestrian or demeaning," says Dr. Kasten. "A cardiologist doesn’t
want to be told something he or she already knows."
To some extent, this is probably a matter of simple professional
courtesy, but it may also touch on the more serious issue of liability,
Dr. Kasten says. One of the open-ended questions implicit in the
deployment of a rules system, he suggests, is whether the providers
of rules systems incur any medical liability. "I would hope they
don’t, because they are always offered as suggestions to augment
physician judgment," he says. "Their intention is to assist the
physician and guide a possible course of action, not pre-empt physician
For LIS vendors and others, managing this problem is straightforward.
It involves working at the outset of a new installation to make
sure alerts are deployed to address problems that are neither trivial
nor overambitious. "What we do is go in and sit down with the relevant
people at the site and say, ’Let’s assess your problem, where do
you want to focus?’" reports Scott Mattingly, product line director
for enterprisewide solutions for Misys Healthcare Systems. Mattingly
is describing the implementation of the Misys Insight clinical decision
support system. The process begins with consultants who spend time
on-site interviewing staff to determine the functions most in need
of clinical decision support, those in which appropriate alerts
can be quickly leveraged to return the greatest immediate benefit.
"We don’t try to draw on all of our 500-plus rules and roll this
out to the entire enterprise up front," Mattingly says. "Instead,
we try to select the top five problems, create the handful of alerts
that will really help those wrestling with these problems, make
sure the alerts work and that the site will get the reduction in
errors it is looking for, then return later and begin extending
the use of alerts beyond that initial target group."
By their very nature, many alerts must be presented at the time
of ordering to have as much impact as possible. Fulfilling this
function efficiently depends largely on the speed of the underlying
hardware and software, which in turn touches on a longstanding topic
in health care—that is, the relative performance merits of
single-platform, homogeneous, highly integrated solutions versus
the more highly interfaced, heterogeneous solutions (those supporting
so-called best-of-breed systems). With respect to CPOE development,
vendors with highly integrated solutions argue that they offer a
significant performance advantage in ensuring that alerts are presented
as immediately as possible to the ordering physician.
"If I’m on a single data model platform and the lab value is processed
and available to me, as a physician, immediately, I’m getting real-time
access to that value," says Bryan Christianson, product marketing
manager of physician solutions marketing, Cerner Corp. To put it
more metaphorically, says Cerner’s Julie Hull, director of product
management, "the difference between alert speed of access in a system
like ours versus others can be like the difference between driving
a car with warning signals that sound off or light up before you
hit a pedestrian and signals that warn you as you hit a pedestrian."
In contrast, systems that present an alert only after the order
has been sent and a resource such as a departmental database has
been accessed may be at a significant performance disadvantage.
"I agree with that perspective," Dr. Kasten says. "If you have
to crawl back into a legacy system with no real-time data access,
your CPOE system won’t meet the needs of busy physicians." However,
Dr. Kasten adds, the potential performance disadvantages inherent
in heterogeneous, highly interfaced systems can be mitigated by
creating a clinical data repository against which the ordering rules
fire. Citing his own experience at MedPlus with ChartMaxx, designed
for hospital clients, and eMaxx, designed for physician and clinic
use, Dr. Kasten explains that since these solutions incorporate
clinical data repositories, "users have instant access to their
data—they’re not trying to go back to a legacy database on
a real-time basis."
Of course, the use of rules, clinical databases, and alerts to shore up patient
safety through CPOE systems implies a process for making sure the rules and
the data are as current as possible, which is in itself no small undertaking.
Well-trained, experienced, and highly informed though they may be, clinicians
cannot stay abreast of all medical research and its clinical implications. "Some
of what I learned in med school just isn’t true anymore; it’s been supplanted
by more recent data," says Dr. Kasten. "But rules should be based on evidence,
and that evidence must be kept current, because yesterday’s medical truth is
not today’s medical truth."
Managing multiple workflows
The patient safety challenge presents another longstanding question:
How can physicians best be encouraged to use CPOE systems? Understandably,
physicians have responded to health care computerization in a decidedly
It is still easier and faster to tick off boxes on a form, scrawl
an order in a chart, or tell a staff member to take action, than
to log on to a computer system—no matter how fast it is—call
up the appropriate screen, examine the information presented, and
"I saw a presentation many years ago on this topic in which the
individual making it began by projecting an image of a No. 2 pencil
and saying, ’Gentlemen, this is our competition. We may be able
to beat it in our lifetime,’" recalls Bill Blair, vice president
of sales and marketing for SIA. True, says Blair, the earliest electronic
ordering systems were focused more on billing than on clinical data
and were designed for use by clerical staff, not clinicians. That
has changed, of course, and many ordering systems now in use are
designed to present clinical, patient-centric information directly
to physicians and other frontline caregivers.
Nonetheless, some doubt this challenge can be accomplished. "Doctors
will not tolerate the rigors that a really sophisticated order-entry
system must impose on them," says Janet Chennault, vice president
of Schuyler House Software. And this physician impatience is only
exacerbated by a health care system that seeks to impose tight constraints
on the time doctors spend with patients. "The sad state of medicine
right now is that your typical physician encounter involves less
and less encounter," says Bill Shipley, president of Schuyler House.
"It’s probably not a wise idea to waste any of that limited time
risking having the physician spend it cursing at the computer."
The problem may lie in the fact that ordering systems have not
incorporated sufficient intelligence about the intricacy of ordering.
Order entry often takes place within complex systems comprising
many people and thus many overlapping, intersecting, and interdependent
workflows. Next-generation CPOE systems are likely to include tools
that reflect this fact more fully.
"Dealing with physician order entry requires managing many workflows,"
says Siemens’ Dr. Eisenberg. "It’s not just a matter of encouraging
physicians to get online and put orders in an electronic system."
A doctor writing an order is more often than not writing an order
for other orders, taking an action that will affect many workflows.
"For instance," Dr. Eisenberg says, "if I write an order for a lab
study, I may just write that I want a certain drug level done in
the morning, say half an hour before the next dose of the drug is
administered." That brief note may translate into placing the order
on a list of scheduled draws, timing the draw based on when the
medication is to be given, performing quality checks to make sure
the drug was not administered before the draw, conducting lab tests,
and reviewing and transmitting results. Some of the tasks involved
can be handled concurrently; others must be handled sequentially.
Some of the people involved need to know only about their own steps;
others need to have a comprehensive overview of the process.
If it lives up to its promise, an automated workflow manager should
be able to help track these intersecting tasks, compiling information
about their completion and moving the entire array of interdependencies
through the patient care process with a minimum of errors. Such
efforts are underway in many health care IT companies, including
Siemens, which is incorporating a workflow engine into its next-generation
clinical access system, Soarian, scheduled for release early next
Real benefits, slowly realized
CPOE implementation is still in its infancy. The Leap Frog Group
estimates that only two percent of health care providers have deployed
a CPOE system. CPOE prevalence will grow—but probably slowly.
According to several researchers, fully realizing CPOE’s benefits
is likely to take a decade or more.
Though CPOE is still new, its earliest implementations are already
reducing medical error. Given the emphasis by the IOM, the Leap
Frog Group, and others on medication errors, much of the data thus
far focuses on avoiding adverse drug reactions and shortening medication
delivery turnaround time. "A number of our CPOE customers are already
reporting good results," says Dr. Eisenberg. "At the Ohio State
University Medical Center, where 100 percent of physician orders
are entered electronically, they have seen a 25 percent reduction
in turnaround from the time a lab order is placed until the result
is back from the lab, a 43 percent reduction in radiology turnaround
time, and a 64 percent reduction in medication turnaround time."
Similarly, says Dr. Eisenberg, Siemens’ CPOE systems at Rush Presbyterian-St.
Luke’s in Chicago have facilitated a 64 percent reduction in medication
turnaround time (the time between when a medication is ordered and
the patient receives it), and Meridian Health Systems in New Jersey
has seen an 84 percent reduction in medication TAT. In addition,
says Dr. Eisenberg, these sites report significant cost reductions
derived from reduced lengths of stay and fewer unnecessary or duplicate
laboratory, medication, and radiology orders.
Similarly, says Misys’ Mattingly, Palmetto Health Richland in
Columbia, SC, among other benefits, has reaped $91,000 in reduced
medication costs and an estimated $440,000 per year in total cost
savings for all interventions based on alerts from its first year
of Misys Insight clinical decision support system use.
While patient safety is the overriding rationale for developing
and adopting CPOE systems, the systems provide a compelling opportunity
to integrate additional information. For example, information on
patient sensitivity to specific medications can easily be integrated
with recommendations for alternative medication choices, including
efficacy data and cost data.
The process might work something like this: "The physician could
get a lab result back that says this patient has E. coli,
along with a list of drugs that have proven to have varying degrees
of effectiveness in dealing with this variant of this bug," says
Will Campbell, senior product manager for Impac Medical Systems.
Too often, Campbell says, the physician’s reaction to this information
and his or her subsequent order is likely to be based on inadequate
information. The physician will look at such a list and choose a
medication based largely on past experience. "That’s not enough
information," Campbell adds. "If all you present to the doctor is
a list of four drugs of varying efficacy, you haven’t really given
the physician as much information as you could and probably should."
The physician in this case should, Campbell argues, be presented
with lab results, medication choices, the efficacy of those choices,
and their cost. "He or she is then in a position to make an intelligent
ordering choice," Campbell says. "He or she can say, well, Choice
A looks like it’s the cheapest and it has good efficacy, but I know
it will be incompatible with other things I am prescribing for this
patient, so this next choice, which looks like it works just as
well and is about the same cost, will do the job nicely."
Electronic ordering can, in short, leverage much more information
during the ordering process, and in so doing contribute additional
value while fulfilling its primary goal—patient safety.
Eric Skjei is a writer in Stinson Beach, Calif.