Computerized Physician Order Entry with Clinical Decision
Computerized Physician Order Entry with Clinical Decision Support in the Long-Term Care Setting: Insights from the Baycrest Centre for Geriatric Care
Paula A. Rochon, MD, MPH,_ Terry S. Field, DSc,w DavidW. Bates, MD,z Monica Lee, MSc, BScPhm,_Linda Gavendo, BScPhm,Janet Erramuspe-Mainard,James Judge, MD,k and Jerry H. Gurwitz, MDw
Contents |
Purpose and Background:
Although computerized physician order entry (CPOE) has been successfully implemented in many acute care hospitals, few descriptions of its use in the long-term care (LTC) setting are available. This article describes the experiences of one LTC facility in developing and implementing a CPOE system with clinical decision support (CDS) The system was designed to meet the needs of healthcare providers in the LTC setting, in particular by informing prescribing decisions, reducing the frequency of prescribing and monitoring errors, and reducing adverse drug event rates. Based on experience adopting this technology early, 10 insights are offered that it is hoped will assist others who are onsidering the implementation of CPOE systems with CDS in the LTC setting.
The Baycrest Centre for Geriatric Care is one of the first LTC institutions to implement CPOE with CDS. It is an academic teaching facility affiliated with the University of Toronto.
Methodology:
The insights gained in the creation of a CPOE/CDS system suitable for the LTC setting are encompassed under different phases of the project: development, implementation, and ongoing improvement and modification .then the authors began with the development stage
- Insight 1. The primary motivating force behind the decision to implement a CPOE/CDS system has a large effect on the success or failure of the venture.
- Insight 2. The entire range of specialties that the implementation of CPOE/CDS affects should be represented on the development team, but their expectations must be
balanced against reality.
- Insight 3. Selection of software for CPOE requires compromises; the continued commitment of the vendor to the product is essential.
- Insight 4. CPOE software is likely to require extensive , repeated testing of its functionality and its fit within the institution’s procedures for managing medications.
- Insight 5. There are prescribing issues unique to the LTC setting that require special modifications of CPOE software.
- Insight 6. Extensive accommodations may need to be made to ensure that physicians use the system.
- Insight 7. CPOE/CDS systems place a large burden on existing computer networks; implementation may require hardware and network upgrades.
- Insight 8. The ability to add CDS to a CPOE system is critical.
- Insight 9. (In the implementation stage ) one can plan for the implementation of CPOE, but the actual process takes on a life of its own that calls for flexibility.
Implementation of the CPOE system proved to be a much greater task than anticipated, eventually involving virtually all healthcare professionals working at the facility. Then the authors discussed a set of 39 relevant rules was developed to target prescribing issues of greatest concern in the LTC setting. To do this, the drug therapies most frequently associated with ADEs in LTC were identified. these rules were tested, revised and implemented then the authors . During the implementation phase, support was needed on the resident care units at all times to assist and encourage staff and to provide ongoing training and reinforcement.
Ongoing improvements and modifications:
Insight 10. CPOE affects the institution, and the institution affects the CPOE system. The improvement/modification phase of the CPOE/CDS project is a continuous and ongoing effort that is leading to expanded applications of health information technology at the Baycrest Centre that were not foreseen in the initial plans. The focus on ensuring that physicians enter their medication orders directly and receive feedback through the CDS system has led to a number of interesting suggestions. The resulting modification to the CPOE system electronically transfers medication orders to the ‘‘accepting physician’’ without requiring rewriting of orders.
Conclusion:
LTC residents are at high risk for experiencing ADEs. Successful implementation of CPOE adapted for the LTC setting may have the potential to reduce this risk, although this should be formally studied. Experience from this study is consistent with the published literature, indicating that a CPOE/CDS system does not initially save time for the clinician. This has produced concerns and some resistance to the implementation of the CPOE system.
Medhat Elhalim
