Successful Pathway to Computerized Physician Order Entry (CPOE) in Ambulatory Setting
Even under the best circumstances, Computerized Physician Order Entry (CPOE) in the ambulatory setting has its challenges. The paper process can be advantageous and preferred by many physicians because of its efficiency and familiarity. Selecting check boxes or scribbling a line item on a paper form may be hard to beat when transitioning to CPOE for some.
The ability to define workflows and configure an Electronic Health Record (EHR) to support efficient operational processes is critical for meaningful adoption and achieving the highest standards of patient care. CPOE improves order tracking and compliance and leverages the synergies and reporting capabilities gained by using the complete EHR to effectively document, monitor and manage the care of patients.
CPOE impacts almost every clinical encounter and department. Operationally, the transition from paper orders to electronic orders is, in most cases, one of the biggest adjustments required when adopting an EHR. In addition to physicians and nurses, all clinic staff, schedulers, check-out teams, laboratory and radiology techs, phlebotomists, billing departments and patients are impacted as well. For many departments, the paper process has evolved over many, many years undergoing multiple optimizations while taking into account pre-existing systems, space and available resources. The current paper processes aren't perfect, but they can be difficult and, in some cases, impossible to replace while making ALL stakeholders happy. With that being said, there are very good reasons to move to CPOE: among them, better order tracking and compliance, improved electronic documentation, reduction in errors, medical necessity checking and government incentives and penalties.
An assessment of workflow and processes impacting each of the stakeholders is critical to identifying a solution that will work given current software behavior (EHR and ancillary systems) as well as space and resources. Checking a box on a paper encounter form is relatively easy which forces its replacement to be as streamlined as possible.
Workflow analysis identifies areas for optimization as well as gaps in the software build that need to be addressed to streamline order entry. The system must be optimized to allow the orders to be selected and placed with minimum number of "clicks" for the physicians and supporting staff. Orderables should be synchronized to remove confusion regarding which "CBC" should be selected by the physician depending on where the test will be performed based on patient location and in some cases insurance. Problem based or evidence based order sets can be leveraged to make the selection of relevant orderables more efficient from one screen within the application. Worklists should be created based on role and defined to support the recoding of additional information, specimen collection and order processing. Auto-print/fax defaults can be defined to facilitate the printing of requisitions to accompany the specimens. Billing or CPT codes should be linked to appropriate orderables to facilitate medical necessity checking, Advanced Beneficiary Notification (ABN) process and billing. Order reminders, alerts and reports can be used to flag patients needing follow-up to help manage chronic conditions, assist with preventative health management and improve order tracking amd compliance.
Interfaces can slow down the processing of orders from one system to another, therefore, it is critical that the interface server and the performance of the interfaces are optimized for real-time communication of orders allowing appropriate scheduling and processing to support the patient workflow and checkout process while removing wait time.
Improved electronic documentation
Improved order tracking and compliance
Reduction in chances of human error
Medical Necessity Checking
Improved reporting capabilities
Satisfying Stage 2 and 3 Meaningful Use Requirements
Change is difficult. The transition from paper orders to CPOE is significant and requires a commitment and strategy that can resolve numerous operational and technical challenges that must be appropriately managed for a successful implementation with meaningful adoption by all stakeholders.