Enhancing Computerized Physician Order Entry (CPOE) to Improve Patient Care and the Medication Order Process

Fred R. Hargrove, D.Ph., James R. Knight, M.S., FASHP, Douglas Talbert, Ph.D., Randolph Miller, M.D., Stephen K. Huffines, Pharm.D.

Vanderbilt University Medical Center

Nashville, Tennessee

Introduction

This project details the experience of Vanderbilt University Medical Center in improving an electronic medication order entry system (CPOE) by creating a robust clinical decision support system (CDSS) and enhancing the interface intelligence between the prescribing (CPOE) and dispensing pharmacy computer systems. The complete project covers a span of 8 years. CPOE is currently implemented on all patient care units with the exception of a Neonatal Intensive Care Unit. Approximately 2800 medication orders are input into the CPOE system each day and electronically communicated to the pharmacy. We feel these results merit recognition of a Best Practice Award by the American Society of Health-system Pharmacists because of the impact at our institution and potential impact at other institutions that implement CPOE.

Rationale and Objective

Since the beginning of this project, the pharmacy made a commitment to aggressively support and participate in the continuous development of the CPOE system. This has proven to be a critical decision and positioned the pharmacy to dramatically impact the content and functionality of the CPOE system. The objective of this ongoing project has been to improve patient care and safety by:

1. improving the intelligence of the interface that creates a default order in the pharmacy system from the CPOE system,
2. improving the Clinical Decision Support System available to the prescriber in the CPOE system.

To continue improving the medication component of the system, the pharmacy provides resources including an Informatics Pharmacist, a Clinical Pharmacist, and a hospital wide Systems Support Pharmacist. The medication order entry functionality of this CPOE system is recognized within the institution and externally as one of the most robust and critical portions of the system. This was a major selling point of the system during implementation and subsequently on the sale and marketing of the product to other institutions.

Description of the Program

After the initial implementation of CPOE at our institution, it became clear that this was a powerful tool to improve patient care and workflow. The pharmacy realized the positive impact this could have on the medication ordering and delivery process and committed to providing appropriate resources in enhancing both the medication component of CPOE and the orders interface to the pharmacy.

Summary of Actions

The pharmacy has been able to develop extensive interfaces between the CPOE and Pharmacy Dispensing Systems. This functionality facilitates medication orders being converted from a prescribing order (CPOE) to a dispensing order (Pharmacy System) without manipulation by the pharmacist. This greatly reduces the opportunity for medication errors and enhances efficiency. This functionality was expanded to include conversion of a prescribing order to a dispensing medication order which is contained in the Automated Dispensing Device on the patient care unit. This permits medications to be readily available, yet with all the controls to insure safe therapy.

The CPOE Clinical Decision Support System provides various interventions critical to quality drug therapy including:

1. Alerts or Bulletins
2. Formulary Substitution
3. Appropriate Use Criteria
4. Prescribing Assistance
5. Specialized Pediatric Dosing
6. Investigational Drug Prescribing
7. Pediatric and Oncology Dose Range Check

This functionality and database is developed and maintained by the pharmacy.

Conclusions

Eight years of experience in planning, developing, implementing, and enhancing an advanced CPOE system illustrates the critical need for extensive pharmacy involvement. Leveraging the knowledge and expertise of the pharmacist is vital to the success of such an undertaking. The active role that pharmacy has taken in developing clinically relevant interventions has improved patient care and provided a powerful tool for the pharmacist to impact therapy at the time of prescribing. A clear benefit within the pharmacy has been the opportunity to improve workflow and order processing.

The potential of the system has continually motivated us to make quality improvements through hard work, creativity, and innovation. Not only have we worked very hard to maximize the system at Vanderbilt University Medical Center, but we have readily shared our experience with others who may be embarking on this journey.