Defining the limits of computerized physician order entry systems

(Philadelphia, PA) - In the July 12 issue of The American Journal of Managed Care, sociologist Ross Koppel, PhD of the Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania School of Medicine, analyzes two well-known medical information technology systems in light of a study published in the same issue. Researchers from the Colorado Permanente Medical Group (Galen et al.) found no positive value to computerized reminders for laboratory tests needed to accompany 25 major medications. These two systems are CPOE (computerized physician order entry) and DSS (Decision Support Systems).

CPOE is regarded as the major technological solution for the problems of medication ordering error. It eliminates handwriting errors and instantly sends orders to the pharmacist. Unfortunately, many of the CPOE software programs are not responsive to the realities of hospital work; and CPOE systems are often seen by clinicians as irrational impositions rather than as helpful tools, according to Koppel.

DSS (Decision Support Systems) is designed to warn physicians about possible errors and/or provide useful guidelines to prescribing, including reminders about needed laboratory tests when certain drugs are prescribed. Often, however, DSS produces obvious and annoying reminders, false alarms, or useless and constant warnings. Alarm fatigue is a frequent problem, and many hospitals are forced to shut off the DSS function within hours of its introduction.

Koppel first points out that DSS is not an integral part of CPOE, as many who work in health care purport. "Only a very small proportion of hospitals with CPOE also have DSS; and fewer than 10 percent of hospitals have CPOE," he notes. Secondly, he says that by lumping CPOE with the advantages of DSS, CPOE's supporters also must take on the problems of DSS: "CPOE is an imperfect technology that nonetheless has many virtues, which will increase when it is more fully developed. DSS also has many virtues, but it has even more problems than CPOE."

His commentary, entitled, "Defending Computerized Physician Order Entry From Its Supporters," addresses the fact that expansive definitions of CPOE defining CPOE in ways that claim the benefits of all sorts of healthcare information technology might backfire, resulting in an incorrectly low estimate of CPOE's efficacy because overarching definitions of CPOE will unintentionally pick up the problems with the advantages of other technologies.

"In the article by Palen and colleagues, the DSS failed drastically," explains Koppel. "The reminders had no beneficial impact on what physicians did. But Palen et al., accepting the overly broad definition of CPOE, conclude that CPOE was shown to be faulty. I argue that their findings of DSS's failure have little to do with CPOE's problems. That's why I'm defending CPOE from its supporters."

In general, Koppel states that CPOE is a very promising technology, but the supporters of CPOE fail to evaluate its strengths and weaknesses. "They also expansively accept other forms of healthcare information technology such as electronic health records and electronic medication administration records under a CPOE portmanteau. By doing that, they misleadingly claim a wide range of successes. In the Palen et al study, however, they picked up a rather resounding failure."

Koppel argues that defining the scope of CPOE is not just an academic exercise. CPOE has become a major part of federal healthcare policy, hospital and investor strategies, and hardball market economics. "In their passion to promote CPOE, its supporters have both ignored its problems and have embraced an imprecise and ultimately self-defeating definition," he says. "We need a clear definition of the technology and we need independent analyses of its utility. Currently, we have neither.

"I am a passionate supporter of health information technology and CPOE," says Koppel. "I argue, however, that clinicians and hospitals should seek good healthcare information technology that helps with patient care and patient safety. Expensive systems backed by promises and elaborate marketing efforts should not be the defining characteristics."

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This release can also be seen at: www.uphs.upenn.edu/news.

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