DNP 805 Describe how CPOE and CDSS embedded in the EHR can be useful towards a specific patient population of your choice

The use of computerized provider order entry (CPOE) and clinical decision support systems (CDSS) have greatly impacted the healthcare system. In comparison to the previous workflow where providers would have to physically handwrite orders or provide telephone orders, they can now easily enter their orders electronically. This is beneficial for all patient populations, especially adults who are admitted to the intensive care units (ICU). CPOE has contributed to patient safety in the ICUs since orders are very specific. CPOE and CDSS have prevented medication errors by about 55% as the system is able to catch miscalculations ahead of time (Metcalfe et al., 2017). Having the ability of CPOE and CDSS in place has also prevented uncertainties caused by illegible handwriting, which has also led to errors and patient harm in the past. CPOE has also improved administration time as it has enabled for faster communication between other departments such as the laboratory and pharmacy (Abraham et al., 2020). CPOE and CDSS have also contributed to cost reduction as it helps eliminate duplicate and unnecessary orders. In my professional opinion, having order sets in place would be an advantage for ICU patients. Since patients in the ICU have high acuities and need more frequent attention, having order sets in place for the physicians may help speed the admission process. Order sets help by ensuring appropriate orders are in place, and none are missed (Abraham et al., 2020).

References

Abraham, J., Kitsiou, S., Meng, A., Burton, S., Vatani, H., & Kannampallil, T. (2020). Effects of CPOE-based medication ordering on outcomes: an overview of systematic reviews. BMJ Quality & Safety, 29(10), 1–2. https://doi-org.lopes.idm.oclc.org/10.1136/bmjqs-2019-010436

Metcalfe, J., Lam, A., Lam, S. S. H., Clifford, J. ‐ M., & Schramm, P. (2017). Impact of the introduction of computerized physician order entry ( CPOE) on the surveillance of restricted antimicrobials and compliance with policy. Journal of Pharmacy Practice & Research, 47(3), 200–206. https://doi-org.lopes.idm.oclc.org/10.1002/jppr.1227

The office of the National Coordinator (ONC) for Health Information Technology defined clinical decision-support system (CDSS). It is a system that supports clinical decisions of health care practitioners, patients and other knowledgeable people to guide the clinical practice with filtered specific information to be presented at the right time to help improve the health of patients and to advance health care in general. This clinical decision support has a variety of tools which is used to improve decisions made in the clinical workflows. Some of the tools in CDSS are alerts and reminders that are computerized for the patients and clinicians, specific orders that are set to a specific condition, data reports that are focused on patients, supports with diagnostics and templates for documentations (Alexander, Hoy, & Frith, 2019). Computerized provider order entry (CPOE) is the process by which health care providers (HCP) enter and send orders and treatment instructions such as medications, laboratory, and radiology through the computer applications and not by using paper, fax, or telephone (HealtIT.gov., 2018).

The use of CDSS and CPOE that is embedded within the EHR can help to reduce errors, improve the efficiency and the safety of the care processes, increases consistency in decisions made thereby reducing increased variations which are used to provide care for the patients as well as improve the efficiency of reimbursements for care provided. It can also delay and hinder the delivery of care when the focus is on problems that lack importance and widening of digital inequalities. When the HCP enter orders into the computer, it interfaces with the EHR. It is analyzed and gives a clinical picture for the HCP of the situation of the patient. If it is abnormal, it triggers a parameter alert for the HCP to seek out the problem and perform an intervention (Alexander, Hoy, & Frith, 2019) (Mebrahtu, Skyrme, Randell, Keenan, Bloor, Yang, Andre, Ledward, King, & Thompson, 2021).

One of the tools that CDSS and CPOE is used in the cardiac patients is in the alerts that are used in the telemetry units for the heart monitors. When the patient is in distress when the vital signs are abnormal either too low or too high, the CDSS begins to alert to draw the attention of the HCP. This helps to monitor the patients and intervene promptly to prevent them from going into severe cardiac events.

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One of the elements that I would like to improve would be when the monitors come off or when the patient is moving so much the alarm continues to beep. There is no distinction with the different alarms. The alarms all sound the same except when it is ventricular tachycardia or ventricular fibrillation. So, I would like to make different alarm sounds for each specific situation so that the HCP is not wandering what is causing the alarm and wasting time deciphering what is causing the alarm.

References:

Alexander, S., Hoy, H., & Frith, K. (2019). Applied clinical informatics for nurses (2nd ed.). Jones & Bartlett Learning.

HealtIT.gov. (2018, March 21). What is computerized provider order entry? | HealthIT.gov. ONC | Office of the National Coordinator for Health Information Technology. https://www.healthit.gov/faq/what-computerized-provider-order-entry

Mebrahtu, T. F., Skyrme, S., Randell, R., Keenan, A., Bloor, K., Yang, H., Andre, D., Ledward, A., King, H., & Thompson, C. (2021). Effects of computerized clinical decision support systems (CDSS) on nursing and allied health professional performance and patient outcomes: A systematic review of experimental and observational studies. BMJ Open, 11(12), e053886. https://doi.org/10.1136/bmjopen-2021-053886

Both Computerized Provider Order Entry (CPOE) and Clinical Decision Support System (CDSS) should be at the foundation of any Electronic Medical Record (EMR). These two together aid in the promotion of high quality safe patient care. CPOE at a baseline gets orders in more timely and accurately. When nursing is transcribing written orders it opens up a large room the error (Jungreithmayr et al., 2021). It is also pulling nursing from providing nursing care. This CPOE entry promotes timely and accurate order entry. This with the added benefit of a CDSS really elevates the quality of care provided. There are significant quality, safety, and economic impacts that are linked to the implementation of a CDSS (Belard et al., 2017). Some of the would be the autodetection of drug interactions and allergies. Other advances include but are not limited to documentation reminders to meet core measures, auto linking of orders that need to be ordered together, and duplicate order notifications.

DNP 805 Describe how CPOE and CDSS embedded in the EHR can be useful towards a specific patient population of your choice

Providing the safest care is what we strive for. Both CPOE and CDSS aid in us striving towards being high reliability organizations. This is the got to have less serious safety events and preventable poor patient outcomes and these are two excellent places to start.

References

Belard, A., Buchman, T., Forsberg, J., Potter, B., Dente, C., Kirk, A., Elster, E., Potter, B. K., & Dente, C. J. (2017). Precision diagnosis: a view of the clinical decision support systems (CDSS) landscape through the lens of critical care. Journal of Clinical Monitoring & Computing, 31(2), 261–271. https://doi-org.lopes.idm.oclc.org/10.1007/s10877-016-9849-1

Jungreithmayr, V., Meid, A. D., Implementation Team, Bittmann, J., Fabian, M., Klein, U., Kugler, S., Löpprich, M., Reinhard, O., Scholz, L., Zeeh, B., Bitz, W., Bugaj, T., Kihm, L., Kopf, S., Liemann, A., Wagenlechner, P., Zemva, J., Benkert, C., & Merle, C. (2021). The impact of a computerized physician order entry system implementation on 20 different criteria of medication documentation-a before-and-after study. BMC Medical Informatics & Decision Making, 21(1), 1–12. https://doi-org.lopes.idm.oclc.org/10.1186/s12911-021-01607-6

Clinical decision support includes a variety of tools and interventions, computerized as well as non- computerized. Non-computerized tools include clinical guidelines or digital clinical decision support resources. Clinical decision support systems (CDSS) are characterized as tools for information management. Examples of such CDSS include laboratory information systems (LISs) highlighting critical care values or pharmacy information systems (PISs) presenting an alert ordering a new drug and proposing a possible drug-drug interaction. Most focus in the past few decades however has gone to tools to provide patient-specific recommendations called advanced CDSS. Advanced CDSS may include, checking drug disease interactions, individualized dosing support during renal impairment, or recommendations on laboratory testing during drug use (P. Kubben et al. (eds.), 2019).

CPOE being the system that enabled physicians to prescribe medication using electronic entry. The combination of CPOE and CDSS helped physicians choose the right drug in the right dose and alert the physician during prescribing if the patient is allergic to any medications. Combining CPOE with basic medication related CDSS meant a giant leap in safer medication prescribing

CPOE systems are generally paired with some form of clinical decision support system (CDSS), which can help prevent errors at the medication ordering and dispensing stages and can improve safety of other types of orders as well. CDSS suggests default values for drug doses, routes of administration, and frequency and may offer more sophisticated drug safety features, such as checking for drug allergies or drug–drug or even drug–laboratory interactions, CDSSs prevent not only errors of commission but also of omission (Mamlin BW, Tierney WM, 2016).

CPOE offers numerous advantages over traditional paper-based order-writing systems such as averting problems with handwriting, similar drug names, drug interactions, and specification errors; integration with electronic medical records, clinical decision support systems, and adverse drug event reporting systems (Grizzle AJ, Mahmood MH, Ko Y, et al, 2019).

Despite evidence that these systems can improve patient care and safety, they have not been widely adopted. Institutions like the place where I will be doing my clinical are hesitant to invest considerable resources into these systems without proof that they will be cost-effective. Many providers remain skeptical that these systems will improve patient care without overburdening them with additional tasks, these concerns need to be addressed.

References

Grizzle AJ, Mahmood MH, Ko Y, et al, (2019). Computerized Provider Order Entry: https://psnet.ahrq.gov/primer/computerized-provider-order-entry

Mamlin BW, Tierney WM, (2016). The promise of information and communication technology in healthcare: extracting value from the chaos. Am J Med Sci. 2016;351(1):59–68.

P. Kubben et al. (eds.), (2019). Fundamentals of Clinical Data Science, https://doi.org/10.1007/978-3-319-99713-1_11

Clinical decision support systems (CDSS) are programs that prompt providers with suggestions related to the information entered into the patient’s electronic health record (EHR). This may include prompts regarding medication interaction or suggested tests. CDSS allows providers have ease of access to current practice and information. (Wasylewicz & Scheepers-Hoeks, 2018) Through CDSS, providers can receive early identification of critical situations that may otherwise go unnoticed for long periods. Computer provider order entry (CPOE) is precisely what it says. Providers electronically enter orders in the EHR, with those being directly sent to different departments or clinicians. Nurses no longer need to decipher written orders and make fewer mistakes due to illegible information.

Many patients are seen throughout the day in the emergency department (ED). Providing safe, timely care can be challenging with high volumes and high acuity situations. Alarms triggered through a CDSS program help for early warning and possible adverse events. CPOE gives clear written instructions rather than a path for mistakes through verbal or written orders. An area that continues to be one issue is that of the adverse drug event. In the ED, patients may not be able to give the information needed due to their reason for the visit. Obtaining simple information can be difficult if a patient is brought in unresponsive or aphasic. With CDSS, suggestions are made based on the information given and any data that resides in the patient medical record. This helps eliminate adverse reactions. (Hajesmaeel Gohari et al., 2020)

An area for improvement within my current facility would be the alert system. As of right now, all alerts that pop up look precisely the same. If the patient is on a security alert, it looks the same as if they are a sepsis alert. This, unfortunately, leads to many warnings being dismissed no matter what they are. Design is essential, and it would be desirable to have them look different based on what they are. Whether by color, shape or even blinking, this could make a difference. In the ED, timing is everything, and alerts that are not recognized can lead to patient demise.

References

Hajesmaeel Gohari, S., Bahaadinbeigy, K., Tajoddini, S., & R. Niakan Kalhori, S. (2020). Effect of computerized physician order entry and clinical decision support system on adverse drug events prevention in the emergency department: A systematic review. Journal of Pharmacy Technology, 37(1), 53–61. https://doi.org/10.1177/8755122520958160

Wasylewicz, A., & Scheepers-Hoeks, A. (2018). Clinical Decision Support Systems. In M. Dumontier, P. Kubben, & A. Dekker (Eds.), Fundamentals of Clinical Data Science. https://www.ncbi.nlm.nih.gov/books/NBK543516/

DNP 805 Describe how CPOE and CDSS embedded in the EHR can be useful towards a specific patient population of your choice