Computerized Physician Order Entry (CPOE) and Meaningful Use

Over the past few weeks, since the ONC released its recommendations to CMS concerning Meaningful Use of Electronic Health Records (EHRs), as well as the Initial Set of Standards and Certification, we have been blogging on a variety of implications these rules have on physician practices.

The documents lay out 25 criteria which are required for EHRs to become Certified (and the actual certification process is currently being detailed). Performance thresholds for each of these 25 criteria are also defined in these documents, which detail exactly what an Eligible Provider (e.g. a physician) must do in order to qualify for HITECH incentive payments beginning in 2011.

We have commented on laboratory integration, on interfacing with regional immunization registries, on the role of billing systems, on the state of hospital readiness, and on electronic prescribing.

Another of the 25 criteria defined by Meaningful Use is about Computerized Physician Order Entry (CPOE). The Meaningful Use measure is that for Eligible Providers (EPs), CPOE is used for at least 80% of all orders.

What does this mean, exactly? And how does it relate to an ambulatory setting? In a hospital setting, Order Entry is pretty well understood by physicians – it is central to the in-hospital workflow. In a patient’s chart there is a Doctor’s Orders form, which is where the physicians involved in the case write their orders for nursing instructions, medication orders, IV and diet instructions, lab tests to be drawn, imaging studies to be done, physical therapy to be performed, etc. Converting this process to an electronic platform, though challenging (and the Meaningful Use criteria for hospitals is for only 10% of orders to be done electronically), is nevertheless in-line with familiar work patterns.

In an ambulatory setting, however, this hospital-based term is a little more unclear. Ambulatory charts in physician’s offices don’t traditionally have Doctor’s Orders forms. Instructions initiated by the physician for medications, lab ordering, referral, imaging ordering, etc., are carried out by prescription writing, messaging to office personnel (e.g. for referrals or setting up imaging studies), or filling out and directly handing to the patient a lab order form. Since “Doctor’s Orders” don’t typically flow through one central location (like in a hospital), the meaning of CPOE in an office setting is a bit more vague.

On page 49 of the Meaningful Use document, there is some clarification: “We propose to define CPOE as entailing the provider’s use of computer assistance to directly enter medical orders (for example, medications, consultations with other providers, laboratory services, imaging studies, and other auxiliary services) from a computer or mobile device. The order is also documented or captured in a digital, structured, and computable format for use in improving safety and organization. For Stage 1 criteria, we propose that it will not include the electronic transmittal of that order to the pharmacy, laboratory, or diagnostic imaging center.”

The intention is to begin capturing data in a way that can be utilized by Decision Support. For example, using a computerized Messaging system within an EHR (an “exit orders” type message to be implemented at the conclusion of a patient visit) that instructs staff members to do the things specified – (1) order laboratory services, (2) set up imaging studies, (3) make referrals, (4) administer or order medications. Electronic prescribing, though technically a part of CPOE, is actually covered in its own criteria measure.

Once the data is being captured electronically, down-the-road decision support tools can be brought into play – laboratory services can be directly entered into linked laboratory ordering systems (with the correct diagnosis coding justifying each test, as is done currently in a manual and mistake-prone way); imaging studies can be directly sent to radiology order-entry systems (with the opportunity to initiate insurance plan authorization, and with consequent feedback as to appropriate indications); referrals can be directly created with appropriate chart data becoming available automatically to the referral-recipient provider (and with initiation of referral/authorization steps that might be needed depending on the patient’s insurance plan). These integrations are not needed for Stage 1 Meaningful Use, but that is the direction this is building towards.

In the broadest sense of the word, in an ambulatory setting much of what constitutes “doctors orders” are verbal and ad-hoc – on exiting the exam room, the physician verbally tells the nurse “Mr. Gomez needs a flu vaccine.” These items are not what is included in the Meaningful Use definition of CPOE.

Instead, CPOE refers to instructions for care that are out-bound and leave the “practice walls” – lab orders, imaging orders, referrals, medications. These things that will eventually connect to systems outside the confines of the practice are what is meant here. And the Stage 1 criteria are simply to record the Orders for such outside care activities. The actual direct connection with those outside systems, and the opportunity to bring Decision Support into the process, are addressed later, in Stages 2 and 3.

Given this, with a EHR system that is Certified to offer this capability (electronically documenting Order Entry in a structured, computerized way), a physician should be able to demonstrate at least 80% of “outbound” orders are thusly recorded. The ability to use such CPOE continuously and routinely (“meaningfully”) will be a function of EHR design – good design should make using such a tool a true “shortcut” (rather than a duplication of effort), and will accomplish Meaningful Use documentation as well as the intended improvement in quality of clinical care.

Robert Rowley, MD
Chief Medical Officer, Practice Fusion, Inc.