The impact of CPOE on ambulatory practice

Computerized Physician Order Entry (CPOE) is one of the leading features of an Electronic Health Records (EHR) system, as envisioned by the Office of the National Coordinator (ONC) for Health IT. It is a Meaningful Use criteria, both for hospital-based EHRs and for ambulatory EHRs – meaning that physicians must be able to demonstrate that at least 80% of their “orders” are captured electronically, and that it is the physician (and not a surrogate) who enters these orders.

Why the emphasis on this piece of EHR technology? What difference will it make? Will it hinder workflows, and thus slow down adoption of EHRs overall? Or will the positive impact be so compelling that everyone will see it as a “must have?”

Some of the evidence that was considered by the ONC’s Policy Committee came from a study of a 7-year time analysis published in Radiology in 2009 – very striking evidence of “bending the curve” in the growth of outpatient procedure volumes was seen when CPOE was combined with Integrated Decision Support. By itself, as we have discussed, Clinical Decision Support has been less-than-stellar in affecting outcomes (or even “good” processes). And CPOE, by itself, will not change much, since it is merely an electronic translation of work items ordered by clinicians already.

But it is the linkage of CPOE with Decision Support that has raised hopes of improvement in health care quality (or at least stemming the tide of runaway utilization of higher-end radiologic studies – which is what the study was measuring).

This eventual goal of tying together CPOE with Decision Support is part of the vision of the ONC. And to get there, a step-wise assemblage of the building blocks needs to be created. The first step is the capture of physician orders into a CPOE system (Meaningful Use criteria for Stage 1, in 2011) – the orders don’t even have to be transmitted anywhere at first; just collected. Stage 2 then expects that CPOE systems (once clinicians have gotten a little used to entering their orders in the first place) can transmit those orders to the intended recipients. Stage 3 expects Decision Support to be tied into all of this.

For a hospital setting, Physician Orders are a basic, familiar process. There is a Physician Order sheet in a patient’s chart, onto which a physician writes orders for all manner of things – medication changes, nursing orders, radiology/imaging orders, lab test orders, diet orders, etc. In fact, for hospital EHR systems, there are 12 different kinds of orders which need to be captured, in order to satisfy HHS Certification (needed for access to Meaningful Use bonus money).

In an ambulatory setting, the kinds of “orders” defined by CPOE can be thought of as “creating workflows that leave the walls of the clinic.” There are only 4 kinds of things considered CPOE for ambulatory EHRs: (1) medications/prescriptions, (2) lab test orders, (3) radiology/imaging orders, and (4) referrals to other providers. In other words, in-office “orders” – the physician telling the nurse “give Mr. Hernandez, in Room 3, a flu shot” – are not CPOE; only orders that “leave the clinic” are CPOE for the purposes of Certification and Meaningful Use.

Whether compelling physicians to enter their “orders” into an EHR system will slow physicians down (in an ambulatory setting) remains to be seen – our view is that this is a function of how well designed the EHR is. It is incumbent upon EHR vendors to create tools that don’t make this work activity burdensome. Easily capturing these orders as part of charting, or as stand-alone orders, is the goal needed to facilitate adoption.

Since physicians in ambulatory settings have not ever systematically had to write orders into a system – often, surrogates such as nursing or front-desk staff, have done this for them – good EHR design is critical. One “reward” for such CPOE is the simple ability to easily follow up on orders that have been written but not yet carried out (“I ordered a mammogram for this patient last month, but don’t see any results back in the chart – let’s check with her to see what’s going on”).

Farther down the road, when ambulatory CPOE is tied in with recipient systems (directly enter lab orders, so when the patient goes to the lab for a blood draw, they already have the order on file), then the real benefits will become clearer. Ordering an imaging study can directly initiate insurance prior-authorization requests, with the criteria for the study visible to the ordering physician, and feedback on whether the study is authorized can be had while-you-wait.

In ambulatory settings, where the traditional “physician order” workflow has not historically been present like it has been in a hospital setting, getting used to CPOE (orders “leaving the walls” of the clinic) will be a learning step. Depending on EHR design, this requirement may be a slowdown (or may be seamless, if done right) – but over time, as the CPOE system is first connected with recipient systems, and then tied in with Decision Support systems, the true promise of this endeavor will be felt.

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