This blog was triggered by a colleague on a project on which I am currently engaged – the design, build and implementation of CPOM.  The conversation followed a presentation summary of the Current State Assessment that was conducted earlier in the year.  I thank him for the thought provoking comments.

Most hospital and physician practices are scrambling to meet 14 required and 5 optional measures of Meaningful Use of EHR’s within the governmentally prescribed time frames.  One of those required Meaningful Use (MU) measures is CPOE.  When the final rules were released on July  13^th this measure was modified in the final rule to require 30% of the IP or ED medication orders be entered by a licensed healthcare professional rather than the original 10% of all IP orders by the licensed provider (physician). 

Due to 1) the change in type of order, 2) who is allowed to enter the orders and 3) the inclusion of ED patients you could chose to look at this rule as “relaxed”.   Some will interpret this as a rule that now says “the physician writes the order and a pharmacist transcribes the order into the computer” as meeting the Stage 1 CPOE requirement.  This would be to lull one’s self into a sense of false security that will rapidly disappear when the actual impact of the change is understood.   

Physician’s need a quick and safe way to manage all types of patient orders.  In today’s environment the physician may write the patient orders and the ward secretary transcribes all but the medication orders to the hospital order entry system.  It is single mode of Order Management for the physician – to write all the orders.   The medication order is then scanned to the Pharmacy and a professional pharmacist enters the medication orders to the pharmacy system.  (I have a good friend who is a pharmacist and does exactly this from her home office for multiple hospitals.)  The reason that the ward secretary does not enter the medication orders is because there is a level of clinical knowledge and decision making that accompanies this function.  If drug alerts are triggered we know that a professional is best equipped to respond and make decisions regarding duplicates, interactions or allergy warnings.  The secretary is deemed potentially capable of dealing with the duplicate alerts that might be encountered during lab or other diagnostic testing order entry or these warnings are encountered in the department systems and dealt with by those professionals.  For the physician this is considered quick and perhaps not so safe any longer but it works and has for a long time.  For an organization with these processes – do they meet Stage 1 MU already?  The answer is unfortunately likely to be interpreted in the affirmative.

However, many of the improved practice and safety goals of CPOM are not met by this revised rule in my opinion.  One of the consistently reported benefits of CPOM is the decreased time between the orders written and the patient treatment started.  One metric that is most impacted is the time to first dose given.  If we believe that current state meets MU Stage 1 (and maybe stage 2 as well*) what happens to the goal of improving the quality of patient care?  We lose the opportunity to cut the time to treatment – not just for medications - but for lab tests, adjustments to treatment and for other diagnostic testing as well.  We lose the ability of the providing prescriber, the physician, to react to suggestions of lower cost but effective alternatives, warnings of drug-drug interactions, etc and still cut the time to treatment.  In this new scenario – the pharmacist calls the physician to discuss the warnings and suggest the alternatives – still delaying just as in current state the time to treatment start. 

At least part of the reason I chose to focus my nursing career in healthcare information technology 15 years ago was the belief that I could positively impact the quality of patient care and the job satisfaction of my peers in a broader way.  Later, along came the IOM study and I found that patient safety could also be positively impacted by the reasoned and well designed implementation of HIT.  The reason that I support the meaningful use of EHR’s is the exactly the same. 

Unfortunately, the revised MU rule for CPOE, I believe, has diluted the energy and drive toward what should be our goal of improving patient safety and the quality of patient care.  CPOM – Computerized Physician Order Management – was not intended JUST for medications but for all the patient orders.  We cannot ask and support our medical colleagues to do part computer orders and part non-computer orders.  We cannot provide the full benefit of CPOM with this half way there strategy.  We must continue to strive for the toughest change in HIT – the 100% use of CPOM.  To set a goal that is less is unworthy of the patients that we serve.

*“Therefore, we are finalizing a Stage 2 measure for CPOE at §495.6(h) for

EPs and §495.6(i) for eligible hospitals and CAHs as “More than 60 percent of all unique patients with at least one medication in their medication list seen by the EP or admitted to the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period have at least medication one order entered using CPOE”. 

Page 80 FR Doc. 2010-17207 Filed 07/13/2010 at 8:45 am

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