CPOE and CDSS for Intravenous Heparin Order Entry Safety

Overview of the CPOE/CDSS Heparin Order Entry Interface

The following represents a sample Computerized Provider Order Entry (CPOE) screen with embedded Clinical Decision Support System (CDSS) alerts for an intravenous heparin order. Patient weight, the last heparin dose, and related laboratory results are displayed on the screen.

Patient data displayed:
Wt 94.0 kg (206 lbs) — recorded 25 Aug 2247
Plt | INR | aPTT | Hgb | Hct | Preg | Lact | Hep IVP
Med Allergies: NKDA — 25 Aug 2247

HePARIN Drip — New Order

Rationale for CPOE and CDSS Integration

Platelet Warning: Low platelet count warning. Recommendation: Stop heparin and send Heparin-Induced Thrombocytopenia antibodies (Platelet Factor 4). Patient platelet count has dropped by more than 50% or is less than 100 × 10⁹/L.

Weight Consideration: Weight alert. Recommendation: Re-take weight. Weight was recorded more than 72 hours ago.

Baseline Labs: Missing baseline laboratory results warning. Recommendation: Obtain baseline aPTT, platelet count, and INR lab values prior to proceeding with the order.

Implementing the CPOE/CDS System

Suggested IV Dose: Suggested weight-based dose — 1,395 units/hr (weight [kg] × 15 units/kg/hr).

Max Dose Alert: Recommendation: Maximum dose 1,000 units/hr. Maximum rate 10 mL/hr.

CPOE — Computerized Provider Order Entry — combined with Clinical Decision Support (CDS) systems can enhance the safety of medication prescribing (Kuperman et al., 2007). The rationale for developing a physician order entry system with CDSS encompasses process improvement, support for cost-based and clinical decisions, and optimization of physicians' time. CPOE with CDS is widely considered one of the most effective approaches to improving healthcare service quality and patient safety. As electronic patient records become increasingly accessible, these systems will inevitably become the method of choice for medical care staff.

Creating a CPOE/CDS system is a complex undertaking, and some implementations fail even after consuming significant resources and time. Nevertheless, the potential benefits for patient safety and prescribing accuracy make the effort worthwhile.

CPOE presents both advantages and disadvantages. Without a staged implementation approach, organizations are likely to experience the full extent of its pitfalls. The process should begin with viewing functions in the laboratory, followed by the addition of dictation capabilities, image viewing, and basic charting, before graduating to a full CPOE system. Even with such pre-implementation precautions, the system can still confuse physicians due to its order structure and the volume of mouse-clicking required. Physician workflow may be slowed in some situations — the system requires five mouse clicks to replace a single non-formulary drug. For an average patient requiring four different medication substitutions, this translates to twenty clicks, a common and burdensome occurrence.

CDSS was incorporated into order sets within the CPOE build, with a number of these sets created specifically for individual services and guided by established principles. Adopting and implementing CPOE can take considerable time due to resistance from nursing staff and physicians as well as technical barriers. Training must be made available to all staff, and physicians in particular. Staff at health facilities must fully understand the workings of the system. Suppliers should also provide 24/7 technical support following delivery to a health facility.

Each department should create order sets that are validated by the medical personnel who will use the system. The decision support rules entered into the system on a daily basis are critical to its effective use. Enhanced interfacing of new standards is necessary when systems from different suppliers are used, in order to facilitate the transfer of information among pharmacists, providers, pharmacy benefit managers, and payers. Technologies also need to be standardized, with shared procedures established for the assessment and documentation of medication dosages, drug reactions, and allergies.

Further research is needed to establish the full implementation costs and benefits of CPOE. The central role of CPOE in reducing adverse drug events (ADEs) and medical errors should be clearly communicated. Rural and small hospitals will require specialized attention based on dedicated research, as variation in available resources may influence the rate of CPOE adoption. A systematic review and meta-analysis should also be conducted to obtain a precise measure of both the benefits of and barriers to CPOE adoption (Charles, Cannon, Hall, & Coustasse, 2014).