The report is on critically reviewing literatures on computerized physician order entry to determine the effectiveness of the technology for health care system and issues faced in implementation of the technology in health care field. In order to carry out the literature review, research articles were searched from google scholar, PubMed, Cochrane Library, MEDLINE and NCBI databases. The key search term for identifying relevant literature included “computerized physician order entry (CPOE)”, “issues in implementation of CPOE”, “factors affecting the adoption of CPOE, “transition from traditional method to CPOE system” and “prevention of medical errors through CPOE”. The inclusion criteria for the literature review was to include current article published within 10 years and all those which gives an idea of development in health care setting. The research article which provided development in other field of practice except the medical field was excluded from the research. It helped in refining the search process and getting that literature article which gives a scope for current development and identifying gaps in study related to CPOE.
There has been a boom in the evolution of Information Technology in the last few decades and Internet has been an integral part of the evolution. The development of telegraph, radio, telephone and computers have paved the way for the evolution of internet. The role of internet in daily life has become indispensible almost for all individuals worldwide, in our professional, educational as well as personal lives. Internet is a global network that connects million of computers and electronic devices and where information can be posted and shared with anybody. The influence of internet has spread to every domain of science and markedly increased the productivity and efficacy of the same (Gössling & Lane, 2015).
Medical science has utilized the resources of internet in various ways. Huge amount of data is collected on a regular basis from several fields of medical science, which is not possible to store and analyze without the aid of computers and internet (Polepalli et al., 2016). The application of internet in this field is diverse and of immense significance. It has been applied in areas like patient care, medical and health literacy and medical research. Electronic mail, WWW, and file storage and transfer capabilities can be of immense use in providing efficient healthcare. Emails are the most cheap and useful way to communicate between doctors and patients as well as between doctors from different domains. The internet all provides a wide array of data sources ranging from scientific journal, peer-reviewed articles, medical databases, educational sites, so on and so forth. Internet being the most efficient media can provide emergency medical expertise in life and death situations. The scenario of primary healthcare practice has undergone a surge due to changes in healthcare delivery and the explosion of health information (Ek et al., 2013).
Health Information System (HIS) is the building blocks of efficient health systems. The aim of Health Information System is to have transparency in information accessibility for enhanced accountability. Low and middle-income countries mostly lag behind in this department. Health Information System aid in decision making in the field of healthcare. Data generation, compilation, analysis, synthesis, communication and use are the key aspects of Health Information System. It collects information from health and other relevant sectors and applies it to provide quality healthcare (Abdelhak et al., 2014). In addition to monitoring and evaluation, it has broader aspects such as providing support to patients and health facility management, providing alert and early warnings. Information is required from different sectors including different confounding factors that affect health outcomes like socio economic, environmental behavior and genetic factors, the health outcomes and health inequalities in the different sections of the society. Overall, a Health Information System provides information for policymakers and decision makers and gives appropriate frameworks for policy development and implementation (Kellermann & Jones, 2013). Information is often obtained from various government sectors and agencies at country, regional and global level. Health surveys, birth and death registration, census, health facility reporting, health system resource tracking and capacity for analysis, synthesis and validation of health data are primary indicators for efficient health information system performance (Watson et al., 2014).
The evolution of the information technology has led to digital innovation and has played a role in revolutionizing the health care. The technology used in medical filed have turned out be very efficient in transforming the manner of delivery of care. Medical field now works by utilization of range of health technology to change the landscape of care. Medical technology is now widely utilized to improve the hospital experience, facilitate surgery simulation, streamline lab testing and create referrals through the use of cloud based data and software (How Technology is Improving Medical Care, 2016). For example medical technology has been used to update hospital experience and keep with pace demands of patients. Technological innovation ranged from improving the room design of the hospital and eliminates redundant clutter that acts as barrier in modern approach to health care facilities. Information technology has also been useful in improving referrals process and reaching out to millions of health care providers and patients digitally. It also aids in eliminating the gap in health delivery caused due to delay in treatment process or being able to reach patient on time (Street et al., (2013). Software innovations like computerized physician order entry (CPOE) has also provided solution to medication order errors and store and analyze data in a digital format (Nuckols et al., 2014).
Computerized physician order entry (CPOE) is the process of electronically entering clinical instruction to reduce medication errors in the health care system. The CPOE system was designed to minimize the work burden due to paper chart. This is the best example of digital transformation in health care system where clinicians got the option to transfer all health information to patients digitally. The rise in usage of CPOE became evident after the introduction of federal HITECH Act and the Meaningful Use program which helped in rapid usage of CPOE in health care setting. CPOE system came up originally to improve errors in medication orders and facilitate safety in health care delivery. Medication error can be expensive and risk patient’s life. A research investigated the reduction in medication errors through CPOE system. A national representative data of American Hospital was estimated for percentage reduction in medication error through CPOE. The results showed that processing of medication through CPOE system decreases clinical error by 48% and this can reduce significant medical cost associated with errors. Current policies related to increase in CPOE adoption system can be effective in preventing medication errors every year (Radley et al., 2013).
However, with advancement in health informatics, modern system of CPOE has involved. In order to reduce vulnerabilities in the system, it is necessary that clinicians select the appropriate dose and frequency of medication, efficiently transcribe the prescription, proper dispensing of medication after consideration of drug-drug interaction and administration of the medicine at the right time. The integration of CPOE system with clinical decision support system is an effective approach to reduce errors. The adoption of CPOE in the health market has evolved after the introduction of computerized decision support system for prescribing medicines. In case of England, the uptake of CPOE has been very slow due to conflict in localized adapter practice and generic system and due to unrealistic adopter demands. Immaturity in the market has been regarded as the major reason for slow uptake of CPOE. This comes from the fact that policy makers have incomplete insight about the technology and negative adopters reaction to the technology (Mozaffar et al., 2015). Hence lack of insight for effective implementation process might be the reason for slow growth. However, the use of technology can be enhanced by new federal policy initiatives.
CPOE system has been found to be effective in improving efficiency in workflow and reducing medical errors. The research study by Schneider et al., (2013) is an evidence of the advantage of CPOE in health care system. The purpose of the study was to eliminate the problem of delay in magnetic resonance examination through the use of electronic magnetic resonance (MR) safety screening process in CPOE system. The MR examination reports and orders of all patients within the period of 4 months were assessed after the implementation of MR safety system. The data was assessed regarding the time from first order to final report, time required for completion of MR examination and length of stay in the hospital. The results showed that electronic safety screening process resulted in a decrease in the time between first MR order till the completion of MR examination. A significant reduction in time for MR report was seen in CPOE system compared to paper processing. Hence, this literature review was significant in enabling early diagnosis, starting treatment process effectively and then reducing the length of stay in the hospital.
The CPOE system can be useful in improving adherence to clinical guidelines and improving the delivery in health care system. This finding is supported by review of article which investigated whether the automated alerts within the CPOE system can improve practice guidelines for ordering Pap test or not. It proposed that electronic health record can be useful in enhancing test utilization in health care system. The study was also significant due to limited research on automatic alert system on Pap ordering according to screening guidelines (Howell et al., 2014). According to American Cancer Society guidelines for prevention and early detection of cervical cancer, it is also essential to begin screening test at the age of 21 (The American Cancer Society guidelines for the prevention and early detection of cervical cancer, 2016). The alert system prevented Pap orders in women less than 21 years as presented in guidelines and greater than 71 years and the limitation of each Pap order was recorded. Results were compared during periods of pre-alert, post-alert, errors in alert system (glitch period) and the post-glitch period. The research findings showed that alert system was effective in reducing the Pap test frequency in the post alert period. The result is reflective of the practical guidelines in Pap test as it included patients with history of abnormal Pap test and to discontinue testing for patients with normal Pap results in the past (Howell et al., 2014). Hence, from this literature review one can get an idea that alert system in health informatics can help to improve compliance to organizational guidelines and enable effective utilization of lab test.
Computerized physician order entry can help in improving screening process for diseases. Development in health informatics and introduction of CPOE is acting as a revolution in the ordering process of health data and eliminating misuse of health care service. There are several research which shows the benefit of CPOE in decreasing cost in health care service, shortening the length of stay in hospital, reducing medical errors and improving adherence with clinical guidelines. However, as it is a relatively new technology, there is no best approach to its implementation and organization leaders must play a role in meeting challenges in the system and efficiently implementing it in health care setting to improve the quality of care (Computer physician order entry: benefits, costs, and issues. - PubMed – NCBI, 2016). The research study by Cabezas et al., (2016) explained that screening of hepatitis B virus is essential before initiation of cytotoxic chemotherapy for treating patients with malignant disease. This screening process is essential to decide the type of intervention for patients who are hepatitis B surface antigen (HBsAg) positive and patients who are HBsAg negative. It helps in deciding the treatment required before or after the chemotherapy treatment. The research indicated that CPOE system can be applied to improve the rate of screening process and hence CPOE system along with efforts on proper management of the system can help in improving the screening rate for Hepatitis B virus screening (Cabezas et al., 2016).
Despite advantage in the utilization of CPOE system in health care setting, there are many issues that health staff experience due to change in processing of health care information. This fact became clear with the review of a literature on the attitude of clinical physicians towards the use of automatic alert in CPOE system. The study based on quantitative and qualitative survey was done with physician in 11 hospitals in 9 different countries. Among the hospitals, some of them were using the CPOE system while in some CPOE system was not implemented. Although majority of physicians supported the fact that CPOE system has enhanced alert system to improve medication safety, however it is necessary to introduce such system according to clinical context to avoid chaotic situation due to adopting new technology (Jung et al., 2013). The literature was useful in bringing the issue of alert overload and this helped in identifying the need to provide more information to staff to maintain this technology for smooth running of the system. Hence, a sophisticated strategy will minimize disruptions in health care practice and also lead to proper adoption of the system among clinicians.
CPOE has been regarded as an important element in modernization of medical field and facilitating quality improvement in health care setting. However, the initial phase of adoption is difficult due to presence of many internal and external factors within health care organization. Certain local factors might facilitate uptake of CPOE or it might also stall the rollout of CPOE in hospitals (Khanna & Yen, 2014). This is evident from one study which showed that CPOE lead to errors due to duplication of medical dose and poor design of the leading to error in displaying dose options of medications. There were also reports that implementation of CPOE lead to significant increase in mortality rate after the implementation of CPOE compared to the period before CPOE implementation (Han et al., 2005). Hence, the technology has been found to impede the clinical workflow when the system fails to recognize important clinical information. With this issues faced in adoption of the system, it is necessary that this technology should be examined by ethnographer to understand the efficacy of complex processing system.
To identify the factors that influence adoption of CPOE system, a recent review article is effective in giving information about the reasons for medication error related to CPOE system. To monitor the medication errors, the medication reports of patients were assessed to find the errors occurring in the prescribing period or due to CPOE. The results showed that more than 50% of errors were related to CPOE. The problem arose mainly due to delay in making medicines available to patients or due to patients receiving duplicate or higher dose of drugs. Inefficiency and error was also seen in categorization and formatting of reports which lead to wrong transmission of information, dosing error and duplicate orders (Amato et al., 2016). Hence, this literature provided insight into the reasons leading to error after CPOE and safety can be maintained only by using taxonomy which all health care staffs can understand. This will help in meeting the objective of introducing CPOE and lead to speedy treatment process.
The specialty of physician might also be a factor affecting the adoption of CPOE. This aspect of adoption of new technology in health care setting was investigated by cross-sectional study and the researchers regarded the fully functional CPOE as an indicator of successful adoption of the technology in health care setting. All the predictive factors related to impact of geographical location, characteristics of physician and the degree of physician was analyzed by logistic regression analyses. The results showed that specialty of physician influenced the adoption process. Primary care physician were found to highly use the technology compared to surgical specialties physician. However, it was found that the adoption did not dependent on geographical location or health care ownership. This literature review article was successful in identifying major predictors of adopting CPOE which were specialty of clinicians, status of practice and the level of consultation by internet (Malhani et al., 2016).
User satisfaction is also the most critical factor in implementation of health care informatics. There are many reports which showed that CPOE system failed or were successful in hospitals due to resistance or acceptability by the users respectively. Failure in efficiently adopting the system might occur when patient’s needs are not considered during introducing the technology or when patients do not receive timely intervention due to disruption in work flow due to the technology. To determine the satisfactions level of patients due changes in health information processing over time, a cross sectional survey was done to know about the advantages and disadvantage of CPOE. It was found that end-users were moderately satisfied with the technology; however difference in opinion were seen according to user groups. For example in case of providers, the perception about CPOE remained positive from the beginning, but for nurses, the satisfaction level gradually increased when they got well-acquainted with the technology (Hoonakker et al., 2013).
Review of another research article was useful in providing insight into the factors that affect the adoption of CPOE in hospitals. Although CPOE has been introduced to maintain quality and safety of health care service; however the health care setting can face many issues in adopting to a new technology. These issues may range from resistance to the new system among health staffs to the issues related to cost involved in efficiently running such technology. The research article gave an idea about the lessons that health care organizations have learnt while implementing CPOE in their hospitals. The experiences and attitude of physicians and administrators at hospitals in USA revealed that successful implementation process of CPOE depended on clinical governance, preparation for change and support and perception of key health care team. In hospitals where the CPOE process was successful, it was because of effective organization decision making and engaging clinicians to clear any doubts about the process. Preparation and advance planning was also essential and this helped in adopting to the system because health staffs were given necessary training to use the technology and computer application without any error. Support from highly trained person who has good grasp with the CPOE system also helped in providing instant support to staffs in case of any query. In hospitals who failed to adopt the system, it was mainly because of negative perception about new technology (Simon et al., 2013). Many were afraid of the change and felt that it will hamper their workflow. However, strong clinical leader can intervene to develop positive attitude towards the new technology. Hence, this literature review helped in identifying the critical role of health care leaders in addressing issues related to adoption of CPOE and facilitating smooth transition of health informatics.
Majority of resistance in adopting CPOE is due to speculations that it might lead to decrease in utilization of hospital resource. As there were very little evidence regarding the lower resource utilization due to CPOE, this factor was investigated by (Teufel et al., 2012) who tried to analyze the relationship between CPOE use and other the resource utilization in children health care unit. A cross-sectional design helped in getting answer to the research question. The results showed that although CPOE implementation is expensive process, however compared to hospitals without this system, hospitals with CPOE did not lead to lower cost per case. Hence, very few financial benefits for hospital were found according to this literature study. It is necessary to emphasize on strategies that promote adoption of CPOE and also lead to financial benefits. The research is useful for early adopters of the system to estimate cost savings in the process.
There might be unintended socio-technical consequences of CPOE. To investigate the impact of this factor on outpatient setting, ethnographic and interview data were collected from an interdisciplinary team in four hospitals. The consequences were distinguished according to the Diffusion of Innovations theory and it showed that desirable and undesirable consequences may occur due to CPOE system. While the undesirable consequences were related to improvement in patient safety and fast diagnosis, the undesirable consequences included problem in workflow and interpersonal relationship among health care team. Many hazardous situations also arose due to error in alert system leading to misinterpretation of patient’s critical health information. Anticipated benefits of the system were elimination of illegible order, fewer medical errors. Howevr it also lead to undesirable impact such as physicians leaving the organization or longer time for completing the order due to lack of training. Other unanticipated benefits included better collaboration of activities due to alert system and creating safety net by giving alert system the trigger to identify wrong drug and give correct order. Unanticipated issues related to the system were also found such as too many alerts leading to missing good alerts and lower satisfaction level in physician due to coding errors. The key leanings from this literature review is that people involved in CPOE implementation should understand the unintended consequence properly in order to foresee problem before hand and be prepared to counter those situations (Ash et al., 2007).
Social issues might also be reason for failure in the implementation of CPOE. This element of resistance in adoption of CPOE was explained by a research study investigating the social issues surrounding CPOE implementation process. The main objective was to analyze the interrelated effects of the factors in medical setting and to recommended ideal steps to manage the issues during the implementation process. A semi-structures interview was conducted with the people involved in CPOE implementation process and grounded theory approach was used to evaluate specific problems and analyze the situation. The findings that emerged from the study was that social and technical issues negatively hampered workflow and this was the reason for withdrawal of end-users from the system. Hence, a cumulative effect of both social and organizational issues can lead to failure in introducing the CPOE system in health care setting. This literature is useful lesson for people engaged in such project and it will help them to understand the aspects of workflow before initiating such ventures in health care setting (Peute et al., 2010).
User satisfaction is also an indicator of the acceptability of health technology and realizing its benefits in promoting good health. High user satisfaction with CPOE can be achieved when users can easily access health information, immediately act according to those information and alerts were given regarding any potential error (Murray-Weir et al., 2014). A review article gave greater insights into factors that influence user satisfaction by use of a model to investigate about level of acceptance and actual use of electronic patient record in acute care setting. A randomized stratified sampling approach was taken to recruit nurses and explain them the actual use of technology. 33.6% variation were found in actual use and greater effects were seen between expectancy and actual use, presence of facilitating factors and effort put in it and the level of compatibility with the service. The literature was useful in providing a mediation relationship between effort expectancy and performance expectancy (Maillet et al., 2015).
The current advances in eHealth technology have given immense functional benefits in data storage, management and retrieval, and supports decision making process. Electronic patient record or electronic transfer of prescription is the eHealth technology useful in health data storage while CPOE and CDSS give decision making support. CDSS linked with CPOE provides guidance with diagnosis, giving recommendations for treatment and including alert system to enable safe prescribing method (Cooper et al., 2015). Health care staffs and key stakeholders working in leading clinical sites need to perform a range of activities to provide support in clinical decision making. Literature review of one article provided insight into the activities that people engage in during implementation of clinical decision support system (CDS). This ethnographic research revealed that major activities were in the area of fostering relationship with activities like training, assembling the system with technical support and content development, utilizing the system appropriately to meet organization goal and participating in policy activities for smooth flow of the system (Wright et al., 2014).
Benefits of health information technology are also interrelated with the role of organization and other informational complementary. Majority of the research articles are of the opinion that adoption of new health technology will dramatically change the scenarios in hospital setting and lead to drastic improvement in patient care. The research study McCullough et al., (2013) analyzed the impact of IT adoption on patient outcomes and identify the hidden mechanism through which this technology facilitates input of labour. The investigation into the matter showed that although IT adoption lead to significant improvement in mortality rate, however the impact was not significant for median patients. Thus results gave the implication that benefits of the technology can be seen in large health care organization which have mix of critically and moderately ill patients. Secondly, successful integration of the system in hospital setting is also possible after proper coordination and health information management. Therefore direct benefits are seen in those patients who required cross specialty diagnosis involving complex management of health data.
User interface design of CPOE has an impact on the accessing important clinical information during diagnostic and treatment process. A review article on similar topic supports this view and the researcher analyzed whether user interface design of CPOE can affect the access rate to patient’s record when linking infrequently accessed data through user interface. The Vanderbilt University Hospital augmented clinical support advice with other education support features. A randomized controlled trial analyzed the utilization rate of the interfaces among clinicians. The control groups were able to access decision support from a menu in CPOE interface and the intervention group received active notification through sensitive hyperlinks with decision support data. The results showed that access rate for decision support data was higher in intervention group compared to control group. Therefore this literature review was a useful evidence to prove that availability of context sensitive data can increase the utilization rate of user-interface (Rosenbloom et al., 2005)
Many health care professionals have resisted use of this technology because of lack of computer experience and this even makes them leave the health clinic. There is also a speculation regarding whether clinical role or position has impact on the adoption of CPOE in hospitals. A mixed method study in Canada evaluated the barriers to adoption on electronic medical record in physician practice. After reviewing so many articles on use of CPOE system, it is clear that CPOE has been implemented to solve the problem associated with paper system, improve the quality of health decision making and improving cost return in practice by reducing the cost involved in health data management. Despite so many benefits, it is still not clear why many countries have not yet decided to adopt this system in the clinic. This was the motivation behind the investigation the reasons for withdrawal from CPOE. A mixed method study was done with highly qualified physicians with good IT knowledge and with family physician who practice without EMR system. The results revealed that initial decision in investing on the system becomes difficult due to behavioral, technical, economic and knowledge based factors. Knowledge barrier was one of the vital reasons for not investing in the system. However, in some no barriers were seen but stills they had not invested in electronic medical record (Paré et al., 2014). Hence, from this literature review, the recommendation is that the government and policies should take relevant action to mitigate the barriers and provide support to medical practices.
Another important development in health informatics was seen from a literature review which brought to the forefront the integration of CPOE with cloud-based BP to improve self-management in hypertensive patients. This discovery became important when it was found that majority of hypertensive patient cannot maintain normal blood pressure level and hence cannot self-manage the disease. Therefore the researcher tried to speculate whether the integration of cloud based BP system with CPOE will lead to improvements in BP management compared to traditional care methods or not. A randomized controlled study was done with participants diagnosed with hypertension. The physicians had access to cloud based BP data of all participants. The results demonstrated that the intervention group had better control over BP compared to control BP over a period of six months. Hence, the benefits of CPOE in the self-management of illness also became evident from the literature review. There is also minimum chance of resistance from users as it does not require any technical skills and it will lead to positive attitude in patient and better adherence to medication (Lee et al., 2016).
The above report on literature review of computerized physician order entry (CPOE) started with the introduction on the development of the internet and how it has revolutionized the whole world. It direct benefits on the medical world was also seen with range of health information technologies like electronic health record, CPOE, CDSS and many other innovative technology. It gave an idea about the developments in HIS to support health care system and improve the quality of health care delivery. As the literature review mainly focused on CPOE, an short overview of the topic was given by explaining about the need for such system and how its use actually started. It brought to the forefront the drawbacks of the traditional paper system on medication orders and how the complex management of paper data led to medical errors. Hence, literature review into the topic helped in getting idea about the immense benefits of the system and its use has gradually widened in all aspects of medical field. Different research on the developments in CPOE system revealed range of information about the system such as its efficacy in reducing medical error, facilitating work flow on care implementation of the system, improving the screening process for disease, adhering to clinical guideline and many other issues. However, despite enormous benefits challenges and the issues faced in adopting the system in different hospitals in different countries was also seen. Analysis of the issues showed that all sorts of technical, social, economic or knowledge based issues mainly occurred due to ineffective planning at the initiation phase. Success in implementation process can occur when adequate training and skills is given regarding management of such system. The scope for further research in this topic is to identify other critical areas in medical practice where the system can be exploited to gain maximum benefits.
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