Computerized physician order entry can reduce errors and improve clinical outcomes, but introducing the technology in the hospital setting is an exercise in caution.

That was the key message delivered at the HIMSS Nursing Symposium by Barbara Radice, R.N., vice president of clinical informatics at Sharp Healthcare, a six-hospital system in San Diego. Radice’s talk highlighted Sharp’s progress toward an inpatient EHR, which includes an order entry module. To date, four Sharp hospitals have deployed the technology, with two more in line this spring. The effort began in 2008.

Sharp’s system has a number of built-in medication alerts and clinical reminders, Radice said. For patients with poor eating history noted in the chart, the system will fire an automatic order for dietary consultation. And as a safety measure, no order can be placed for any patient under the age of 12 who is lacking documented weight. Their weight must be entered before any medication orders can be processed. “CPOE changes everything, including how orders are managed,” Radice said.

For example, when Sharp relied on paper-driven orders, it was easy to tell when a physician began and discontinued an order. The physician likely started writing an order, then stopped, but left the order on paper. If the physician wrote another order later for the same patient, the nursing staff would know by tracking the paper pile. With a computer, it’s another scenario, however.

Now, if a physician starts, and then discontinues the order, the pending order remains in the system. And physicians (or nurses) may be surprised to see multiple orders pertaining to the same patient, she noted.

“Alert fatigue” is another issue associated with CPOE, Radice said. It’s a “tricky balance” knowing how many electronic interventions to introduce to physicians during the ordering process, she said. “There can be so many alerts, physicians just start clicking through them.”

Yet, the advantages of CPOE outweigh the pitfalls, she emphasized. The use of pre-written order sets can be a boost in keeping the hospital up to date with best practices, for one. The main temptation to avoid is over-reliance on technology. “Doctors should still tell nurses when they have placed new orders,” she noted.


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