While implementing computerized physician order entry (CPOE) is a monumental task, it can have a resounding impact on medication delivery in the hospital. Automating the functions associated with medication ordering creates safety checks, streamlines the medication delivery process, and frees pharmacists, physicians, and nurses to focus on patient care, as opposed to more tedious, albeit critical, medication delivery tasks, such as order transcription and drug allergy review.

Automating Medication Ordering Functions
One of the benefits of CPOE is that it automates medication ordering functions and standardizes the ordering process, thereby eliminating the opportunity to cherry-pick orders and overlook onerous tasks.

When dealing with paper charts, pertinent patient information, such as drug or food allergies, may not get placed on the pharmacy profile, requiring personnel to spend time searching through a chart in order to retrieve necessary patient information. CPOE eliminates this, as drug allergies, height, and weight are required on assessment and placed in a standard electronic field in the chart. If this field is not populated, the system is configured such that physicians can still order medications, but pharmacists will not verify those orders and can summarily suspend all orders in the system until the required patient information is provided. The suspension of orders serves two purposes: First, it notifies both the nursing and medical staff that the orders were received and reviewed; second, it alerts staff that there is a piece of information missing that prevents acting on those orders. Having this safety feature in place ensures patients are appropriately assessed and reviewed for 100% of all drug orders, and, ideally, eliminates the risk of a patient receiving a medication they are allergic to.
Using these principles, we enabled our system to limit the prescribing of clozapine. As only patients in the clozapine registry are eligible for receiving this drug, we created an electronic form that forces the prescriber to validate the patient’s registration—only then can the medication be ordered.

CPOE and Drug Recalls

CPOE can significantly help with efforts to respond to FDA drug-recall alerts. For example, in late January, the ETHEX Corporation issued a voluntary drug recall of its metoprolol succinate ER (generic Toprol-XL). As a result of the generic drug recall, demand for the branded product increased rapidly causing a national shortage in a matter of days. With the help of our CPOE system, the pharmacy was able to alert all prescribers of the situation, identify the patients with active orders in the medical center, and work with the medical staff leaders to implement an alternate treatment protocol. The automatic switch to metoprolol tartrate (Lopressor) was loaded into the system and served as an information trigger to prescribers of new Toprol-XL orders. All recalled stock was removed and sequestered. With pharmacy management enlisting the help of the IT department, this was completed in less than two hours.

Warfarin also is subject to a forced function upon ordering. If an indication, such as atrial fibrillation is not documented, the prescriber is not allowed to complete the order. As a reference, a menu of approved indications are available to the prescriber for selection on ordering; in this manner, the system serves as an educational tool for all caregivers that use it, as well as a documentation tool for administering this potentially dangerous but necessary therapeutic agent.

In addition, our system is set up to limit prescriber access to specialty pharmaceuticals. With this computer application (known as the “availability policy”) only infectious disease physicians can order restricted antibiotics and chemotherapy ordering is limited to oncology-credentialed prescribers, for example. This affords compliance with hospital protocols that limit use of targeted agents to specific circumstances or criteria, and, in the case of chemotherapy, eliminates the potential for an unintended order if a user incorrectly selects a product.

We also instituted forced functions in conjunction with removing certain medications from automated dispensing cabinets (ADCs); clinical alerts are triggered and must be acknowledged by the nursing staff prior to procuring certain medications. For instance, anticoagulant products, such as warfarin, lovenox, and heparin, set off the following message—“Has the patient been evaluated for signs of bruising?”

Standardized Dosing and Concentrations
Another safety feature of CPOE is the ability to set up standardized dosing and concentrations for medications used in intensive care units and emergency rooms (e.g., dobutamine, labetalol, or alteplase). Not only does this standardize physician prescribing practices, it reinforces a standard of care for the nursing staff as well. Since rate and dosing information does not vary among providers, the chance of errors when programming drip rates is reduced. Standardized concentrations also can be configured to match pre-mixed commercially available products, reducing the potential for mixing errors by pharmacy. This is further reinforced by the use of volumetric infusion devices that are programmable with those same medication-specific standard concentrations.

With this functionality, normal dose ranges can be configured into each order so that alerts for either high or low doses will be triggered upon order entry, should the dose fall outside the appropriate range limits. In addition, we created several customized frequency tables for categories, such as IV infusions and extended-release products, so that inappropriate frequency choices would be eliminated. With a more targeted menu, users do not waste time scrolling for their choice and then inadvertently select the wrong frequency.

CPOE and the OR
One of the more unique functions of our CPOE system is the OR suspend/un-suspend feature we designed to handle the order changes required when a patient is transferred to the OR. At all hospitals, transferring a patient to the OR requires their medications be discontinued and then reordered upon leaving the OR. Manual execution of this process is extremely labor intensive and almost always requires that physicians “renew all medications” when a patient is returned to the floor. Previously at our hospital, only through a telephone order by the nursing or pharmacy staff could all medications be itemized for appropriate documentation and review. With our current system, upon admission/transfer to the OR, a member of the OR staff electronically validates the transfer which signals the program to send an e-mail notification to the pharmacy. The pharmacist, alerted of the station change, then electronically suspends all the patient’s medications by protocol. Upon release of the patient to the PACU, the surgeon reviews the patient’s medications and un-suspends (in effect, reorders) all necessary treatment for the patient’s return to the inpatient area. In this manner, “renew all medication” is no longer a part of the chart documentation requiring clarification. This action takes only a few seconds and the system provides an electronic trail for auditing purposes when necessary.

Preservation of the Formulary
Other helpful CPOE features are the ability to program an automatic therapeutic switch (ATS) function into the order entry process, preservation of the formulary, and the ability to effectively separate combination drugs into their respective components (e.g, amiloride-hydrochlorothiazide).

The system requires practitioners to provide validation for non-formulary agents. This function, along with the ATS function, allows for the bulk of orders to be in compliance with the formulary, while providing specialization when necessary. In addition, linked order sets can be used to order combination drugs whereby the brand name is ordered but the item sent is the equivalent components, thus minimizing stock duplication.

Improving Medication Order Processing
Since implementing CPOE, our medication order processing turn-around time (the time it takes for a medication to be ordered, appropriately reviewed, and made available for removal from an ADC) has been under 30 minutes 90% of the time, and under 60 minutes 96% of the time. Our statistics show that we average 32,000 orders and 150,000 dispensed doses per month with a mean order availability time of about five minutes. Prior to this, the mean order availability time was approximately 45 to 60 minutes, with some orders taking around six to eight hours if the order was not faxed immediately after it was written.

Impact on Pharmacist Responsibilities
With CPOE, pharmacists at our hospital have been able to increase their focus on clinical services, while maintaining supervision of distributive functions. Transcription work (traditional pharmacist order entry) has diminished significantly, and just-in-time technology (ADCs) provides for a safe method of drug distribution without the redundant send and return aspects of the cart fill and robot processes. Our department, using the same complement of staff, is now able to accomplish the following clinical pharmacy activities consistently for all patients:

• Review profiles for duplicate orders/duplicate therapies
• Review orders that are due for renewal (e.g., antibiotics and narcotics) and consult with prescribers regarding a patient’s continued need for treatment
• Review opportunities for IV to oral medication switches
• Review hemoglobin levels of patients on erythropoiesis-stimulating agents (ESA) and provide feedback to prescribers when values are out of range
• Monitor INR levels for patients on warfarin
• Clarify orders and treatment protocols: In one case, a pharmacist was able to determine that a chemotherapy regimen had failed in a previous month, assessed that the dose was too low and contacted the prescriber to review the regimen
• Clarify allergy alerts
• Review medication dosing in renally compromised patients
• Provide drug information
• Reconcile and decipher work process issues that affect timely drug delivery
• Attend multidisciplinary rounds
• Oversee the medication reconciliation process, which is still reviewed manually and thus, is quite labor intensive

Conclusion
With thousands of doses dispensed every day, CPOE has helped us streamline the medication delivery process while providing a safety net for patient care in a systematic, automated, and consistent manner. Implementing this system not only bolstered patient safety efforts, but also created high nursing, physician, and pharmacist satisfaction at our hospital.

Cheryl L. Krempa, RPh, MBA, serves as a pharmacy manager for the Pharmacy Solutions Division of Cardinal Health. Her responsibilities include opening new pharmacy accounts and special project work. She previously served as pharmacy director for Trinitas Regional Medical Center (TRMC), a Cardinal Health managed pharmacy, and is currently serving as a consultant to TRMC to manage its CPOE system. During the span of her career, Cheryl served as pharmacy director at several sites in New Jersey including Newark Beth Israel Medical Center, JFK Medical Center in Edison, and United Children’s Hospital in Newark. Cheryl earned a BS in pharmacy from Rutgers University College of Pharmacy and an MBA from Farleigh Dickinson University. Cheryl is a past president of NJSHP and a current member of ASHP.