Review
The impact of computerized physician medication order entry in hospitalized patients—A systematic review

https://doi.org/10.1016/j.ijmedinf.2007.10.001Get rights and content

Abstract

Objective

To identify all published studies evaluating computerized physician order entry (CPOE) in the inpatient setting and uniformly classify these studies on outcome measure and study design.

Data sources

All studies that evaluated the effect of CPOE on outcomes pertaining to the medication process in inpatients were electronically searched in MEDLINE® (1966 to August 2006), EMBASE® (1980 to August 2006) and the Cochrane library. In addition, the bibliographies of retrieved articles were manually searched. Articles were selected if one of their main objectives was CPOE evaluation in an inpatient setting.

Review method

Identified titles and abstracts were independently screened by three reviewers to determine eligibility for further review.

Results

We found 67 articles, which included articles on CPOE evaluation on some outcome at the time of ordering. Most papers evaluated multiple outcome measures. The outcome measures were clustered in the following categories: adherence (n = 22); alerts and appropriateness of alerts (n = 7); safety (n = 21); time (n = 7); costs and (organizational) efficiency (n = 23); and satisfaction, usage and usability (n = 10). Most studies used a before–after design (n = 35) followed by observational studies (n = 24) and randomized controlled trials (n = 8).

Conclusion

The impact of CPOE systems was especially positive in the category adherence to guidelines, but also to some extent in alerts and appropriateness of alerts; costs and organizational efficiency; and satisfaction and usability. Although on average, there seems to be a positive effect of CPOE on safety, studies tended to be non-randomized and were focused on medication error rates, not powered to detect a difference in adverse drug event rates. Some recent studies suggested that errors, adverse drug events (ADEs) and even mortality increased after CPOE implementation. Only in the category time the impact has been shown to be negative, but this only refers to the physician's time, not the net time. Except for safety, on the whole spectrum of outcomes, results of RCT studies were in line with non-RCT study results.

Introduction

Medication prescription plays a central role in health care. It concerns 65% of the US population and it annually accounts for 13% of health care expenditures [1]. Various studies show that adverse drug events (ADEs), many of which are preventable, form a major problem in the US [2], [3], [4], [5]. In the early 1990s, it was estimated that there are 3.7 adverse events per 100 admissions in the US [6]. Of these, 28% are medication related, half of which preventable. From an economic point of view, hospital costs of adverse drug events were estimated at $2 billion per year. Similar reports in other countries show that medication errors indeed have important impact on mortality, morbidity and cost of care [7].

Medication errors are usually the result of failures during the medication process. Errors can occur in any step of this process: taking history, ordering, pharmacy management, administration management or surveillance [8]. A medication error may or may not result in patient harm, but almost all medication errors are considered to be preventable. adverse drug events (ADEs) are usually considered to include both medication errors that result in harm (preventable ADEs), and adverse drug reactions (ADRs), which are considered unpreventable [9]. Although high workload [10] and failures in monitoring patients [11] have been reported as a possible causes of medication errors, most medication errors and preventable ADEs are related to the medication process and mainly occur during the ordering step [3], [12]. In addition to the inability of the average physician to memorize the ever increasing number of drugs, treatment regiments and side effects, prescribing the old fashioned way with pen and pad is prone to slips which are sometimes errors of inattention [13].

The institute of medicine and other important stakeholders have identified computerized physician order entry (CPOE) or electronic prescription (EP) as the main opportunity to reduce medication errors and thereby improve safety [2], [14] especially when decision support is provided. CPOE systems promise to have also effects on outcomes other than safety, such as medication and process costs. A CPOE system refers to a variety of computer-based systems that share the common features of automating the medication ordering process and that ensure standardized, legible, and complete orders [15]. Electronic medical record systems which merely document medication orders and medication administration, after the time of ordering, are beyond the scope of this paper and are therefore excluded. In addition, we defined a decision support system (DSS) in this context as any system designed to aid a health professional in decision-making at the moment of ordering medication. A DSS can be an inherent part of CPOE or a separate system communicating with the CPOE system. The main objective of this review is to identify, uniformly characterize, and assess the reported CPOE impact in all published studies evaluating any aspect, safety and otherwise, associated with the use of a CPOE system in the inpatient setting. We excluded all studies in the outpatient setting since this is a completely different context with different challenges and a review on CPOE in the outpatient setting is published elsewhere [16]. The measured effects are summarized and associated with an evidence level. One should, however, realize that the assessment of effects of information technology in health care is inherently hard because the technology is only part of a much larger and complex social system [17]. Nevertheless, by presenting and assessing the state-of-the-art in CPOE evaluation studies, this review contributes to a better understanding of the merits of CPOE systems in the inpatient setting, and identifies lacunas in current research on CPOE evaluation.

Section snippets

Methods

We searched for relevant english language articles, based on keywords in title, abstract and MeSH terms, using Ovid MEDLINE® & MEDLINE® in-process (1966 to August 2006), Embase® (1980 to August 2006), and Cochrane library. Fig. 1 shows the two applied search strategies and the corresponding search flowchart. In strategy 1, keywords and MeSH terms that are currently in use for referring to a CPOE system (part A) are combined with terms related to inpatient care (part B). In strategy 2, computer

Results

Searching the online databases resulted in 1,004 articles from Ovid MEDLINE®, Ovid MEDLINE® In-process, Ovid EMBASE®, and the Cochrane library. After initial screening of titles and abstracts, 74 articles were considered for full text review. Six additional articles were identified by reviewing bibliographies, yielding a total of 80 articles. Based on the full text review, six articles were excluded because they turned out not to address a CPOE system according to our definition, and seven

Discussion

We identified and described the results of 67 papers on evaluation of CPOE systems in hospitalized patients. The number of such evaluation studies shows a strong increase in recent years.

Our findings suggest that the impact of CPOE systems has been shown to be positive especially in Adherence to guidelines, but also in Alerts and Appropriateness of alerts; costs and organizational efficiency, and satisfaction and usability. A major goal for the implementation of CPOE is safety improvement.

Conclusion

In conclusion, CPOE evaluation studies vary in scope, aims and results, and one should not expect unequivocal judgment about their effects. One could perhaps argue for more RCT studies in the evaluation of CPOEs but they do have prohibitive costs. One fruitful way to proceed with is the use of controlled trials focusing on CPOE systems with more decision support for specific patient groups, high risk drugs, typical ADEs, using more powerful designs like interrupted time-series. Another fruitful

References (92)

  • J. Horsky et al.

    Comprehensive analysis of a medication dosing error related to CPOE

    J. Am. Med. Inform. Assoc.

    (2005)
  • W.L. Galanter et al.

    A trial of automated decision support alerts for contraindicated medications using computerized physician order entry

    J. Am. Med. Inform. Assoc.

    (2005)
  • S.T. Rosenbloom et al.

    Effect of CPOE user interface design on user-initiated access to educational and patient information during clinical care

    J. Am. Med. Inform. Assoc.

    (2005)
  • R. Kaushal et al.

    Return on investment for a computerized physician order entry system

    J. Am. Med. Inform. Assoc.

    (2006)
  • M.C. Beuscart-Zephir et al.

    Impact of CPOE on doctor–nurse cooperation for the medication ordering and administration process

    Int. J. Med. Inform.

    (2005)
  • A.L. Costa et al.

    An information system for drug prescription and distribution in public hospital

    Int. J. Med. Inform.

    (2004)
  • S.T. Rosenbloom et al.

    Clinicians’ perceptions of clinical decision support integrated into computerized provider order entry

    Int. J. Med. Inform.

    (2004)
  • H. Van der Sijs et al.

    Overriding of drug safety alerts in computerized physician order entry

    J. Am. Med. Inform. Assoc.

    (2006)
  • J. Niinimaki et al.

    Approaches for certification of electronic prescription software

    Int. J. Med. Inform.

    (1997)
  • B. Kaplan

    Evaluating informatics applications—some alternative approaches: theory, social interactionism, and call for methodological pluralism

    Int. J. Med. Inform.

    (2001)
  • L.T. Kohn et al.

    To Err is Human: Building a Safer Health Syst.

    (1999)
  • D.W. Bates et al.

    Incidence of adverse drug events and potential adverse drug events

    JAMA

    (1995)
  • D.W. Bates et al.

    Top priority actions for preventing adverse drug events in hospitals: recommendation of an expert panel

    Am. J. Health-Syst. Ph.

    (1996)
  • T.A. Brennan et al.

    Incidence of adverse events and negligence in hospitalized patients. Results of Harvard medical practice study I

    New Engl. J. Med.

    (1991)
  • C. Vincent et al.

    Adverse events in British hospitals: preliminary retrospective record review

    BMJ

    (2001)
  • P. Kilbridge et al.

    A process model of inpatient medication management and information technology interventions to improve patient safety

    VHA's research series

    (2001)
  • B.D. Franklin et al.

    The incidence of prescribing errors in hospital inpatients: an overview of the research methods

    Drug Safety

    (2005)
  • R. Griffith et al.

    Administration of medicine. part 1: the law and nursing

    Nurs. Stand

    (2003)
  • S. Jordan et al.

    Minimizing side-effects: the clinical impact of nurse-administered ‘side effect’ checklist

    J Adv. Nurs.

    (2002)
  • T.S. Lesar et al.

    Factors related to errors in medication prescribing

    JAMA

    (1997)
  • A. Milstein et al.

    Improving the safety of health care: the leapfrog initiative

    Eff. Clin. Pract.

    (2000)
  • R. Kaushal et al.

    Effects of computerized physician order entry and clinical decision support systems on medication safety

    Arch. Int. Med.

    (2003)
  • J. Aarts et al.

    Same system, different outcomes: comparing the implementation of computerized physician order entry in two Dutch hospitals

    Method. Inform. Med.

    (2006)
  • M.I. Oppenheim et al.

    Impact of a computerized alert during physician order entry on medication dosing in patients with renal impairment

  • B. Dubeshter et al.

    Chemotherapy dose limits set users of a computer order entry system

    Hosp. Pharm.

    (2006)
  • J.M. Overhage et al.

    Computer reminders to implement preventive care guidelines for hospitalized patients

    Arch. Int. Med.

    (1996)
  • J.M. Teich et al.

    Effects of computerized physician order entry on prescribing practices

    Arch. Int. Med.

    (2000)
  • G.M. Chertow et al.

    Guided medication dosing for inpatients with renal insufficiency

    JAMA

    (2001)
  • N.E. Kawahara et al.

    Influencing prescribing behavior by adapting computerized order-entry pathways

    Am. J. Hosp. Pharm.

    (1989)
  • J.M. Overhage et al.

    A randomized trial of “corollary orders” to prevent error of omission

    J. Am. Med. Inform. Assoc.

    (1997)
  • K.G. Shojania et al.

    Reducing vancomycin use utilizing a computer guideline

    J. Am. Med. Inform. Assoc.

    (1998)
  • M.A. Fischer et al.

    Conversion from intravenous to oral medications

    Arch. Int. Med.

    (2003)
  • B. Bogugki et al.

    Computerized reminders reduce the use of medications during shortages

    J. Am. Med. Inform. Assoc.

    (2004)
  • T. Hulgan et al.

    Oral quinolones in hospitalized patients: an evaluation of a computerized decision support intervention

    J. Int. Med.

    (2004)
  • P.R. Dexter et al.

    A computerized reminder system to increase the use of preventive care for hospitalized patients

    New Engl. J. Med.

    (2001)
  • N.A. Ali et al.

    Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients

    Crit. Care Med.

    (2005)
  • View full text