Improve your CPOE to save time and patients

System settings should be customized to individual needs.

Computerized physician order entry (CPOE) systems should help physicians work faster and smarter, Kendall Rogers, MD, FACP, told attendees at Hospital Medicine 2015.

“Those are our 2 primary goals for technology to be integrated within our care. Most of us would agree we're not achieving that right now,” said Dr. Rogers, an associate professor and chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque.

Kendall Rogers MD FACP
Kendall Rogers, MD, FACP

To get from the current state of affairs, where “across the country, people will list interacting with their [electronic medical record] as one of their #1 frustration factors,” hospitalists need to take action, Dr. Rogers said. “We've been sitting back and waiting for someone to build something where we can say, ‘Yes, that's it.’ We haven't seen it, so we need to get involved.”

Hospitalists can improve the functioning of CPOEs by changing the way they use them themselves but also by lobbying for changes from hospitals and system vendors, he advised.

Tips for your CPOE

“Be vigilant” was Dr. Rogers' first piece of advice for safe and effective use. Physicians, nurses, and other clinicians have already learned to employ a certain level of vigilance with computerized systems, he noted. “It's due to this vigilance that these systems have not harmed many more patients,” Dr. Rogers said.

Areas where hospitalists should be especially diligent include checking units of dosing, for example, milligrams versus milliliters or weight-based dosing, and keeping orders as clean as possible. “It means small tasks of cleaning up that order list, trying to display data in a way that we're going to recognize when errors are there,” said Dr. Rogers.

Errors are also easier to spot if you know your CPOE system well, another important step. “When you put in a search term, you need to know that [to search for a term that] ‘contains,’ you have to have at least 3 letters, but ‘starts with,’ I can put 2 letters in. You need to know that PRN medications don't populate a nursing task list,” Dr. Rogers offered as examples.

Training sessions and written resources can teach these key details. “There are actually very useful resources, likely up in the toolbar somewhere of your own system. If they don't exist there, you need to find a place to get this information out to your providers very clearly,” said Dr. Rogers.

Although general training on the system will help, many of the settings will be local to the hospital. “These systems vary greatly even when they're the same vendor, because of local customization and the changes that we've made,” said Dr. Rogers.

Individual customization of one's own CPOE interface is another way to make the system work better. It's like moving the driver's seat and mirrors when you climb into a car, Dr. Rogers said. “When I sit down with residents or anyone else, the first thing that I do is say, ‘What buttons do you use? Let's put all of those in a row and only have the buttons you actually use.’”

Hospitalists should customize their folders, favorites, toolbars, document views, and medication record settings, which should only take about 15 minutes, according to Dr. Rogers. “It may only save you a few seconds here or there or may give you back 10% or 20% of your screen, but these little adjustments are a big deal when we're talking about safety,” he said.

The menu bars, table of contents, and views also can, and should, be customized. Dr. Rogers also recommends changing the definition of a day in the medication administration record, to 7 a.m. to 7 a.m. instead of midnight to midnight, and viewing a 24-hour block of time instead of the 4-hour blocks used by nurses.

These are default settings that should be customized to the user, or even type of user. “Most people don't even know that they can customize things to the way that they actually think,” he said. “I set up for all of my residents a document view that pulls in every note that they actually want to see for the past 24 hours ... It's always an amazing thing for them when they see, ‘Oh, there are the 12 notes that were written yesterday, instead of them being hidden in all these folders.’”

Continuing the driving metaphor, Dr. Rogers' next advice was that physicians treat clinical decision support like a car's global positioning system (GPS). “You're not only looking at the GPS, you're also looking out your window, and you're trying to assess the information that's on that GPS. We follow that in addition to the information that we have right in front of us,” he said.

This is particularly an issue for interns and residents, who sometimes conclude that if they found an action in an order set, it must be appropriate. “We have to be aware who it is intended for, and whether it actually applies to our patients,” said Dr. Rogers.

Finally, “The #1 thing we can do as individuals is avoid wrong patient errors,” said Dr. Rogers. “It is estimated that up to a half percent of every note and order in our [electronic health record] systems are on the wrong patient.”

The causes of these errors include interruptions, confusing screens and layouts, not having patients' names and IDs on every screen, and cursor/stylus errors. Tablet users are particularly likely to make the last of these errors. “On the patient list, you were trying to hit one patient, but it opened the patient right below, and you didn't really look,” described Dr. Rogers.

Some institutions have prevented clinicians from having more than 1 chart open at a time, in an effort to prevent wrong patient errors, but it's unclear whether that works, especially since everyone finds workarounds, Dr. Rogers said.

Other solutions include an alert that asks for verification of the patient's identity before an order is finalized and a more time-consuming version that asks the clinician to re-enter the patient's name and birth date. The least invasive but effective method may be adding patients' photos to their electronic records (a trial of which was covered in the March 2013 ACP Hospitalist), according to Dr. Rogers.

“Until the system is fixed at your institutions, all of us should adopt some process, some rote routine ... some system to make sure that you always double check that this is the right patient,” he said.

System improvements

There are a number of fixes that institutions and hospital medicine programs could make to generally improve their CPOE use, according to Dr. Rogers. Trainings should be held not just before a new system is implemented, but after users are familiar with it. “That pretraining before you ever interact with the system is not nearly as effective,” he said.

Hospitalist groups should try to build a group of clinicians who are skilled with a system, or “superusers,” who help their peers, by developing tip sheets, an internal wiki, or even videos of multistep tasks. Everyone should also help each other by reporting problems with the system, even if they find a workaround. “Yes, you personally figured it out,” said Dr. Rogers. “You have to report these. I guarantee most of the people who are making all of the decisions don't know that all of those issues exist. They value front-line provider reporting.”

Dr. Rogers and others have lobbied for every system to have a “report” button to allow easy reporting of problems with a screenshot to the hospital or system manufacturer, but this feature is not currently universal. Reporting system problems to anyone other than the manufacturer is dicier, since all purchase agreements require users to not share such information.

“The nondisclosure clause states that even if you identify an error in their system, you can only report it to them... . You can't go public about it. We cannot share screenshots,” said Dr. Rogers. “We should actively resist [this requirement] as it goes against a safety culture.”

Hospitalists should also resist vendors' and hospitals' reluctance to fix identified problems, he advised. “Any time they're repeating, ‘That's a training issue,’ that's likely something that needs to be changed... . They'll say that things are hard coded. That's not an excuse. The code can be changed,” said Dr. Rogers.

Many changes can actually be made at a hospital level, for example, eliminating unnecessary buttons and choices. “There are 400 different options for ordering Tylenol ... Our institution chose at first to list them all,” said Dr. Rogers. It soon became apparent that fewer choices made the system much more usable for prescribing physicians.

“Usability is a safety issue. Without usability, we are prone to make errors,” said Dr. Rogers. “When you argue these things with your local institution or with your vendor, you need to classify them as safety issues, not conveniences.”

Order sets can also improve patient safety. Hospitalists should build them, and then monitor them, to make sure they're being used appropriately and don't become outdated, Dr. Rogers advised.

Those who are at all interested should advance from such tasks to greater involvement in the future of electronic health records and CPOE systems, he urged. “We need hospitalists to be involved in designing these systems and advocating for what is needed,” Dr. Rogers said. “The ideas of tomorrow need to come from us.”