October 31, 2011

ICD-10 and Computer Provider Order Entry: Implementation Poses Challenges


Computerized provider order entry (CPOE) is one of the 15 core objectives required for Stage 1 of Meaningful Use under the federal Electronic Health Records (HER) Incentive Program. This objective requires the use of CPOE for medication orders entered directly by any licensed healthcare professional who can enter orders into the medical record in accordance with state, local and professional guidelines. According to CMS, CPOE entails the provider’s use of computer assistance to enter medication orders directly from a computer or mobile device. The orders also are documented or captured in a digital, structured and computable format for use in improving safety and organization.

The implementation of CPOE is expected to reduce medication errors, to limit adverse effects and to improve patient safety. However, many healthcare facilities and providers are struggling with this core objective due to a number of difficulties. While there have been many successful implementations, the objective is viewed by some as one of the major stumbling blocks in EHR adoption.

The core measure for CPOE implementation requires that more than 30 percent of all unique patients with at least one medication in their medication list who are seen by the eligible professional (EP) have at least one medication order entered using CPOE. The exception to this measure is any EP who writes fewer than 100 prescriptions during the EHR reporting period. In addition, the CPOE order must be entered by someone with the ability to exercise clinical judgment in case the entry generates any alerts about possible harmful interactions or requires other forms of clinical decisions.

Studies have indicated that in those hospitals that have implemented CPOE successfully, the ability to identify potentially harmful medication orders varies significantly. One of the key success factors in implementation of CPOE is whether clinical decision support systems (CDSS) are utilized. CDSS for CPOE assists providers by suggesting appropriate orders  (using, for example, disease-based drug protocols) or analyzing completed orders using alerts or messages (warning of, for example, drug interactions). While nearly all CPOE systems either include CDSS or have interface capability, there is a great deal of variability. This variability can pose problems for healthcare facilities and providers implementing EHR systems.

The development of standard order sets or templates is critical to the implementation of CPOE.  Standard order sets are important because they are an essential part of clinical protocols and algorithms used to aid clinical decision-making. It also is important to ensure that standard order sets are complete and reflect best practices. Healthcare facilities and providers that have not taken the necessary steps in this respect may encounter difficulties meeting this core objective. The Institute for Safe Medical Practices advocates the application of a multi-disciplinary approach in the development of standard order sets to avoid potential problems. Guidelines for the development of standard order sets can be found online at http://www.ismp.org/Tools/guidelines/StandardOrderSets.asp

About the Author

As Director of ICD-10 and Educational Services for Precyse, Anita Majerowicz, MS, RHIA, is the director of ICD-10 and educational services for Precyse. Anita manages Precyse’s ICD-10 education and implementation services working closely with Precyse University, the organization’s industry-leading education platform. She has more than 25 years experience in the HIM field. She most recently was Director of Clinical Coding and Reimbursement at AHIMA.

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