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Hospital Pharmacy Volume 37, Number 3, pp 321­325 2002 Facts and Comparisons

Computerized Prescriber Order Entry Nursing Issues

Alicia S. Miller, MS, RPh*

This continuing feature will inform readers about the process of implementing, maintaining, and supporting computerized prescriber order entry (CPOE) at the Ohio State University Medical Center. (By "prescribers," we refer to health care professionals authorized to prescribe medications by their states.) Practical information on what worked and what failed will be provided, along with current updates on the status of CPOE at the Medical Center. Questions or suggestions should be addressed to Alicia S. Miller, Department of Pharmacy, The Ohio State University Medical Center, 368 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210. E-mail: [email protected]

Eventually, all of these issues were resolved by system enhancements or further clarification and retraining in the use of CPOE. Impact on Patient Care: Actual or Perceived? The nurses' perception of CPOE was an interesting phenomenon to observe. Nurses did not trust the computer and often used it as an excuse when problems surfaced. The statement, "the computer made me do it" was prevalent during the early stages of implementation. Another common expression was, "it's the computer's fault." Do these statements reflect insufficient training for the nurses, system design issues, or the concern that CPOE is an imperfect system? I believe that a combination of all these factors led nurses to feel initially uncomfortable with the accuracy and benefits of CPOE. Once this perception took hold, it became an uphill battle to change nurses' opinion from the negative to the positive. Nurses' perception of CPOE was justly based on actual changes. One major change was the ordering and displaying of medications by their generic names. Prior to CPOE, most medications were ordered by their trade names and nurses were familiar with these names. With CPOE, nurses had to learn generic names. Another change was interpreting computer-generated orders. In the beginning, nurses fell into the same trap as the pharmacists, that

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ast month, we discussed the operating room process and nursing issues related to CPOE medication/IV charting. This month, we will continue the topic of nursing and CPOE.

NURSING ISSUES Background Of all the disciplines working in the health system, nursing is most affected by the implementation of CPOE. Nurses are responsible for the accuracy of generated orders, have the most contact with physicians, and are usually delegated to clean up or fix problem orders. It is not surprising, therefore, that nurses need to be an integral part of the design, implementation, and maintenance of CPOE. CPOE entails new

*Associate Director of Pharmacy, The Ohio State University Medical Center, Department of Pharmacy, 368 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210. E-mail: [email protected]

workflow and unit procedures, so nurses must learn CPOE and change operational processes at the same time. Nursing support is a key factor during the implementation phase of CPOE. For success, nurses must become believers in and champions of the CPOE process. The benefits of CPOE for nursing are similar to those realized by pharmacy, but also include nursing-specific benefits like the ability to display all active orders on the computer screen. This is a big improvement over the paper environment, in which orders were listed in chronological order and active orders were dispersed throughout the physicians' order book. Having active orders easily grouped and displayed in CPOE has made it easier to review and clarify patients' medication orders. Nurses also confronted the same challenges as pharmacy. These included the problem of duplicate orders, interpretation of CPOE orders, and dealing with "stat" and one-time orders.

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FIGURE 1. Pharmacy consults

FIGURE 2. Restrict patient information

is, believing that the orders were always correct. They quickly learned not to accept the orders at face value and to question ambiguous or inappropriate orders. Changes in Policies and Procedures Nursing policies and procedures had to be reviewed and rewritten to incorporate the changes entailed by CPOE. The policies and procedures and nursing practices that changed the most at the Medical Center were related

to note orders, transcription process, patient confidentiality, transfer/discharge process, operating room/recovery room process, specimen labeling, laboratory requisition ordering, blood administration, medication administration, standardizing frequencies, and security. The majority of the these items were discussed in previous CPOE articles because of their connection with pharmacy and the medication use system. I leave the remaining items for nursing to resolve and write about.

Verbal and Implied Orders The intent of CPOE is to reduce the number of verbal orders from physicians. With CPOE, nurses had to balance accepting appropriate versus inappropriate verbal orders. As one nurse stated, "the war intensifies." New criteria for acceptable verbal orders were drafted with input from the residents, nurses, nursing administration, and medical staff. The criteria provided specific "do's and don'ts" for both the residents and nurses to follow. With the new criteria, the number of verbal orders has stabilized and a truce has been called between nurses and residents. Implied orders include open-ended orders, such as "discontinue when..." or "may advance...," and one order that generates multiple orders such as "remove foley catheter." Each implied order requires additional work by nurses, who must identify and discontinue associated orders within CPOE. Once the open-ended orders reach an endpoint, nurses must discontinue the original orders and the implied orders. The "one equals many" order combination also requires that nurses select all associated orders for discontinuation along with the implied order. Nurses call these actions "order clean up," and they have added to nurses' workload since the implementation of CPOE. You might ask, "Shouldn't the physicians be doing the discontinuing and order clean-up?" Nurses have been gently reminding physicians to do the clean up, but nevertheless, when they run into resistance, clean up becomes their responsibility. Physician Cosignature of Orders All verbal orders must be cosigned prior to the patient being discharged. Physicians receive every opportunity to cosign orders when they login to CPOE. Patients' orders are flagged for cosigning and physicians have the option to immediately cosign all orders, cosign selective orders, or delay cosigning. If

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physicians delay the cosigning process until a patient is ready to be discharged, then the patient can't be discharged until the orders are cosigned. It then falls upon the nurse to track down and find the physician to cosign the orders. Cosigning orders is one function that nursing cannot perform, yet they must deal with potentially irate patients and family members if the discharge process is delayed. Pharmacy Interaction Communication of orders improved between nursing and pharmacy to such an extent that nursing at first expected medications to be delivered instantaneously once pharmacy received the orders. It took time for nursing to realize that pharmacy still needed time to enter and review orders, prepare and check the doses, and deliver the medications. Pharmacy was receiving "missing medication" phone calls from nursing for orders not more than 5 minutes old. These calls have decreased but still occur. It has also helped both departments to have online access to orders for review and retrieval. If there are any questions or discrepancies between how pharmacy entered the order within the pharmacy computer system and what nursing thinks the order should be, pharmacy personnel can login to CPOE and recheck the actual order. This has saved time in both departments: Pharmacy does not have to sort through hard-copy orders and nursing does not have to fax orders again. Standardization Nursing has realized an improvement in standardization of patient care through development of ordersets, online documentation, and implementation of standard frequencies. This has helped with "float" nurses, agency

nurses, and nurses who rotate between units, and can only help in reducing medication errors. WORK IN PROGRESS UPDATE Pharmacy Consults One nice feature of CPOE is the ability of physicians to request pharmacy consults online. This eliminates the production of the generic two-part physician consult form, provides the physicians with predefined choices, and displays the status of the consult. The pharmacy consult is contained within the ancillary consult ordering function and consists of several option as follows (see Figure 1). The physician can select from a list of most frequently requested drugs or manually type an unlisted drug. Then the physician selects the requested action or types an unlisted request. The physician pager number field is extremely helpful to pharmacists in locating and communicating the results of the consult to the ordering physician. The physician uses the "relevant info" field to provide additional information that might be needed by the pharmacist to make an accurate and thorough assessment of drug therapy. Once the physician completes the pharmacy consult, the consult prints in pharmacy and the pharmacist who is responsible for the patient is notified. The pharmacist can record the status (eg, received, in process, completed) of the consult within CPOE as the pharmacist moves through the various stages. The physician can monitor the progress of the consult and is assured that someone is acting on the request. When the pharmacist completes the consult, the results are still documented in the patient's paper medical record. CPOE is not a documenting

system for posting consult results. Patient Privacy Notification Pre-CPOE, a "no release of information" sticker was placed on a confidential medical record and was the trigger for the staff not to release information on the patient. However, with CPOE, the staff rarely accesses the patient's medical record and some information has been inappropriately released. CPOE was modified to include a field for specifying whether the patient's information can be released. This field was added to the census screen and is also displayed on the patient demographic screen. Figure 2 shows the census screen with the "RI?" abbreviation, for "restrict information." The field is populated by the admitting system and will either display an "N" to not restrict information or a "Y" to restrict information. This enhancement has improved the protection of patients' information within the Medical Center and provided an additional level of control for the staff. ACKNOWLEDGEMENT I would like to thank Leslie Crain, RN, who assisted in providing information on nursing and CPOE. n

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