Health - Treatments
By: - at July 19, 2013

Computerized Physician Order Entry and ePrescribing

CPOE and e-Prescribing – Vendor Market Analysis
Given there are approximately 10,000 different diseases and conditions that can affect the human being it is easy to understand that there are many different components to the workflow within a hospital (Wager, Wickham-Lee & Glaser, 2009). For this analysis of physician order entry and prescription ordering, we can simplify this overall workflow into two particular modules of these two components: triage and intervention. These two large components of the workflow include the modules of ordering of further tests and the intervention involves placing an order for a medication.

Hot pharmacist with tablet

Traditional methods of paper-based order entry and prescription writing provide many potential opportunities for error, including illegibility, poor accountability of all written documentation, and time-intensive querying of all written documentation (Hemens, Holbrook, Tonkin, Mackay, Weise-Kelley, Navarro, Wilczynski & Haynes, 2011). The following analysis will be a review of functions and features of two computerized physician provider, or prescriber order entry (CPOE) products and two e-Prescribing products. The healthcare industry demands that these software products and companies be able to mimic the flexibility of paper systems, be accurate with the timing delivery of notifications, and show successful installations with a long-term plan for the future (Perna & Turisco, 2012).

Clinical Decision Support (CDS) Systems
A digital revolution has been happening in healthcare as more of the workflow is being enhanced by Clinical Decision Support (CDS) systems. Errors related to ordering of patient medication and testing has been a known problem (Corrigan, Donaldson, Kohn, McKay & Pike, 2000). CDS is essentially a list of instructions for the computer, and in the case of CPOE and e-Prescribing it means a list of checks and verifications built in the processing of an order form.

Prescribing information

These instructions can be modularized to provide components, which might include antibiotic dosage calculation, cost determination, and when connected to an electronic health record (EHR) include: drug interaction verification and patient history review (Wang, Lu, Wu, Huang, & Huang, 2012; Hebda & Czar, 2013). Given that approximately 400,000 articles are added to the cumulative medical knowledge each year, the CDS must be extremely adaptable (Wager, Wickham-Lee & Glaser, 2009). Therefore, CPOE and e-Prescription systems may actually not be desktop installed computer applications but software as a service (SaaS) applications which users login to an online account similar to online banking. The database and algorithms are stored on a remote server which can be updated to account for the rapidly changing industry standards. Also important is system to system communication, and the current standard for this is generated by Health Level Seven International, simply known as HL7 (Health Level Seven International, 2013).

Cerner’s PowerOrders®
Based on the 2012 United States EMR Adoption Model conducted by HIMMS Analytics, which is an analysis of the current status of 5,458 healthcare centers in implementation of total electronic data collection processes in an eight stage analysis, achieving CPOE with CDS components is considered stage four, which 61.7% of facilities have yet to reach (HIMSS Analytics, 2012). The third largest healthcare information technology (HIT) provider in terms of annual revenue, The Cerner Corporation, offers a CPOE software titled PowerOrders® ("2013 hci100," 2013). The company claims to have tested the software with the physician in mind and allows the physician to handle orders from many different departments, orders for medication, large sets or orders, and recurring orders ("Powerorders," 2013).

Stethoscope and laptop

According to Cerner, costs depend on number of beds and the modules included in the implementation. Any prospective purchaser would login into the website and create an account and choose piecemeal the suite of modules, then sign a contract for service. The PowerOrders® CPOE solution is a module of the Cerner PowerChart® electronic medical record (EMR) implementation. A requirement for the software is a CDS component from Cerner called MediSource®, which offers many CDS features and functionality including medication information lookup, dosage verification, and more. The Cerner website indicates that it was developed utilizing HL7 compliant standards. The Cerner software can be utilized as a SaaS or as a client-side installation and SaaS customers’ servers are located in either Kansas City, MO or Minneapolis, MN (American EHR Partners, 2013). If a contract expires at any time, Cerner allows export of data from the servers. The software appears to have many benefits including: 1,645 full time employees (FTE) dedicated to support and maintenance, capabilities for web-based service and data storage overhead, and a tested CDS system (American EHR Partners, 2013).

Medisphere’s OpenVista
The second piece of CPOE software reviewed was the open sourced initiative OpenVista by Medisphere Systems Corporation. According to Medisphere, OpenVista is an open sourced version of VistaA which was the EHR system developed by the Department of Veteran’s Affairs over the course of the last twenty years ("About medisphere," 2013). Unlike the Cerner package, OpenVista according to the Medisphere website does not offer a SaaS implementation, although in the future is looking to offer some sort of cloud computing or internet service provider based product. Given this drawback, organizations may have to invest more IT staff work hours into updates and networking to ensure effective communication. The company does claim to offer service agreement plans which users can sign up for on their website which could be an option for care centers with low IT staff members. The software utilizes the HL7 engine for system to system compliant communication and offers some form of CDS, which was not well documented on their website. In my hospital I would likely choose the Cerner CPOE implementation due to the full support, although would have to conduct a test drive of each software.

e-Prescription Vendor Analysis
In the same 2012 United States EMR Adoption Model study conducted by HIMMS Analytics, 75.9% have yet to attain stage five, or closed-loop medication administration (HIMSS Analytics, 2012). e-Prescribing is one facet of the closed-loop medication administration process and involves an electronic form for a physician to place a medication order which has connection to a pharmacy electronic system to fulfill the order. After a review of the software solutions for e-Prescribing, it appears many utilize a third-party vendor called SureScripts® which is a company providing data stores about national pharmacies and also drug information. The Cerner Corporation also has developed a stand alone e-Prescribing module available for purchase, which utilizes SureScripts® called ePrescribe. The website for ePrescribe was not very helpful and did not answer any of the detail oriented questions a health IT staff member would need to know like what are the hardware and software requirements, what are the specific functionality of the CDS involved, what form of communication and data storage is utilized.

digital pharmacy

Another interesting e-Prescription product reviewed was Practice Fusion’s free SaaS EHR application with e-Prescription capabilities. The SaaS utilizes SureScripts® for e-Prescription capabilities and does not charge an upfront fee for the service. It runs on an advertising driven funding model. The software requires that each prescriber fill out a verification request form to verify the right to write prescriptions. Practice Fusion claims the highest level of internet security and physical security at their server locations including continuous surveillance monitoring systems, and they even declare free support for the software including free training videos (Practice Fusion, 2013). In my hospital I would likely choose the Cerner ePrescribe implementation due to the integration with the installed CPOE application.

Meaningful Usage
The choices for electronic CPOE and e-Prescribing solutions can appear daunting and choices made will depend largely on size of the organization, connectivity and hardware requirements, and IT staff available for implementation. Furthermore, current legislation should be reviewed to determine if the chosen vendor products will apply for current incentive programs.





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