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.
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.
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
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).
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).
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.
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.
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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