Order entry rules: healthcare enterprise achieves physician acceptance, reduced medication errors and improved patient outcomes through CIS and CPOE technology - What works: clinical information systems - Sunrise Clinical Manager for Boston University School of Medicine

Health Management Technology, July, 2002

Both the successful implementation and the widespread use today of this system hail from strong support of all of the executive management team. In particular, the chief medical officer, who believes in the ability of clinical information systems to transform the delivery of patient care throughout the organization, served as champion for the concept of computerized physician order-entry. Strong steering committee and physician and nursing leadership garnered commitment from key personnel throughout the implementation lifecycle and beyond.

RESULTS

Since first introducing CPOE, overall medication errors have steadily decreased. When medication errors are analyzed by category, we see that errors attributed to the prescribing/order-writing function have dropped by 37 percent. Later implementation of the documentation module is expected to impact the administration and MAR transcription categories.

By the time phase two was activated in December 2000, physicians were engaged and ready for enhanced decision support at the point of entry. This stage of the deployment provided nearly 100 percent direct-physician order entry and included a real-time rules engine embedded in the clinical order entry module.

The clinician order-entry module not only provides clinical decision support during order entry, it also transmits the order message electronically to nurses, therapists, pharmacists and diagnostic ancillary departments. The need for printing paper requisitions of orders has been eliminated via automated interfaces.

While clinical decision support has received substantial attention from our industry, we know from research on quality and safety across all industries that it is at the time of task hand-offs that we are most vulnerable to error. Our system implementation has eliminated three transition steps in the order communication process and the possibility of error associated with each: The transcription from order sheet to order requisition, the pickup and delivery of the requisition to the ancillary department, and the re-entry of the order into the ancillary system.

While we did not do a controlled study on this aspect of the system, we ate satisfied that we have created a strong, safer design by eliminating known sources of potential error. Because the system supports order management as well as order entry, physicians can initiate, modify and discontinue active patient orders online, and recipients of the physicians' orders can immediately access that information. Audit trails of each order are accessible from any workstation.

Automation of the order communication process has resulted in an unanticipated benefit of reduced process checking. Both ancillary and nursing staff report fewer phone calls to check on the status of an order that is in process, since that information is available real-time through the system. For example, nurses can now see when an order has been received by the lab, when the test has been begun, and when there is an available result. Anxiety about potentially misplaced requests has been eliminated by making the steps "visible."