CPOE (Computer Provider Order Entry) Versus

Traditional Written Orders

Initiate CPOE

Writer: Anjoli Cagle

Date Complete: 5/2/15

Table of Contents
Table of Contents..i
Illustration(s)ii
Abstract...iii
What CPOE is..1
Problems and Solutions of Traditional Documentation and Orders1, 2
Advantages and Disadvantages of CPOE... 3-6
How CPOE is viewed by Nurses................6
How CPOE Can Affect Management Positively 7, 8
How CPOE Can Affect Management Negatively...8, 9
Glossary.....10
Works Cited.11, 12
Appendix13

Illustration

Figure 1. Example of CPOE pre-selectable Health Assessment Screen.. 4

ii

Abstract
This proposal discusses the benefits of CPOE (computer provider order entry) versus traditional
paper orders in the healthcare arena (CPOE, 2015). More hospitals are conforming to this form
of ordering system due to safety and cost effective reasons (HealthIT.gov, 2015). Traditional
orders are often prone to multiple human errors; that of the writer, the reader, and the deliverer.
This is an issue that may be overcome by revamping our healthcare systems to become entirely
paperless, but we will start by looking at why this would be beneficial. Then we will take a look
at how CPOE may be a great solution for doctors, nurse managers, and nurses, as well as
healthcare as a whole- through prevention of errors and the possibility of overall cost reduction
(Medication Error Prevention, 2015).

iii

How New Innovations in Computer Provider Entry

Are Improving Healthcare
New innovations such as CPOE (computer provider order entry) can improve how
healthcare is approached in a beneficial way versus traditional paper orders in the healthcare
arena (CPOE, 2015). More hospitals are conforming to this form of ordering system due to
safety and cost effective reasons (HealthIT.gov, 2015). Traditional orders are often prone to
multiple human errors by the writer, the reader, and the deliverer.
What is CPOE? CPOE is a relatively new way of entering patient orders given by the
doctor. CPOE has been optional for several years, but in recent years is becoming mandatory in
many facilities due to new healthcare regulations. Earlier adoption of CPOE will ease the
transition period for our medical center. Electronic methods will lead to better accuracy of order
entry, and ability for nurses to clearly understand the order the doctor wants to enact. With any
new system, there is a period where glitches have to be worked out, however compared to
written orders, CPOE can be more accurate.
In the past, doctors wrote their orders, but as many nurses and experienced patients
realized, sometimes these written orders were not accurate. Here are some examples: qd means
every day, but if written sloppily can look like qid, meaning that the patient would receive the
dose 4 times a day instead of once daily. Writing 10 U sloppily might make a nurse believe the
order to read 100 units, and with a medication such as insulin, a mistake like this can be deadly
(see appendix). Another frequent badly written order is mg versus mcg, when written quickly it
is difficult to decipher, leaving an inexperienced nurse in an awkward position of calling the
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doctor to clarify a frequently given drug, or an experienced nurse wondering if they should guess
on a rarely given medication or call the doctor again. This report will be discussing both positive
and negative aspects of CPOE, as well as how it affects the work environment. An overview of
how CPOE may be a great solution for improving healthcare and preventing errors is included
within this report (Computerized Provider, 2015).
Problem- Traditional orders are often prone to multiple human errors by the writer, the reader,
and the deliverer. Failure of traditional orders can be related to a human tendency of being
rushed, being stressed, or being exhausted (Medication Error Prevention, 2015). Many hospitals
are converting to a mixed system of paper and computer orders, which complicates the situation,
making it more difficult to find and carry out orders. Immediate nurse managers have to be
involved in more conflict resolutions between doctors and nurses due to doctors combining
written orders and CPOE instead of choosing one or the other (Nurse Views, 2015).
Solution- CPOE implementation would reduce awkward and tense situations with the doctors
when they asked nurses why orders were not found in the chart in a timely manner, or why they
were completely missed. Medicare and other insurance companies are now able to monitor care
given by the provider, which is an improvement in the system (Medicares Failure, 2013).
Instead of having multiple types of orders to shuffle through, one unified computer system can
keep orders from being missed or repeated and ensure patients receive the best care in a timely
manner. Failures of paper provider orders may be overcome by revamping our healthcare
systems to become entirely paperless (Computerized Provider, 2015).

Advantages of CPOE
When all users effectively use the ordering system, much valuable time can be saved. For
example, if a doctor puts in an order to take out a patients catheter at 4 p.m., wait until patient
voids to discharge. If patient does not void prior to 8 p.m., call, a nurse can carry out this order
with no questions. If a nurse sees an order to dc foley and discharge and has no experience
with the procedure, she may think it is ok to discharge the patient immediately or even several
hours later with no thought to urine output. Most nurses know this, but for new nurses CPOE
used appropriately can add another layer of protection.
When nurse communication boxes are filled out appropriately, there is less room for error
and less time is spent questioning doctors to clarify what the doctor wanted (see appendix).
Fewer phone calls mean happier doctors. If doctors enter their own orders as they should, nurses
can spend less time entering them and more time carrying them out. CPOE is easier to read than
handwritten orders, meaning that if a doctor did enter a questionable order, a nurse is more apt to
catch it and call the doctor, preventing patients from having unnecessary procedures or
inappropriate orders, thus improving healthcare (Computerized Provider, 2015).
Doctors and nurses who are willing to sit for a brief CPOE class can end up saving much
time and end up finding shortcuts to become proficient at CPOE. Nurses have been flexible and
are accepting to the new ideas of CPOE. Doctors are conforming to CPOE standards throughout
hospitals everywhere as part of the new healthcare reform, leading to more doctors becoming
proficient in this CPOE. Initial costs of CPOE can be recovered at anywhere from 5-10 million
per year (Survey, 2015). CPOE can save much time in health assessments when the health
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histories are already selectable in screens such as the one above, aiding in provider order entry.
See Fig. 1.

Fig. 1. Example of pre-selectable health histories.

10 Innovative Clinical Decision Support Programs::Brought to You by TechWeb." TechWeb.
N.p., 19 Dec. 2011. Web. 16 Apr. 2015; page 3.

Disadvantages of CPOE
Computer order entries work great if all parties have the time to read listings before
entering orders and/or carrying them out. For example, some doctors get in a hurry to get to the
next patient or meeting and stop searching through to find the order that they want. This leads to
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them just clicking on nursing communication. Sometimes they fill in the box so nurses know
what to do, and sometimes they do not (see appendix). Open ended orders lead to more loss of
time, as the nurses have to keep clicking on boxes until hopefully they find the order, or if it was
not put in, then they have to call the doctor to verify what the doctor wanted and then add the
order themselves.
Nurses are allowed to add in the verbal or telephone orders given by the doctor, but those
orders are counted to see how often the doctors put them rather than the nurses. If too many are
entered by the nurses, Medicare and some other forms of insurance refuse payment (see
appendix). Wrong orders can be selected from a drop down box by the doctor. An experienced
nurse will probably catch that the orders would not be relevant to the patient, while a new nurse
may not realize that it does not apply. Orders entered in this way may lead to patients having
tests and getting charged or receiving an inappropriate treatment where it was not necessary
(Computerized Provider, 2015).
Other issues encountered with CPOE (computer provider order entry) include doctors
who have no computer experience that are unable or unwilling to be educated in order entry.
Older doctors are often seen refusing to use the system and continuing to write ordersleading
to nurses or secretaries having to discern what the doctor wrote and entering the orders
themselves. These doctors are now being told by Weatherford Regional Medical Center that they
may have to work somewhere else if they do not start entering orders in CPOE by April 31st of
2015. Cost of initial installation can be $1.9 million, with maintenance costs of $500,000 per

year (Survey, 2015). Not every health history condition option is available on the assessment
portions of computer entry, so at times entering histories can be difficult. See Fig. 2.
Positive Nurse Outlooks
Positive aspects included immediate access to orders as well as test results. Electronic
medication administration records (eMAR) and patient information would be directly available.
A more comprehensive history of the patient along with their overall assessment can be easily
accessed. Safety seems to be easier to obtain with CPOE than a physicians written orders, due to
being more legible. The learning curve of the system can be overcome, and following orders and
looking up patient data becomes quicker and easier. CPOE and electronic health access lead to
quicker access to patient records- a better clinical picture can be developed for future plans of
care, thus increasing patient safety through more legible order access (Nurses Views, 2013).
Negative Nurse Outlooks
Nurse views on CPOE have been mixed, some hating to have to learn a new system to
carry out orders, and others loving the new system because of user access. Interviews were
conducted with over 30 nurses regarding new CPOE systems in a recent study in the Journal of
Health Information Management. Out of these nurses, many mentioned that the CPOE systems
could be easier to use. Issues involved with the use of CPOE are: changes in communication
patterns with doctors, less clarification of orders with doctors, chances of missing orders, and
less face time to collaborate with doctors. Learning the system can be very complicated (Nurses
Views, 2013).

How CPOE Can Affect Management Positively

CPOE changes how Nurse Managers perform their job duties. For example, in one
article, one change noted is how emergency or crisis situations are handled. With the previous
old written orders, patient history, and physical assessments, someone had to run down the hall
to grab the paper chart, wasting valuable time in an emergency. Now a nurse/nurse manager can
access valuable patient information with just a few clicks on the computer. Managers have seen
improvement in accessing valuable patient information in emergency situations (Computerized
Physician, 2015).
A nurse manager can help to keep the line of communication open between nurses and
the doctors on their floors: before, during and after any conflicts to ease the transition with new
CPOE systems (Hoonakker, 2015). Overall patient satisfaction scores can be monitored. Nurse
assessment, medication administration and patient contact can be monitored, making it easier for
managers to keep up with productivity. Decreased medication errors can mean fewer corrective
actions or training for nurses, increasing time nurse managers can have available for other job
duties. When nurses and doctors use CPOE effectively, both medication and physical orders such
as discontinuing or discharge orders are easier to carry out, and there are less chances for order
error. Patient satisfaction can also be monitored with new CPOE data bases.
Efficiency is gained when all are using the programs effectively. Computer Provider
Order Entry can aid nurse managers support of their nursing team when patients or lawyers are
questioning nursing care. CPOE can be used as an aid for nurse managers to ensure that their
team is meeting federal and state regulations. If nurses keep good notes and administer
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medications and other orders as entered by the providers, then there is a good tracking system to
defend a managers team (Ethical Problems, 2010).
How CPOE Can Affect Management Negatively
Ongoing issues for how orders are carried out include conflict resolution between nurses
and doctors. Without adequate communication between doctors and nurses the system fails.
Sometimes doctors say that the orders were put in, but then the nurses say that the orders were
incomplete and could not be carried out. When nurses try to clarify these orders sometimes
physicians become angry, saying that the orders were entered and asking why they are being
called.
When situations like these occur, nurse managers may have to step in to clarify what the
nurses view on the orders appears like on the screen, versus what the physicians remembered
entering. Tense situations can arise from these orders. Many times these situations come from
doctors who are not familiar with the system, or refuse to put the orders in properly because they
think that nurses should know what the doctors intended.
New nurses and doctors, or even expert nurses and doctors who just cannot seem to get
the flow of the system may need the assistance of the nurse managers on the floor (Hoonakker,
2015). There are other trying situations that managers still have to overcome. Examples of some
situations include: nurses giving medications prior to scanning or someone accidentally giving a
medication that was not scanned for the patient but was in the patients room (Computerized
Physician, 2015). If either a doctor or nurse does not document effectively, a nurse manager may

have a difficult time defending her team if the topic arises from a disgruntled patient or a legal
team is questioning care (Ethical Problems, 2010).
What CPOE Means to Weatherford Regional Medical Center
So, is CPOE right for our team of staff of medical-surgical care? Although there will
likely continue to be a few bumps in the road as everyone is learning and improving on the new
CPOE system, on the whole, the benefits outweigh the risks involved in the system. The
improvement in patient health and safety goals, along with nurse safety, doctor safety, and
performance improvement, demonstrates that CPOE is a computer system that can benefit our
healthcare system. Cost productivity can be affected in a very positive way as our medical center
continues to grow.

The hospitalists that we have already seen applying the system creatively and
productively have been having success with both nurses and patients. Nurses know how to
update their patients on new orders and procedures that are next in line. The more everyone
practices and uses this system, the more patient care will benefit. Nurse managers can have more
time available for other responsibilities as the system is more readily adopted. As doctors
become more adept at communicating their orders in the system, nursing workflow will become
more fluid, cutting down on the time management has to get involved with communication
breakdown. Overall, Computer Provider Order Entry would be a great goal for our medical
center to review and apply hospital wide.

Glossary
CPOE- Computer Provider Order Entry: A new system designed for electronically entering and
sending orders from a provider such as a hospitalist to another healthcare provider such as a
nurse to be able to carry out those orders.
DC/dc- To discontinue something; for example when a doctors order is read, dc foley, a nurse
knows that the foley catheter can be removed from the patient and discontinued from use.
eMar- This is an electronic list of a patients medications.
Foley- A type of catheter, or tube, inserted into a patients bladder to drain urine.
Hospitalist- A provider with prescription and ordering abilities; may include a nurse
practitioner, or doctor, as well as outside specialists such as nutritionists.
Nursing Communication Box- This is a very small check box that physicians can use such as
this one: .. Once this boxed is clicked on any custom order can be typed in to another box on
the screen. All too often physicians click this box and do not type specific orders in or enter
incomplete orders.

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Works Cited
Advisory, Pennsylvania Patient Safety. Medication Errors with the Dosing of Insulin: Problems
across the Continuum (n.d.): n. pag. Mar. 2010. Web. 21 April 2015.
<http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/Mar7%281
%29/documents/09.pdf>.
"Computerized Physician Order Entry: Accomplishments And Remaining Challenges." Web log
post. Health Affairs Blog Computerized Physician Order Entry Accomplishments And
Remaining Challenges Comments. N.p., 6 Apr. 2010. Web. 12 Apr. 2015.
<http://healthaffairs.org/blog/2010/04/06/computerized-physician-order-entryaccomplishments-and-remaining-challenges/>.
Computerized Provider Order Entry. Computerized Provider Order Entry. N.p., n.d. Web.31.
Mar. 2015. <http://healthit.ahrq.gov/key-topics/computerized-provider-order-entry>.
"HealthIT.gov." Ready to Meet CPOE Meaningful Use Requirements? N.p., 11 Mar. 2015. Web.
31 Mar. 2015. <http://www.healthit.gov/providers-professionals/achieve-meaningfuluse/core-measures/cpoe-meaningful-use>.
Hoonakker, Peter L.T., Pascale Carayon, James M. Walker, Roger L. Brown, and Randi S.
Cartmill. "The Effects of Computerized Provider Order Entry Implementation on
Communication in Intensive Care Units." International Journal of Medical Informatics.
U.S. National Library of Medicine, 5 Jan. 2015. Web. 12 Apr. 2015.
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3624062/>.
"International Journal for Quality in Health Care." Using an Enhanced Oral Chemotherapy

Computerized Provider Order Entry System to Reduce Prescribing Errors and Improve
Safety. N.p., 17 Nov. 2010. Web. 09 Apr. 2015.
<http://intqhc.oxfordjournals.org/content/23/1/36>.
"Medicares Failure to Track Doctors Wastes Billions on Name-Brand Drugs." Top Stories RSS.
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N.p., 18 Nov. 2013. Web. 31 Mar. 2015. <http://www.propublica.org/article/medicarewastes-billions-on-name-brand-drugs>.

"Medication Error Prevention for Healthcare Providers." Medscape, n.d. Web. 24 Mar. 2015.
<http://www.medscape.org/viewarticle/550273>.
N. "Nurses Views: Transitioning from a Best-of-Breed Clinical Information System to a OneVendor Electronic Health Record with Computerized Provider Order Entry."
Journal of Health Information Management 27 (2013): n. pag. 2013. Web. 09 Apr. 2015.
<http://lhco.ucsd.edu/wp-content/uploads/2014/09/Chow_Alice_fields-et-all-published2-013-Spring-2013.pdf>.
Survey, Leapfrog Hospital. FACT SHEET: Computerized Physician Order Entry(n.d.):n. pag.1
Apr. 2015. Web. 18 Apr. 2015.
<http://www.leapfroggroup.org/media/file/FactSheet_CPOE.pdf >.

"10 Innovative Clinical Decision Support Programs::Brought to You by TechWeb." TechWeb.

N.p., 19 Dec. 2011. Web. 21 Apr. 2015. <http://www.techweb.com/news/232300511/10innovative-clinical-decision-support-programs.html>.

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Appendix

Check box often utilized by doctors to insert orders for nurses to carry out within a
Computer Provider Order Entry Screen. Once this box is checked, a new screen
opens where doctors can write specific orders for nurses that may not have been an
option under the previously provided order sets for nurses.

Just 913 internists, family medicine and general practice physicians cost taxpayers
an extra $300 million in 2011 alone by disproportionately choosing name-brand
drugs. These doctors each wrote at least 5,000 prescriptions that year, including
refills, and ranked among the programs most prolific prescribers. (Medicares
Failure, 2013).

There are between 44,000 and 98,000 individuals who die every year in hospitals
due to preventable medical errors.[1] It has also been reported that this is only part of
the problem, as thousands of other patients are adversely affected by medical errors
or barely avoid injuries that are nonfatal.[2] These medical errors not only cost the
loss of lives, but carry a financial burden that is estimated to be in a range of $17
billion to $29 billion annually. Additionally, there is physical and psychological pain
and suffering related to these errors.[1] Another consequence is that medical errors
diminish trust and satisfaction in the healthcare system and in healthcare
professionals. (Medication Error, 2015).

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