COMPUTERIZED

PROVIDER ORDER
ENTRY
 • two reasons why CPOE is different from other
healthcare information technology implementations. 
State

• at least three common barriers to a successful CPOE

implementation. 
State

• at least three strategies to ensure a successful CPOE

OBJECTIVES
implementation. 
State

• at least two future possible directions of CPOE. 

State

• three core competencies required of the nurse

informaticist working with CPOE
State
 Introduction
C o m p u t e r i z e d p r o v i d e r o rd e r e n t r y ( C P O E ) , s o m e t i m e s
r e f e r r e d t o a s e l e c tr o n i c p r e s c r i b i n g , i s a c o m p u t e r
a p p l i c a t i o n th a t h e a l t h c a re p r o v i d e r s u s e t o e n t e r
o r d e r s or p r e s c r i p ti o n s i n t o a c o m p u t e r s y s t e m . I t i s
used in inpatient and outpatient settings to
electronically order medications, imaging studies,
l a b o ra t or y t e s ts , p ro c e d u r e s , a d m i s s i o n s , a n d r e f e r ra l s
( Co m p u t e r i z e d P r ov i d e r O r d e r E n t r y ( C P O E ) , 2 0 1 5 ) .

B e n e fi t s of t e n h i g h l i g h te d r a n g e f r o m t h e s i m p l e h e l p
o f p hy s i c i a n or d e r l e g i b i l i t y t o t h e m o r e c o m p l e x
d e c i s i o n s u p p o r t re l a te d t o a l l e r g y a n d i n t e r a c t i o n
c h e c ki n g , m e d i c a t i o n d o s i n g g u i d a n c e , a n d i n s o m e
c a s e s c u l m i n a t i n g i n a n o ve ra l l d e c r e a s e i n p a t i e n t
m o r t a l i t y a n d s i g n i fi c a n t fi n a n c i a l r e t u r n o n
i nve s t m e n t .
Two reasons why CPOE is
diff erent from other
healthcare information
technology implementations:

T h e fi r s t r e a s o n i s t h a t t h e “ P ” i n C P O E h a s
m o s t c o m m o n l y s t oo d f o r P r o v i d e r b u t w i l l
a l s o a p p e a r a s P hy s i c i a n o r P r e s c r i b e r. T h i s i s
w h a t m a ke s C P O E d i ff e r e n t f r o m b a s i c
e l e c t r o n i c o rd e r s u b m i s s i o n . T h e t r a n s c r i p t i o n
s t e p i s r e m o ve d , a n d t h e p r o v i d e r p l a c e s t h e
o r d e r d i re c t l y i n t o t h e s y s t e m . B y u s i n g
Provider it is also implied that the user
p l a c i n g t h e or d e r i s a u t h or i z e d t o g i ve or s i g n
t h a t o r d e r a n d l e a ve s r o o m f o r ot h e r
d i s c i p l i n e s i n a d d i ti o n t o p hy s i c i a n s w h o h a ve
a s c op e o f p ra c t i c e t h a t s u p p o r t s C P O E , s u c h
a s a d va n ce d p ra c t i c e n u r s e s a n d p h y s i c i a n
assistants.
Second, CPOE is also diff erent in that
it is inherently tied to a (clinical
decision support) CDS system that
enables the checking and presentation
of patient safety rules during ordering,
such as drug–drug interaction
checking, duplicate checking, corollary
orders, and dose calculations (Tyler,
2009). 
The “E” is also sometimes replaced by an “M”
a n d s t a n d s f or c o m p u t e r i z e d p hy s i c i a n or d e r
m a n a g e m e n t o r c om p u t e r i z e d p r o v i d e r o r d e r
m a n a g e m e n t , f u r t h e r i m p l y i n g t h a t t h e s e or d e r s
are no longer once and done, but will require
o n g o i n g re v i e w a n d u p d a t i n g i n t h e c o n t e x t of
r u l e s , a l e r t s , a n d o th e r f e e d b a c k m e c h a n i s m s a n
E H R m a y p r ov i d e t h a t p a p e r a n d p e n c a n n o t .
Management of an order also implies that it is
m o r e th a n s i m p l y e n t e r e d , b u t a l s o
communicated to other care team members,
r e v i e w e d , a n d a ct e d u p o n .  
State at least three common barriers to
a successful CPOE implementation.

Those at greatest risk include small, primar y care

practices, frequently owned by physicians and with some
evidence suggesting a greater propor tion of patients
that are Medicaid, minority, or uninsured (Ryan, Bishop,
Shih, & Casalino, 2013).  

These sites frequently do not have the practical

knowledge to implement a CPOE system, apply quality
improvement methods to achieve benefi ts from it, or
sustain maintenance.
•Critical access and smaller hospitals are
also at risk due to a low patient volume
that limits the organization’s ability to
apply operational resources to a CPOE
implementation, recruit and retain skilled
IT personnel, and diffi culty fi nding a
suitable vendor that can successfully
accommodate these limitations
(Desroches, Wor zala, & Bates, 2013)
• T h e l i t e ra t u r e a l s o s u g g e s t s t h a t “ fo u r m a i n d r i ve r s i n fl u e n c e a
providers’ decision on electronic health records:  

1. a ff o r d a b i l i t y ;  

2. p r o d u c t a va i l a b i l i t y ;  

3. p ra c t i c e i n te g ra t i o n ;  

4. a n d p r ov i d e r a t t i t u d e s .  

• H I T E C H a d d r e s se s t h e fi r s t t h r e e , b u t p r o v i d e r s ’ a t t i t u d e s [ t h a t a r e ]
c r i t i c a l t o t h e s u c c e s s o f t h e a c t , a r e b e yo n d t h e l e g i s l a t i o n’s c o n t r o l ”
( G o l d , M c L a u g h l i n , D e ve r s , B e r e n s o n , & B o v b j e r g , 2 0 1 2 ) . A n d t h a t
d e s p i t e e st a b l i s h e d b e n e fi t s o f a n E H R ; t h e i m p l e m e n t a t i o n c a n s t i l l b e
d i s r u p t i v e a n d r e q u i r e a s t e e p l e a r n i n g c u r ve fo r p r o v i d e r s t o u s e t h e
fe a t u r e s e ff e c t i ve l y ( R ya n , B i s h o p, S h i h , & C a s a l i n o, 2 0 1 3 ) .
Three strategies to
ensure a successful
CPOE implementation. 

Written in 2000, A Primer on Physician

Order Entry cited executive leadership,
physician involvement, a multi-
disciplinary approach to
implementation, good EHR system
response time, and fl exible training
strategies as the keys to a successful
CPOE implementation (Drazen,
Kilbridge, Metzger, & Turisco, 2000).
 There is an eight
specifi c
building hiring staff that setting realistic ensuring there is
relationships to gain understand the expectations and enough physical implementation
the trust of domain of the obtainable goals space for hardware
providers that will physician practice so that providers approaches that
support the change may work effectively
were reinforced by a
more recent study
that focused on
assisting those
provider practices
aligning the developing a planning for creating a
organization’s vision business case to provider practice sustainable support most at risk for
with the goals of the identify the redesign model for ongoing
implementation expected benefits of improvement efforts successful CPOE
CPOE
adoption:
Two future
possible directions
of CPOE. 
a. The increased number of providers using CPOE
alone will change the course of future development in
this area, not to mention advances in software,
hardware, and interoperability standards. 

As coordinated care becomes the gold standard for

healthcare delivery, pharmacists and nurses are
working to their full scope of practice and partnering
with physicians to facilitate key CPOE processes such
as medication reconciliation and orders management.
Pharmacists and
pharmacy techs:  
•are collecting medication history

•dispensing discharge prescriptions to

ensure continuity of care

•educating patients on medication

management.
Nurses and other inter-disciplinary team
members (respiratory therapists & nutritionists)

Are now not only clarifying orders and

implementing prescribed interventions, but are
also making recommendations through order
entry as pended, protocoled, or suggested sets
that a physician may accept or decline.  

This collaboration will only continue to grow and

will support both improved provider productivity
with CPOE and greater accuracy in the plan of
care for a patient.
b. Increasing patient engagement is another core
component to healthcare reform and may include a
new role for patients in the future of CPOE. Although
medication reconciliation has historically been the
domain of providers, a recent pilot study conducted by
the VA Boston Healthcare System enabled patients to
electronically verify their medication list post-
discharge. This virtual medication reconciliation
avoided potential adverse drug events and reinforced
the patient’s desire to partner directly with their
physician in all aspects of their care (Heyworth et al.,
2014).
 Three core competencies required
of the nurse informaticist
working with CPOE:
a. Application level knowledge represents the
ability to assemble the building blocks of a
clinical information system in the most
eff ective way to meet the needs of the end
user.

•As discussed, the nurse informaticist as

consultant will also possess the domain
knowledge of CPOE workfl ows and clinical
process that is essential for successfully
translating and aligning the needs of the end
user, the patient, and the healthcare organization
into the application, and leveraging its features
and functions to meet those needs.  
b. The nurse informaticist as consultant can also assess
the need for and establish a change management plan for
CPOE. These skills are also learned by nurses early in
their clinical careers, as they relate to providing patients
with education about their plan of care. This may include
anticipatory guidance for changes large and small to a
patient’s lifestyle, daily routine, relationships, and
perception of themselves. The nurse’s ability to establish
a healthy, trusting relationship with the client is at the
core of successful patient education.
c. En sur in g a u sa bl e s y s tem th at pr om otes
pa ti en t s af et y a nd pr ov i de r a dopt ion is
a noth er pr im a r y re qu ire m en t for th e n urs e
in for m at ic is t i m ple m en tin g CPOE . Fa m il ia ri ty
wit h t he h eu ris ti cs of us abi li ty al ong with
th e abi li ty to as ses s com m on hi g h- ris k a nd
hi gh-volu m e us e c a ses f or u ni nt ende d
con se que nc es wil l en sur e tha t ben efi t s of t he
imp lem e nt at ion a re re al iz ed re lia bl y a n d
wit hout c au si ng un due h ar m .  
REFERENCE

Computerized provider order entr y (CPOE) . (2015,

May 1). County Health Rankings & Roadmaps.
https://www.countyhealthrankings.org /take-action-to
-improve-health /what-works-for-health /strategies /co
mputerized-provider-order-entry-cpoe