Electronic Orders

1. ElectronicOrders By Andrew McLuckie NURS457 Fall, 2008

2. Objectives • Describe the electronic orders process • Describe and evaluate related hardware and software • Describe and evaluate nursing information systems using electronic orders • Assess the role and functions of the nurse using electronic orders • Examine related legal or ethical issues • Discuss the nursing advantages and disadvantages

3. Electronic Orders Defined • “Electronic Orders” refers to physician orders that are entered electronically rather than written on paper • They may be entered remotely on a computer network • In some facilities, they may be entered over the internet

4. Increased Safety By entering orders electronically, there is less opportunity for orders to be misunderstood

5. Increased Safety A study led by David Bates MD, Chief of General Medicine at Boston’s Brigham and Women’s Hospital, demonstrated that CPOE (Computerized Physician Order Entry) reduced error rates by 55% — from 10.7 to 4.9 per 1000 patient-days. Rates of serious medication errors fell by 88% in a subsequent study by the same group. (Leapfrog Group, 2008)

6. Application Integration By using electronic ordering, the entire collaborative healthcare team can view orders and results quickly and with greater relevance.

7. Hardware Used in Computerized Physician Order Entry CPOE applications can be accessed through the hospital intranet.

8. HardwareUsed in our Facility The hospital where I work uses numerous workstations, all connected to the hospital intranet for documentation purposes. In the near future, CPOE will occur at these servers, and via Virtual Private Network (VPN) over the internet for off-site physicians.

9. Hardware Used in our Facility Each workstation has access to the Soarian documentation system, MAK medication administration software, and OAS Gold / Invision for patient results.

10. Software • Numerous software packages exist to provide order entry into a clinical documentation system. • The two software systems I have used personally are Cerner Millennium and Soarian by Siemens. • Another new electronic charting package, PatientOS, has also recently included a CPOE module (PatientOS.org, 2008)

11. Usability • Both software platforms have strengths and weaknesses • The hospital system for which I work uses both • Cerner is used by the hospital just acquired by the group, Soarian in the other four • Replacing Cerner was deemed too costly, so it will be used through license expiration • Both platforms conform to Staggers’ Three Axioms of Usability. They include nurses in system design and development, have evolving design through creative input from nurses, and quantitative measure of usability, primarily through super-users. (Staggers, 2003)

12. Cerner Millennium • Cerner’s software is more user-friendly and intuitive, with “dashboard” displays of overall pertinent information about a patient.

13. Soarian Soarian is more content-driven, with a heavier reliance on laboratory data and interaction with other software packages in a client-server format.

14. Information Systems • The information system in use at our facility is an integrated intranet with multiple data sources • Input is gathered from Nursing, Admissions, Physical Therapy, and Physicians through direct human input of data in Soarian • Ancillary sources also enhance the data collected though not directly connected to the intranet

15. Laboratory • Laboratory results populate within Soarian through the intranet • Results are formatted and compiled within the lab’s own software, which then uploads the results to Soarian • The lab software and Soarian are completely separate parallel systems

16. Ancillary Systems There are a number of devices in our facility that report to Soarian wirelessly through the intranet: • Glucose Monitors • EKG Machines • Telemetry Monitors • IV Pumps

17. Advantages of Electronic Charting • Real-time access to medical, nursing, pharmacy, and laboratory records • Improves patient safety • Increased productivity • More thorough documentation • Less confusion • “Standardized order sets, decision support tools, and other customized methods can make hospitalists' jobs easier—if the system is well-designed”. (Beresford, 2008)

18. Disadvantages of Electronic Orders • Resistance by MDs to change. In 2003, Cedars-Sinai Medical Center had to shut their CPOE program down due to a Luddite-like rebellion by doctors. (Beresford, 2008) • Slow data entry • Restrictions on language and diagnoses that can be used • Dependence on software • Downtime occurrences disrupt care

19. Ethical and Legal Issues • Difficulty maintaining confidentiality • Increased opportunity for unintentional HIPAA violation • Data network vulnerability • “The cornerstone of a good patient record system, without regard to the storage medium used, is reliability and security.” (Chhanabhai, 2007)

20. Competencies required of Nurses using Electronic Orders • Familiarity and fluency with NIS software • Integration of ancillary reporting devices through NIS into practice • Willingness for continual improvement and further implementation as systems evolve.

21. Functions and Responsibilities of Informatics Nurses • Advocate for NIS implementation and education in the workplace • Evaluation of new technology and applications • Continuous improvement from user feedback • Collaborative input with IT for future needs • Analysis of outcomes as related to technology integration

22. Summary Electronic Orders provide for increased patient safety, fewer adverse drug errors, and increased nursing efficiency.

23. Summary “It is a given that information technology will continue to be integrated and applied to nursing practice and health care in general. It does so in both visible and invisible ways and permeates nursing more and more with each passing year. It is important that nurses gain knowledge of all of the benefits and implications of this techno-saturation” (Kaminski, 2006)

24. References PatientOS.Org (2008, November 28). PatientOS physician documentation version 0.85 released. Retrieved December 5, 2008, from http://www.patientos.org/phpBB3/viewtopic.php?f=5&t=222 Chhanabhai, P. (2007, January 11). Consumers are ready to accept the transition to online and electronic records if they can be assured of the security measures. Retrieved December 7, 2008, from Medscape for Nurses. http://www.medscape.com/viewarticle/549468 The Leapfrog Group, (2008, April 9). Computerized physician order entry. Retrieved November 2, 2008, from Computerized physician order entry Web site: http://www.leapfroggroup.org/media/file/Leapfrog- Computer_Physician_Order_Entry_Fact_Sheet.pdf Staggers, N. (2003, August). Human Factors: imperative concepts for information systems in critical care. AACN Clinical Issues, 14(3), 310-319. Retrieved September 3, 2008, from Pennsylvania State University Library System Web site: http://reserve.libraries.psu.edu.ezaccess.libraries.psu.edu/nurs/457/45721.pdf Beresford, L. (2008). High-tech nightmare -- Computerized order-entry systems can make hospitalists' jobs easier -- but barriers often are formidable.The Hospitalist. Retrieved December 7, 2008, from Medscape for Nurses. http://www.medscape.com/viewarticle/571964 Kaminski, J. A revealing of nursing informatics. 2006.Retrieved November 27, 2008, from nursing-informatics.com Web site: http://www.nursing-informatics.com/revealing/antithesis.html