CPOE Teams: A Prescription for Pharmacist Intervention.

Abstract

In 2010, roughly 1 in 5 hospitals had implemented computerized provider order entry (CPOE).1 Hospitals are expected to meet the standards for Meaningful Use in order to avoid paying penalties, therefore the number of hospitals adopting CPOE is expected to increase dramatically. What this means for physicians is relatively clear; the way they order medications will change from a paper medium to an electronic one. How to improve physician acceptance of CPOE and factors influencing their use of such systems is well documented. The switch to CPOE for pharmacists, however, is more than a just an exchange of mediums; rather, it is a sweeping transformation in practice and, for some, it creates a need to justify their continued employment. Despite these far-reaching effects on the practice of pharmacy in institutions, pharmacists are not always granted a significant or early position on CPOE implementation teams. Pharmacists are uniquely positioned in the hospital system to see aspects of a CPOE system that no other member of the health care team sees and will likely encounter alerts that no other group will be required to address. In 2001, when CPOE was beginning to take hold and before residency-trained clinical pharmacists were commonplace in hospitals, the American Society of Health-System Pharmacists (ASHP) developed a list of recommendations to address pharmacists’ roles in the implementation process.2 Many things have changed since that list was initially released. CPOE systems have become more sophisticated, and the number of functions they can and should perform has multiplied. The pharmacist’s role will shift from being predominantly order entry toward primarily providing direct patient care. That means the need for pharmacists’ early involvement in CPOE implementation is even greater because pharmacists will be using all aspects of the system and not just processing orders. Clinical and dispensing pharmacists should be involved in choosing and developing the institution’s CPOE system. Both play an important part in the effective functioning of a pharmacy department and both bring unique insights into the process. Clinical pharmacists understand workflow in the context of direct patient care and must be able to enter orders into the system on behalf of the physician; they also need access to the full array of alerts and decision support tools that can impact drug-drug interactions, dosing, allergies, and more. Dispensing pharmacists may not always need the full array of clinical tools, but they frequently have a greater understanding of order verification and may often be called upon to ensure that complex or unusual physician-entered orders are processed in a manner that will be clearly understood by the nursing staff. Dispensing pharmacists and clinical pharmacists both need ready access to more than just the prescription ordering aspects of a CPOE system. To accurately assess presented alerts, pharmacists need easy access to laboratory results, chart notes, and even administration records. Given the breadth of information that pharmacists need to provide comprehensive patient care, they should be recruited from both the clinical and dispensing areas of the pharmacy department when the initial steering committee is formed. CPOE vendors will provide information about their systems and often will provide on-site demonstrations to promote their products. This is a prime time for pharmacists to test the capabilities of a system they will use on a daily basis and to see what the alerts and other clinical decision support tools look like and assess their usability. The preparation of specific scenarios prior to such demonstrations allows for consistency in testing possible CPOE systems and ensures that all functions are usable from the pharmacist’s perspective. This is where the inclusion of clinical and dispensing pharmacists on the CPOE team becomes imperative. A clinical pharmacist with little experience working in order entry/verification may miss limitations inherent in a system that a dispensing pharmacist would catch because of the differences in how they would normally interact with the CPOE system. It is easy to overlook all the components of a CPOE system to which a pharmacist may need access in order to provide appropriate patient care, and it is even easier to think that the most important group for system approval are physicians. CPOE represents a fundamental shift in how hospital pharmacists practice, and their stake in the success or failure of the system is not to be ignored. Pharmacists, both clinical and dispensing, must be involved in the selection and implementation of a suitable CPOE system from the start of the process to make sure that their needs are appropriately addressed. Attempting to implement a CPOE system without a clearly written prescription for both clinical and dispensing pharmacist involvement in the entire process, can slow adoption and acceptance of the system and can also lead to reductions in job satisfaction and increased patient safety risks.