Certified Provider Order Entry (CPOE): To scribe or not to scribe…

The healthcare industry of today is in the birth-pains of change as a complete overhaul of technologies is occurring to meet the increasing demands placed on healthcare professionals globally. The CMS coined term, “Meaningful Use” and all that it implies is unarguably the most crucial, dynamic, and driving force of any new healthcare technology on the market today. These technologies have many promising aspects in what they offer doctors and healthcare organizations however; there are still many concerns both logistically and technologically that can and does occur in the implementation and adoption of such systems.

Electronic medical records and devices have become capable of accessing large medical databases and extrapolating and manipulating data to the benefit of both purveyors of healthcare and those that provide healthcare services. Computerized provider order entry (CPOE) technology has been used in different intervals in the various and numerous fields of healthcare. A good example would be a retail pharmacy where its operations revolve around CPOE technology and that of e-scribe.

What is CPOE? According to AHRQ, “CPOE is an application that enables providers to enter medical orders into a computer system that is located within an inpatient or ambulatory setting. CPOE replaces more traditional methods of placing medication orders, including written (paper prescriptions), verbal (in person or via telephone), and fax. Most CPOE systems allow providers to electronically specify medication orders as well as laboratory, admission, radiology, referral, and procedure orders. On its own, CPOE has an impact on safety by ensuring that orders are legible. Yet the value of this functionality is increased by adding clinical decision support (CDS) systems. CDS is a technology that provides clinicians with real-time feedback about a wide-range of diagnostic and treatment-related information as they are entering electronic orders. By running electronic rules in the background, decision support can check for a variety of potential errors. Examples include drug interactions, patient allergies to prescribed medications, medication contraindications, and renal- and weight-based dosing.”

How does it work? Patients go to their pharmacy of choice with a prescription for a medication (or if their provider is on an e-Scribe system their script is sent electronically to their pharmacy of choice) where the pharmacist and support staff attempts to gain as much clinical and diagnostic information as possible. Pharmacy technicians immediately enter pertinent information for that prescription order, being as careful as possible to avoid mistakes, miscommunications, and other dangerous errors that have the potential of causing serious drug reactions, dispensing the incorrect medication, or dispensing the incorrect dosage of the ordered medication. The logistical issue that is present here is the amount of technological intervention to assist treating each patient in large healthcare facilities, such as hospitals, same day surgical centers, and ambulatory clinics.

Hospitals are sought out more so by designers of CPOE technology because of the large amount of patients treated and the amount of medical information needed to help diagnose patients. Technically speaking, computerized provider order entry technology is the use of an institutional computerized health record by physicians to enter their orders electronically. Current statistics indicate that approximately eighty percent of physicians input patient data themselves. However, this begins to be problematic when there are increasing numbers of patients and not enough support staff to assist operations or the incorrect data is entered. There is also a growing concern relating to the use of scribes by providers and in-fact The Joint Commission (TJC), while it does not endorse nor prohibit the use of scribes, has released the following guidelines for the use of scribes:

•  Scribes can now work for a PA or NP
•  The job description must include unlicensed status and clearly define the qualifications and extent of the responsibilities
•  Orientation and training specific to the organization and role
•  Competency assessment and performance evaluations must exist
•  If employed by the physician, all non-employee HR standards also apply
•  If provided through a contract service then the contract standard also applies
•  Meet all information management standards, HIPAA regulations, HITECH regulations, confidentiality and patient rights standards

It is the Joint Commission’s stand that the scribe does not and may not act independently but documents the physician’s or licensed independent practitioner’s dictation and/or activities.

The physician sees the patient and then enters whatever orders are to be completed (for example labs, dietary plans, medications). Most physicians have standardized orders they use often. Seasoned scribes and long-term employees that are very familiar with the physician’s ordering pattern are not allowed to enter these orders on the provider’s behalf. Thus the concern that healthcare workers that are not licensed as providers will be entering orders. It is vitally important in any CPOE environment for only licensed providers be able to order via the CPOE module—I also highly recommend that fail safes such as random security checks, short duration passwords, and constant reeducation regarding compliance are put into place.

The leading benefit of CPOE technology is the ability to catch as many clinical, diagnostic, financial, or administrative errors in the electronic medical record as possible before any negative consequences or harm is visited upon the patient. According to Karen J. O’Connor, (member of HIMSS’ Board of Directors) the benefits of CPOE include, “Implementing computerized physician order entry (CPOE) systems in urban and suburban hospitals could save 60,000 lives, prevent 500,000 serious medication errors, and save $9.7 billion each year.”

According to a scientific analysis of hospital settings (provided by HealthIT.gov), facilities have experienced dramatic decrease in wait times for radiology reports, laboratory data, and even medications for each patient. Analytical statistics indicate that CPOE technology has reduced clinical errors from fifty-five percent to a dramatic seventeen percent in a ten-year range. This technology actually increases the amount of quality care each patient receives, as well as the time spent acquiring vital information needed for diagnosis and treatment. CPOE technologies not only increase the amount of accurate communication between healthcare providers, but provide real time alerts to assist in the decision making process for each patient and provide reminders for providers of future tests required at a later date. With the addition of predefined order sets that incorporate evidence based practice and articles for providers to review related to the current healthcare condition their patient is experiencing, this puts the power of the internet and proven methodologies at the provider’s fingertips. Although there are several benefits associated with this new technology historically many hospitals and healthcare organizations have been hesitant to employ its use. However, now with the addition of the Meaningful Use requirements and certain new legal statutes from both a state and federal perspective—the choice not to move to a CPOE supportive EMR system is no longer an option.

The amount of money that needs to be invested in such technology far exceeds the budgets of many healthcare facilities. Furthermore, the transition from older technologies to CPOE technology may cause disturbances in the amount of patients that healthcare workers treat on a daily basis. There is a fair amount of education and training needed to show all medical professionals how to navigate through the program to allow for optimal work efficiency. Accordingly, a detailed analysis of in-patient hospital operations shows that less than fifteen percent of hospitals are actually using this new technology. As time wears on and technology evolves along with strict federal mandates governing this industry, hospitals will see less issues and more benefits associated with computerized provider order entry technologies.

In this time of difficult transition to electronic systems for healthcare organizations, hospitals, and providers it is wise to enlist the aid of subject matter experts in the field of healthcare technology. The investment of resources (time, cost, equipment, human capital) to accomplish what is needed for a successful implementation and continued sustainability with system-wide adoption to achieve the maximum return on investment requires both technical and clinical expertise.  Having the right individuals in the key positions of your CPOE project with the mix of skill sets and actual experience of successful go-lives and implementations behind them is critical to your success. Lastly, never let the focus of the project slip from being a provider-driven, provider-focused project. It is absolutely vital to have the providers engaged and involved at each step and phase of the project!




See research statistics posted by The Leapfrog Group on its website at


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