The Meaningful Use 2 requirement, “Use computerized physician order entry (CPOE)” is commonly misunderstood and warrants further clarification. Many organizations have misinterpreted this statement to mean only physicians or other providers can keyboard in test codes for lab and radiology orders, only physicians can send prescriptions to the pharmacy, and that all prescriptions sent by a nurse at the doctor’s direction require co-signature by the physician. This has placed physicians in a thicket of electronic busywork, and needlessly added hours to many primary care physician’s work day.
CMS is very clear that keyboarding in orders for medications, labs and radiology tests does not have to be a physician function. “Any licensed healthcare professionals and credentialed medical assistants, can enter orders into the medical record for purposes of including the order in the numerator for the objective of CPOE if they can originate the order per state, local and professional guidelines.”
We know we are spending our time on the wrong things, and it is a contributor to burnout. One physician told me she can no longer verbally ask her nurse to do an ear wash, but must first go to the computer to type in an order. Another physician reported it takes several minutes just to enter a mammogram in her system. An OB/GYN said she must now create and sign an order for every pregnant woman to take pre-natal vitamins. Many physicians have told me that they just can't take the time to pre-order lab for the next visit even though they know it would save time in the long run and result in better patient care. They are already running behind and can't bear to spend 2 more minutes putting in a future order for an A1c. This waste of physician time on clerical tasks crowds out more valuable work and more efficient workflows.
In our own practice it takes 3 seconds for the physician to order the next steps, including labs and radiology tests on a paper check-list, and 2 minutes to do this work electronically. This can add up to an hour a day of physician time spent on work that others could do. Translate this into access, and it comes at a cost of 3-4 patients per day. Translate this into revenue and it costs almost $60-100,000 per physician per year. Translate into job satisfaction--priceless. Most physicians don't go through medical school and residency for a data entry position.
Policy makers who propose to require that physicians keyboard in all orders see this as a way to mandate physician exposure to point-of-care clinical decision support. While well-intended, such policies inappropriately generalize data from one setting (i.e. decision support to increase medication safety in a hospital setting) to another (ambulatory practice.) In my practice the top 30 tests ordered include glucose, lipids, A1c, Cr, Na, K, INR, microalbumin, mammogram, TSH, hemoglobin, tests that do not require intrusive point-of-order decision support for each act of order. The most common tests that could potentially benefit from point-of-care CDS are CT abdomen (at # 56 on the list) and MRI spine (at # 77), each represent less than 0.1 % of all tests ordered.
No intervention, even CPOE, is without risks. I believe there are hazards in applying a work burden to 100% of orders when less than 0.1% may have useful CDS, and even in these very few, most CDS alerts will not result in a change in the test ordered.
Team-based care involves a willingness to rely on team members to do work for which they are capable, and to preserve physician effort for the work for which they are uniquely capable. One does require advanced clinical education to decide what tests to order for a given patient, but one doesn't need 11 years of post-high school education to type those orders into a computer. Other team-members can be entrusted to do this work. Doing otherwise is to waste healthcare resources.
Our federal and institutional policies, and our technologies should support a comprehensive notion of team-based care, that includes assistant order-entry. Furthermore, institutional leaders should understand that MU2 explicitly allows non-providers to enter medications, lab and radiology tests and have it count for MU2 measurement. We can't let mis-interpretation of MU2 get in the way of physicians' meaningful work.
In “Redesigning Hospital Alarms for Patient Safety: Alarmed and Potentially Dangerous” the authors report that bedside alarms were first developed to provide benefit to an exceedingly small group of high-risk patients….Encouraged by (early) benefits, the medical community expanded this model to other low-risk populations. The consequence of this well-intentioned generalization is epitomized in the din of chirps, beeps, bells and gongs that typify hospitals today. It is not surprising that concerns regarding safety have emerged.
I believe a parallel situation exists with CPOE. CPOE may be appropriate for an exceedingly small group of high-risk orders. Encouraged by belief in benefits, policy makers have expanded CPOE to a large population of low-risk orders. The consequence of this well-intentioned generalization is a time sink of drop-down boxes, slow page loads, and mandatory, sometimes no-exit decision control (not decision support) frustrations. A din of chirps, beeps, bells and gongs typifies the physicians mental space while caring for patients. It is not surprising that concerns regarding safety have emerged.