Journal of the American Medical Informatics Association

Volume 11

Number 2 Mar / Apr 2004

125

Letter to the Editor

Computerized Physician Order Entry Systems: Is the Pharmacists Role Justied?

J Am Med Inform Assoc. 2004;11:125126. DOI 10.1197/jamia.M1469.

In their recent commendable article, A Cross-site Qualitative Study of Physician Order Entry, Ash et al.1 concluded that collaboration and trust among organizational members and active engagement of clinicians are important factors in successfully implementing computerized physician order entry (CPOE) systems. The article contributed to our understanding of the reasons behind physicians resistance and the factors that might promote successful CPOE implementations. Although the article mentioned pharmacists as team members, their role was not described explicitly. We would like to recommend active incorporation of clinical pharmacists in the health care team involved in using CPOE. Well-designed CPOE systems can improve the safety of patient care and reduce health care costs24 caused by medication errors. Yet, as the authors of this study mention, many physicians have been reluctant to use CPOE.1,69 From the physicians perspective, CPOE generally takes more time than writing prescriptions on paper.6,9 Hence, most physicians still prefer the traditional method. It is important to note, however, that the CPOE process is a two-way communication between the physician and the pharmacist. If the physician is resistant to the process, perhaps the pharmacist is not. At Vanderbilt Medical Center, pharmacy staff contributed to the development of particular features of CPOE, such as drug information, dosing regimens, and protocol design.5 Similarly, clinical pharmacists are actively involved in the development of CPOE systems in many other institutions and already have hands-on experience in operating CPOE. Using services of clinical pharmacists can solve the dilemma of physician resistance toward CPOE systems. Clinical pharmacists usually undergo training in drug therapy management and clinical pharmacotherapy through a sixyear doctoral program. Most clinical pharmacists also are

trained through general residency programs and at times specialized fellowships. Many health care systems in the United States currently use clinical pharmacists to avoid medication errors. We recommend a team approach involving physicians, clinical pharmacists, and other health care members for successful implementation of CPOE. In our proposed approach, pharmacists would accompany physicians during their hospital rounds, discuss appropriate medication use for individual patients, and then enter the orders electronically. The drug-use process begins with physician prescribing and is followed by pharmacy review, dispensing, distribution, actual drug administration, and charting. If pharmacists enter the prescribing order directly into the electronic system, the system might automatically provide a secondary review of prescription orders and reduce some medication errors. (Note the clinical pharmacist would enter the order and the dispensing pharmacist would ll it). This new role in computer-aided pharmacist order entry (CphOE) is the best opportunity for pharmacists to expand the boundaries of their work and go beyond the traditional role of dispensing and counseling. Implementing CphOE will also help physicians to concentrate more on their primary responsibilities of diagnosis and patient care. Physicians experience the burden of other responsibilities, distractions, and interruptions while making order entries. As a result, physicians may tend to overlook the clinical alerts such as drug allergy, drugdrug interaction, dosage checks, and duplicate therapies when entering multiple orders in the CPOE system. The enhanced interaction between the physicians and pharmacists would lead to the most effective patient care system.10 CphOE would reduce the time spent by pharmacists in contacting physicians regarding clinical alerts because a clinical pharmacist would be present at the point of order process. Any problem regarding the therapy or medication could be resolved immediately by a discussion between a clinical pharmacist and a physician. CphOE would be helpful for the nursing staff too. The nursing staff is involved in verifying and maintaining medication administration records (MARs). They do so by comparing the pharmacist-generated MAR and the physicians order. In the new system of CphOE, clinical pharmacists would do the order entries along with updating administration records. This would reduce the workload for nurses because they no

Afliation of the authors: Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston, Houston, TX. Correspondence and reprints: Sujit S. Sansgiry, PhD, Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston, Texas Medical Center, 1441 Moursund Street, Houston, TX 77030; e-mail: <ssansgiry@uh.edu>. Received for publication: 10/02/03; accepted for publication: 11/21/03.

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longer would have to compare the administration records generated by the pharmacists and order entries by physicians. Further, with CphOE, pharmacists would have active participation in the entire medication use process, thus they would be in the position to educate patients in the acute care setting. Traditionally, the job of patient education is assigned to the nursing staff. Pharmacists active participation in the medication use process, as in CphOE, would allow them to help nursing staff to educate patients either directly or indirectly by helping the nursing staff to enhance their medication knowledge. Although it is probably naive to recommend this role for clinical pharmacists, CphOE would certainly provide clinical pharmacists an opportunity to offer such services. Diane L. Seger, a pharmaco-informatics specialist at Clinical Systems Research and Development, Partners Health Care System, Boston, Massachusetts, has suggested a key role for clinical pharmacists in management of medication knowledge within CPOE systems where they can engage in designing and implementing such computer-based intervention projects.11 Seger states that The new role represents an opportunity for clinical pharmacists to move beyond traditional patient care and into clinical information systems, decision support, and information management. We think it is necessary to dene another new role for pharmacistsCphOE. With the support and active involvement of pharmacists, systems such as CphOE will successfully make their way into health care systems. Ash et al.1 stated that CPOE implementation is not an overnight success; it will take time, but we believe that pharmacists are ready to take on this role. Once accepted, pharmacists may prove to be the most suitable professionals to carry out the computerized order entries.

BHOSLE, SANSGIRY, Pharmacists Role in CPOE

1. Ash JS, Gorman PN, Lavelle M, Payne TH, Frantz GL, Lyman JA. A cross-site qualitative study of physician order entry. J Am Med Inform Assoc. 2003;10:188200. 2. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277:30711. 3. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:131164. 4. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc. 1999;6:31321. 5. Shapiro K. Whats New in Computerized Prescriber Order Entry? 36th Annual ASHP Midyear Clinical Meeting, Nov 811, 2000, Washington, DC. 6. Ash JS, Gorman PN, Hersh WR. Perceptions of house ofcers who use physician order entry. Proc AMIA Annu Symp. 1999: 47175. 7. Langberg M. Challenges to implementing CPOE. Modern Physician. 2003. Available at: http://www.modernphysician. com/page.cms?pageId=216. Accessed Oct 2003. 8. Sittig DF, Stead WW. Computer-based physician order entry: The state of the art. J Am Med Inform Assoc. 1994;1:10823. 9. Weiner M, Gress T, Thiemann DR, et al. Contrasting views of physicians and nurses about an inpatient computer-based provider order-entry system. J Am Med Inform Assoc. 1999;6: 23444. 10. Mcdeonough RP, Doucette WR. Dynamics of pharmaceutical care: developing collaborative working relationships between pharmacists and physicians. J Am Pharm Assoc. 2001;41: 68292. 11. Seger DL. Computerized POE: changing roles for the clinical pharmacist [editorial]. J Am Pharm Assoc. 1999;39:710.