Inspired-EHRs-Designing-for-Clinicians

5

E-Prescribing and

Computerized Physician Order Entry (CPOE)

E-Prescribing offers an opportunity to improve user accuracy and efficiency, a satisfying experience.

E-Prescribing (eRx) can be one of the most satisfying tasks of the physician because it saves the duplication of effort involved in hand-writing prescriptions, updating the list of medications, and including the changes in the office notes. E-Prescribing can also be frustrating when the EHR does not provide adequate data entry support. E-Prescribing offers the opportunity to reduce the medication errors that can result from pharmacists misreading prescriptions, dispensing an incorrect dose, or even prescribing the wrong drug because its name was similar to the name of the drug the physician actually intended.

The back-end process of e-prescribing sends discrete electronic data to a central hub, which then distributes the prescription message to the target pharmacy electronically (or via fax, if the target pharmacy lacks e-prescribing capabilities). The pharmacy can also send messages for renewal request to the prescribing physician. A new feature, not yet widely adopted, allows prescribers to send a message electronically to a pharmacy to cancel a previously prescribed medication or prescription.

Clinical Scenario — New prescription for Newly Diagnosed Diabetes

Mr. Martin is a 60-year-old construction supervisor. Three months ago, he was diagnosed with diabetes by Dr. Barnes, his family physician. Despite some healthy lifestyle changes, his weight is unchanged. His fingerstick blood sugars are improving, but are still too high at around 200. His goal is 80-140.

Dr. Barnes wants Mr. Martin to take a new medication named metformin to control his blood sugar. Together they look at the EHR screen and see that metformin is on Mr. Martin’s insurance formulary, and has the lowest-tier co-pay. Both are pleased. Mr. Martin wants to start with just a 30 day prescription from his local pharmacy in case he has any side-effects. The new prescription is sent electronically to the local pharmacy.

5.1 Searching for a New Medication

Typically, physicians will have a particular medication in mind when they write prescriptions. In that case, choosing from a “favorites” list or searching for the drug are the quickest routes to new prescription. An EHR can help physicians make the right choices and enter the correct details. In most cases, having the EHR pre-populate the prescription forms will save physicians time and mental effort (cognitive load), and will reduce the risk of errors. It will help the physicians’ search speed and accuracy if the EHR pre-populates the search results from the drug database as the physician types. A predictive algorithm that uses data from the Problem List or Diagnosis List is able to promote likely matches farther up the search result list.

5.1.1 Prescribing a New Medication

Once a physician finds the medication she's looking for, she needs to manage additional details like adding or reviewing the dosage strength, instructions, quantity to dispense, and number of refills to authorize. A thoughtful design will pre-populate fields associated with the medication with, possibly, the instructions for the usual starting dose. The EHR system could recommend a physician’s frequently-used choices or favorites. For a returning patient, it could recommend their chosen pharmacy.

In the United States, health insurance plans often include drug formularies, which are a list of prescription drugs that will be covered by the insurance plan. Within the formulary, the drugs are grouped into a tier assignment that determines the patient’s portion of the drug cost. A typical plan includes 3 or 4 tiers:

• Tier 1 usually includes generic medications (the least expensive)
• Tier 2 usually includes “preferred” brand name medications
• Tier 3 usually includes “non-preferred” brand name medications
• Tier 4 usually includes specialty medications (the most expensive)

If the system knows the patient’s pharmacy benefit plan, it can display the associated formulary information, indicating the tier information at a glance. Also, the system can allow the prescriber to view more detail on demand.

An EHR that provides these details reduces the mental effort a physician needs to expend to accomplish this task, and thus reduces their cognitive load. This EHR can also enhance patients' safety by eliminating physicians' distractions and reducing the margin for error.

An EHR can allow a physician to renew multiple medications at the same time. This saves time and reduces the margin for error. Designing an EHR that can sort and filter the medication list by “renewal due date,” “pharmacy” and “prescribing physician” will minimize physicians' cognitive load and allow them to provide better patient-centered service.

Patients with multiple prescriptions and prescribers are often burdened with poor refill synchronization. Their refills come in on several different dates each month, and their annual renewal due dates are scattered throughout the calendar year. If physicians could easily discern which prescriptions require renewal before the next planned appointment, the physicians could consolidate their patients' prescriptions. This would reduce the physicians' workload and would be more convenient for the patients¹.

Designers could allow users to easily modify existing prescriptions, preserving existing details and offering easy access to common alternative details where users might need to make changes (changing from 10 mg to 20 mg, from 1 tablet to 2 tablets, or from 30 days to 90 days, etc.).

A bar graph data visualization (Figure 5.4 below) displaying “renewal due dates” reduces users' cognitive load.. It allows physicians to note which items need to be managed during the current visit by doing a quick visual scan. The physicians recognize what medications they need to focus on by picking out preattentive attributes, such as color and line length, rather than by having to do complex mental calculations involving reading dates, quantities, and number of refills.

Figure 5.4Icons for “Refills Remaining”— Icons use preattentive attributes to reduce cognitive load during the medication renewal process

From Cerner PowerChart Touch. © 2014 Cerner Corporation. Reproduced by permission of Cerner Corporation.

5.2 Computerized Physician Order Entry (CPOE)

A CPOE (also sometimes referred to asComputerizedProvider Order Entry) is an electronic entry of patient care orders that electronically transmits itself to the departments (lab, radiology, etc.) or outside organizations that will fulfill it. CPOE orders can be distributed more quickly than their predecessors. They eliminate errors based on hand-writing, and can prevent duplicate orders by checking new orders against existing orders.

Clinical Scenario — Placing Future Lab Orders

Mr. Martin has achieved good control of his diabetes, blood pressure, and lipids. For the past year, he's been on stable doses of his medications, and his lab results have been stable as well. He can now settle into a more predictable routine, and won't need to visit the office or undergo lab tests as frequently. In about six months, Mr. Martin will need to come in for a hemoglobin A1c lab test, and then a visit. Another six months after that, he'll need to come in for further tests (another hemoglobin A1c a fasting lipid profile and a urine microalbumin test, both for his diabetes), and then another office visit.

5.2.1 Display Pre-Existing Orders to Prevent Duplication

A patient's EHR often contains unfulfilled orders. Patients forget tests, or can't find the time to get them done. If physicians can't see patients' existing future orders or recent lab results, they may accidentally order tests that have already been done or ordered, or very similar tests. This would duplicate their colleagues' work and spend resources wastefully.

When users place new orders, they can simultaneously be able to see the work that's already been done, without navigating away from their own unfinished orders and losing their work.

Figure 5.5Before: Interruptive Dialog Box— Doesn’t allow the physician to see existing prescription orders

Figure 5.6After: Non-interruptive Dialog Box— Allows users to see existing orders using a separate panel, or by making the dialog box non-interruptive.

5.2.2 Make It Easy to Find the Right Orders

Naming orders can be a challenge, because tests and procedures can have several commonly-used names. Different organizations may use different names for the same test. The physician ordering procedures might not be familiar with precise names listed in the EHR order catalog. The EHR might formally call a chest x-ray "XR chest". A physician, however, might look for it under:

• chest x-ray (or variant spellings like “xray”)
• chest XR
• XR chest
• X-ray chest
• Chest x-ray 2 views
• Chest x-ray PA and Lateral
• CXR (fastest way to hand-write the order)

These are all correct ways to name a chest x-ray. Thus, the interface could allow physicians to find tests and procedures listed under their various commonly-used designations.

5.2.3 Preconfigure Orders with as Much Detail as Possible

Tests physicians order in ER or urgent care scenarios are often high priority and need done STAT. Routine tests physicians order in primary care settings will almost always be lower-priority. They'll need completed today, in the near future, or at some specified future time. An EHR that could be easily configured to a specific care setting, one that established default "priority" settings for the orders it processed, would be a powerful support tool.

Setting the Date for Orders: Using Fuzzy Dates

Sometimes orders demand a precise date and time...Read more

Figure 5.7Before:The physician needs to expend a lot of effort to fill in the many missing details. There are many opportunities for error.

Figure 5.8After: The EHR pre-completes key fields. Less frequently needed details are displayed less prominently.

5.2.4 Assign the Correct Diagnosis for an Order or Prescription

The EHR can make the problem and diagnosis lists readily available to physicians entering orders. It could also allow users to add new diagnoses on the fly, without having to exit the ordering tool to add them.

The EHR can provide clinical decision support by suggesting probable diagnoses based on patients' list entries and lab results.Some orders are almost exclusively associated with a single diagnosis, and in these cases the system could assign this diagnosis to these orders by default. For instance an order for a A hemoglobin A1c lab test will almost always be associated with a diagnosis of diabetes or hyperglycemia.

5.2.5 EHRs Can Adapt to Users, Not Users to EHRs

An adaptable EHR can let physicians “add to the shopping cart” (Figure 5.9), then “continue shopping” without checking out right away. This allows the physicians and patients to make preliminary decisions, and act on them immediately, but also allows them to make adjustments as the visit unfolds.

Figure 5.9New Order Workflow— EHRs must offer users the option of building sets or collections of orders to facilitate their workflow.

5.2.6 Building Groups of Related Orders Function like Checklists

EHRs must offer users the option of building sets or collections of orders to facilitate their workflow. This offers users personalized clinical decision support and frees them from having to depend on their memories or external reference materials to complete involved tasks. Well Child Visits, for example, follow predictable patterns. They involve immunizations at regular, predetermined intervals, specific counseling (anticipatory guidance), and set follow-up visits.

A four-month-old's Well Child Visit would include:

• scheduling the next visit, at six months
• administering several specific vaccines
  • hemophilus B
  • rotavirus
  • pneumococcal 13-valent
  • combination of diphtheria / hepatitis B / pertussis - acellular / polio / tetanus.