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Information technology has experienced significant leaps in its capabilities and operational capacity in recent years, making it a vital adoption in the healthcare system and practice. Computerized information systems are now the backbone of hospital operations, supporting clinical and administrative tasks conducted by staff. Technology has endless possibilities but has led to exponential improvements in the prevention of human error, reduction of costs, and improvement of health care quality (Moghaddasi, Rabiei, Asadi, & Ostvan, 2017).
One of the primary computerized provider order entry systems currently used is electronic health records (EHR). Nurses are expected to be familiar with this technology and efficiently utilize it in daily practice. The purpose of this report is to investigate an example of a computerized provider order entry system and provide a personal experience of its use.
Example
At its core, EHR information systems are a digital manifestation of the patient chart. EHR contains diagnoses, medical history, treatments and care plans, medication or immunization records, and laboratory test results. The main benefit is that they are updated in real-time. Once information is entered, it is securely stored and can be accessed by authorized users anywhere. This eliminates both the tedious task and potential error in updating paper patient charts. As a result, the healthcare provider workflow is automated and optimized. Furthermore, modern EHRs offer options on a broader perspective of patient treatment, offering alerts and guidance to providers based on entered patient information (HealthIt, 2018).
Computerized provider order entry systems can serve the purpose of clinical guidance and decision support in practice and aspects such as pharmacogenomics. In large hospital systems, implementation of such tools is viable and could significantly benefit both staff and patients in the speed, safety, and effectiveness of provided treatments. The service offers the option of custom alerts or pre-established rules that can guide medication prescriptions and pharmacogenomic decision support. Furthermore, the system can be used for data mining for targeting clinical services and consultation requests.
Commercial software can be expanded to include patient scheduling and billing that will improve the post-discharge transition of care. Medication-related support such as interactions, dosages, and prescription refills are mitigated by the computerized order entry. More complex systems can automatically interact with the hospital or patient-selected pharmacy to have prescription pick-ups available at a faster rate (Hicks et al., 2016).
Epic Systems Corporation is a large healthcare software enterprise that develops computerized order entry and EHR information systems. It is one of the largest vendors in the market, capturing 50% of new hospital contracts and holding patient data for approximately 51% of the US population (Koppel & Lehmann, 2014). Its large success is attributed to its stability and standardization, which are vital for implementation in large-scale hospital systems.
Epics systems offer a single, well-developed product that improves governance and care processes. Built-in integration and reduced risk help to relieve pressure on staff and lower IT support costs. The system has paved the way forward in establishing data standards and ad hoc interoperability. It utilizes the Microsoft Windows operating system which is popular and reduces training costs. Furthermore, its interface and formats support simplified and rapid data entry (Koppel & Lehmann, 2014).
Personal Experience
My personal experience with computerized provider order entry comes from utilizing it at my place of employment. The hospital network where I work implemented a widespread EHR system. It is a requirement for nurses and physicians to utilize the system in all relevant interactions with patients. I use it for initial data entry, inputting patient history and complaints based on the first interview and examination.
The software guides me in asking the relevant questions and conducting the examination by asking for input on vital signs. Additional important information such as allergies and medication is collected as well. Based on input symptoms and examination results, the software offers a range of suggestions on which diagnostic tests or medications should be conducted for further treatment.
A significant benefit of computerized order entry systems is that it produces alerts of various types. Other alerts may include medication interaction. If I choose to input an assigned medication that negatively interacts with another or the patient is allergic to, an alert is visible on the screen. This is helpful to protect patient safety and staff liability. Due to the number of patients, it may be difficult to keep track of these aspects.
A negative aspect of technology is that it is seemingly underdeveloped. There are often issues with the slowness of operation, lagging notification, and other software-related issues. Furthermore, the rigid system of inputs often creates problems when certain aspects are unknown or irrelevant. While these systems are generally helpful, it requires significant development to achieve the broad parameters that have been included in its operational capacity.
Conclusion
Computerized provider order entry is an information system that provides a possibility to digitally enter the patient data and chart. Its subsystem EHR is specifically developed for efficiency and security, providing capabilities for rapid data input, storage, and access, and providing an overview of a patients treatment process. Ultimately, the purpose of information technology is to optimize care quality and speed, as well as support administrative tasks.
All of these aspects lead to a reduction in healthcare costs, error, and improvement of care delivery. Medication-related aspects such as interactions, dosage, and adherence can be monitored for computerized order entry. The newfound insight into this technology will help to become more aware of the presence and importance of information systems in nursing practice.
References
HealthIT. (2018). What is an electronic health record (EHR)? Web.
Hicks, J. K., Stowe, D., Willner, M. A., Wai, M., Daly, T., Gordon, S. M.,& Knoer, S. (2016). Implementation of clinical pharmacogenomics within a large health system: From electronic health record decision support to consultation services. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 36(8), 940-948. Web.
Koppel, R., & Lehmann, C. U. (2014). Implications of an emerging EHR monoculture for hospitals and healthcare systems. Journal of the American Medical Informatics Association, 22(2), 465-471. Web.
Moghaddasi, H., Rabiei, R., Asadi, F., & Ostvan, N. (2017). Evaluation of nursing information systems: Application of usability aspects in the development of systems. Healthcare Informatics Research, 23(2), 101-108.
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