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I am a hospital Pharmacist. I know that most of us love CPOE orders and hate written orders. Do most doctors hate it or love it? What is your personal opinion? Thanks.
What's your opinion on CPOE (Computerized Physician Order Entry)?
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I mostly hate it, because it drastically slows the flow of clinic down. There are benefits when it comes to patient safety, though.
Most people on this forum (Allopathic) are medical students and generally don't write orders, so you may not get many responses.
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I prefer it, no handwriting issues and for complicated patients having an order set pre-customized makes it faster. What I really like though are verbal orders, then all I have to do is sign 
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The population you are polling may be skewed due to the limited amount of years they have been practicing in most cases. If their training did not include a lot of hand written orders, only perhaps the occasional one (if that) then your response will be skewed. People will either say they hate it and prefer hand written orders (but perhaps do no have the experience to know what doing everything via hand written orders implies in terms of efficiency, workload, time to process orders etc. or people may say they love it, but it could be because they don't know much else.
Having said that, because for most people on this forum, CPOE, like EMR as a whole is all they know (transition completed) they will likely ( in my opinion) say they prefer it because that's what they are used to and people are creatures of habit.
You may try posting this question in the Resident's sub-forum to get more answers
Having said that, because for most people on this forum, CPOE, like EMR as a whole is all they know (transition completed) they will likely ( in my opinion) say they prefer it because that's what they are used to and people are creatures of habit.
You may try posting this question in the Resident's sub-forum to get more answers
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I think it is the absolute best thing that ever happened in the history of the medical profession.
I went to a medical school that still did all paper charting and orders, and it sucked monkey nuts.
I went to a medical school that still did all paper charting and orders, and it sucked monkey nuts.
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Hate it all day every day. The reason being is that I did all the order entry as a ward clerk. I went to medical school/residency to become a doctor. So now what am I? The highest paid typist and ward clerk there is. My job isn't much different than it was 15 years ago. Think about it. I would go back to paper charting and dictation any day. Instead I sit here every night for 2-3 hours once clinic is closed to type in peace.
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Love/hate.
When I can't find the med I want to give, or the dose I want to give, it's annoying. I spend a lot of time clicking through screens trying to make the computer let me do what I want to do. Those are the times I just want a paper chart so I can write down exactly what I want the person to get.
I also don't like CPOE for medication order sets when it comes to resident education. I see a lot of people learning "for this condition, select this order group" and not really learning what to give, why to give it, and how to adjust the order sets as needed. Having to go through and write each piece makes people think about the parts and what their purpose is. Once people have done that a few times, then I'm fine with them using order sets. Once you demonstrate the understanding of why you're using a therapy, then the CPOE order sets just makes the work day more efficient (in those cases).
I like CPOE when the computer has what I want because then I know it was done the way I want it (rather than having a misinterpretation of my handwritten order). So it's a love/hate relationship. I like and don't like it for pretty much the same reason.
When I can't find the med I want to give, or the dose I want to give, it's annoying. I spend a lot of time clicking through screens trying to make the computer let me do what I want to do. Those are the times I just want a paper chart so I can write down exactly what I want the person to get.
I also don't like CPOE for medication order sets when it comes to resident education. I see a lot of people learning "for this condition, select this order group" and not really learning what to give, why to give it, and how to adjust the order sets as needed. Having to go through and write each piece makes people think about the parts and what their purpose is. Once people have done that a few times, then I'm fine with them using order sets. Once you demonstrate the understanding of why you're using a therapy, then the CPOE order sets just makes the work day more efficient (in those cases).
I like CPOE when the computer has what I want because then I know it was done the way I want it (rather than having a misinterpretation of my handwritten order). So it's a love/hate relationship. I like and don't like it for pretty much the same reason.
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Good points above.
I've experienced both paper charts and CPOE.
I think we can all agree on the positive aspects of CPOE (more accuracy, patients get their meds faster etc). Here are the things I don't like:
1) it takes longer. During residency, the interns had the charts at the bedside and put in the orders during rounds. Orders were racked and taken off and the interns were free to move on to other duties at the end of rounds. Now, even with a mobile COW, it takes longer, so the junior residents spend considerably more time in the morning entering orders and missing OR cases, spending time with patients.
2) Hospitals are increasing shunting the work of CPOE to physicians instead of hospital employees. When I first started in practice, I would provide the hospital with pre-op orders which were filled out on paper. They switched to CPOE and the pre-op nursing staff would take my orders (from the ones I wrote in the office) and enter them into the computer. Then they decided that all orders needed to be written on hospital (not system but individual hospital) specific order forms which then required my office staff to transcribe my orders (in our EMR) to the hospital specific order form, which was then transcribed onto the computerized orders which I had to log in and go through several screens of orders (e.g. for a full days worth of operative patients).
Finally, hospital administration figured why should they pay nurses to enter my orders when they can just require the physician to do it? So now I have to enter my own pre-op orders. When I inquire as to why nursing staff can no longer do it, I'm told its "not legal" or "against the rules" but then I'm given the suggestion that a member of my office staff do it for me. So lets see...its somehow illegal for a licensed RN to enter my orders and send them to me for my signature but its ok for me to share my hospital log on (because only 1 per provider, none allowed for office staff) with my high school educated office staff and have them enter them? That makes no sense (nor would I entrust a non-clinical person to be entering important medical orders).
3) the systems are not clear nor standardized. I use Cerner PowerChart at 3 different hospital systems; all of them have been coded differently. If I want to order SCDs at one, it has to be entered as sequential compression..., at another its DyneMaps, at the third I can enter SCDs, sequential compression, stockings, and even misspell the word and it will figure it out.
Want to order an INR? Forget about it - no one, including the "Super Users" seem to know what the appropriate order for it is.
4) Enough with the pharmacy warnings.
I get it - the pre-op nurse has put in an allergy to Morphine because my patient Mabel told her it made her "sick" in 1954. Never mind that the "sick" sensation was a fleeting period of nausea.
But now everything I order has to have the pop up warning screen. Yes. I understand but I haven't forgotten the warning since 5 seconds ago when I entered the last pain medication order. I also don't appreciate having to tell you why I disagree with your "recommendation" or why I might want to order pain medication for after she leaves the PACU ("WARNING": you have ordered duplicate meds" - this despite the fact that the anesthesiologist's meds are only good for the PACU and mine don't start until admission). Really there should be a box for "because I said so" since the system doesn't seem to accept that not every patient is the same.
5) Residents don't learn the nuances of orders, nor do they remember the actual details. They start using pattern recognition rather than truly understanding the difference between medication dosing. Don't get me started on order sets where they aren't even thinking about what they're entering.
6) ORDER SETS! I understand there are incompetent providers but I resent some suit designing order sets and then I have to justify why I'm not using a specific detail of the set (i.e., why I'm not ordering post op Lovenox). These things lead to lazy practices. Is it me or does every internist just put patients on bed rest (I'm talking a 25 year old with an abscess, not a 90 year old with a STEMI) and then order pharmacologic DVT prophylaxis? Its on the order set, so people just click boxes without thinking.
I'm sure I have other complaints but that should tide you over...
I've experienced both paper charts and CPOE.
I think we can all agree on the positive aspects of CPOE (more accuracy, patients get their meds faster etc). Here are the things I don't like:
1) it takes longer. During residency, the interns had the charts at the bedside and put in the orders during rounds. Orders were racked and taken off and the interns were free to move on to other duties at the end of rounds. Now, even with a mobile COW, it takes longer, so the junior residents spend considerably more time in the morning entering orders and missing OR cases, spending time with patients.
2) Hospitals are increasing shunting the work of CPOE to physicians instead of hospital employees. When I first started in practice, I would provide the hospital with pre-op orders which were filled out on paper. They switched to CPOE and the pre-op nursing staff would take my orders (from the ones I wrote in the office) and enter them into the computer. Then they decided that all orders needed to be written on hospital (not system but individual hospital) specific order forms which then required my office staff to transcribe my orders (in our EMR) to the hospital specific order form, which was then transcribed onto the computerized orders which I had to log in and go through several screens of orders (e.g. for a full days worth of operative patients).
Finally, hospital administration figured why should they pay nurses to enter my orders when they can just require the physician to do it? So now I have to enter my own pre-op orders. When I inquire as to why nursing staff can no longer do it, I'm told its "not legal" or "against the rules" but then I'm given the suggestion that a member of my office staff do it for me. So lets see...its somehow illegal for a licensed RN to enter my orders and send them to me for my signature but its ok for me to share my hospital log on (because only 1 per provider, none allowed for office staff) with my high school educated office staff and have them enter them? That makes no sense (nor would I entrust a non-clinical person to be entering important medical orders).
3) the systems are not clear nor standardized. I use Cerner PowerChart at 3 different hospital systems; all of them have been coded differently. If I want to order SCDs at one, it has to be entered as sequential compression..., at another its DyneMaps, at the third I can enter SCDs, sequential compression, stockings, and even misspell the word and it will figure it out.
Want to order an INR? Forget about it - no one, including the "Super Users" seem to know what the appropriate order for it is.
4) Enough with the pharmacy warnings.
I get it - the pre-op nurse has put in an allergy to Morphine because my patient Mabel told her it made her "sick" in 1954. Never mind that the "sick" sensation was a fleeting period of nausea.
But now everything I order has to have the pop up warning screen. Yes. I understand but I haven't forgotten the warning since 5 seconds ago when I entered the last pain medication order. I also don't appreciate having to tell you why I disagree with your "recommendation" or why I might want to order pain medication for after she leaves the PACU ("WARNING": you have ordered duplicate meds" - this despite the fact that the anesthesiologist's meds are only good for the PACU and mine don't start until admission). Really there should be a box for "because I said so" since the system doesn't seem to accept that not every patient is the same.
5) Residents don't learn the nuances of orders, nor do they remember the actual details. They start using pattern recognition rather than truly understanding the difference between medication dosing. Don't get me started on order sets where they aren't even thinking about what they're entering.
6) ORDER SETS! I understand there are incompetent providers but I resent some suit designing order sets and then I have to justify why I'm not using a specific detail of the set (i.e., why I'm not ordering post op Lovenox). These things lead to lazy practices. Is it me or does every internist just put patients on bed rest (I'm talking a 25 year old with an abscess, not a 90 year old with a STEMI) and then order pharmacologic DVT prophylaxis? Its on the order set, so people just click boxes without thinking.
I'm sure I have other complaints but that should tide you over...
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I like CPOE, but that is all I've known, even as a student. Re: residents just using order sets and not thinking through them, that was quickly cured in my program. All it took was a couple times getting raked over the coals in front of God and everyone at signout for not knowing the rationale of WHY something was part of the order set. I just got a little tachycardic thinking about it.
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Trained with paper orders, attending life started with paper and transitioned to CPOE.
CPOE has some theoretical advantages related to not having to wait for unit clerk to enter orders, eliminating the illegible handwriting problem, and allergy/drug-interaction checking. It's also usually easier to template out a work-up than a blank sheet of paper. It automatically times and dates all orders and clicking the sign button takes less time than writing signature, printing last name, and printing staff ID #.
In practice, entering the orders into the computer may take as much time to find a computer to log into as it took the clerk to enter. Getting them in the computer immediately also doesn't seem to speed up the actual execution of the order. As WS pointed out, the allergy/interaction checking throws out far more noise than signal (1:10-1:15 ratio of important to useless warnings). My favorite is the warnings for KCL on patients with meds that may slow bowel transit time. Followed by the "are you sure you want to give a whole milligram of dilaudid, it's the equivalent of 8(!) mg of morphine" warning on the 110 kg pt. The decision support around med ordering is still pretty pitiful (at least on Cerner) and I despise having to wade through a list of 25 OTC acetaminophen combos before I can order a tylenol suppository. Also, many hospitals purchase an incompletely customized product so it's possible to order things in the computer that the hospital doesn't have or to order protocols that don't actually do anything. For years, our Massive Transfusion Protocol order fired tasks to exactly zero of the people responsible for executing the protocol.
Most hospitals had pretty workable template order forms (although it did suck when they ran out and nobody had remembered to make copies of the form) . And downtime used to be uncomfortable but now is like tasering the entire hospital since most nurses have never used paper and have no ability to structure their workflow without the task driven prompts of CPOE. The last scheduled down-time we had led to an unexpectedly heated discussion with the charge nurse about the need to pull out dry-erase boards and write down which patient was in which room before the system went down and we lost our tracking board.
CPOE has some theoretical advantages related to not having to wait for unit clerk to enter orders, eliminating the illegible handwriting problem, and allergy/drug-interaction checking. It's also usually easier to template out a work-up than a blank sheet of paper. It automatically times and dates all orders and clicking the sign button takes less time than writing signature, printing last name, and printing staff ID #.
In practice, entering the orders into the computer may take as much time to find a computer to log into as it took the clerk to enter. Getting them in the computer immediately also doesn't seem to speed up the actual execution of the order. As WS pointed out, the allergy/interaction checking throws out far more noise than signal (1:10-1:15 ratio of important to useless warnings). My favorite is the warnings for KCL on patients with meds that may slow bowel transit time. Followed by the "are you sure you want to give a whole milligram of dilaudid, it's the equivalent of 8(!) mg of morphine" warning on the 110 kg pt. The decision support around med ordering is still pretty pitiful (at least on Cerner) and I despise having to wade through a list of 25 OTC acetaminophen combos before I can order a tylenol suppository. Also, many hospitals purchase an incompletely customized product so it's possible to order things in the computer that the hospital doesn't have or to order protocols that don't actually do anything. For years, our Massive Transfusion Protocol order fired tasks to exactly zero of the people responsible for executing the protocol.
Most hospitals had pretty workable template order forms (although it did suck when they ran out and nobody had remembered to make copies of the form) . And downtime used to be uncomfortable but now is like tasering the entire hospital since most nurses have never used paper and have no ability to structure their workflow without the task driven prompts of CPOE. The last scheduled down-time we had led to an unexpectedly heated discussion with the charge nurse about the need to pull out dry-erase boards and write down which patient was in which room before the system went down and we lost our tracking board.
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I haven't started med school yet but I'm currently a phlebotomist. CPOE orders are nice in theory but none of the physicians at my hospital seem to know how to enter orders correctly meaning that unit clerks and RNs have to constantly remanage the orders anyway. Doctors are always getting mad that their labs aren't drawn or aren't drawn at the right time but there's little we can do about it if the orders aren't put in correctly in the first place.
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Right? You should have someone who actually GETS TRAINING and who does it all day to put the orders in. How much training do the docs get? Not much. My current job I got 30 minutes of "training" to learn the computer system before the 1st patient walked through the door. The IT person had to sit with me for the first week it was so hard to use.
Just like the whole typing thing irks me. They can hire a transcriptionist for 15/hr who types 10 times faster than me yet I sit here for hours after clinic at $100/hr. Just not cost effective.
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CPOE sucks because they are very poorly made.
The biggest issue is the lack of standardization. This leads to incorrect orders and spending ridiculous amounts of time to enter orders correctly.
Also all the damn pop-ups and 'allergies' that come up. The designers of these systems think "more is better." However, they fail to realize they have created systems where you ignore most of these warnings just to get your job done.
The biggest issue is the lack of standardization. This leads to incorrect orders and spending ridiculous amounts of time to enter orders correctly.
Also all the damn pop-ups and 'allergies' that come up. The designers of these systems think "more is better." However, they fail to realize they have created systems where you ignore most of these warnings just to get your job done.
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Right? I mean, I happen to prefer it to our old paper order system because my handwriting is atrocious and either it would take me forever to put in orders or I'd get 6 pages about them when I was done. But who cares? It's the reality of medicine pretty much everywhere these days. Not worth getting worked up over.
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I posit that most places have more training: a LOT more.
When one of my systems switched to EPIC, they required a whopping 17 hours of unpaid training for physicians. Fortunately I was able to do it in much less time because a couple of the sessions were just me and a private instructor so we were able to move at my pace.
One of my friends got stuck in a class with that guy: you know the one who seemingly has never seen a computer or operated a mouse before. She was about to kill him by the end of the session.
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I grew up "playing" Mavis Beacon, so I don't think of typing as adding any time to my work. For me the rate-limiting factor is computer processing speed, and we got new, faster computers placed in our clinic after I threw a minor hissyfit with our manager.
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I got 3-4 hrs and half of that seemed to be getting everyone logged into the training environment with the other half split 2/3rds stuff that has no application to me and 1/3rd stuff I needed.
At another location I got about an hour to cover two different systems.
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I agree that much of it was stuff that I had no use for; I must have gotten screwed on the time requirement.
I was a med student at my current hospital when they transitioned to electronic discharge orders. There was absolutely zero training. Even the super users had no clue how it worked.
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YMMV.
That surprises me because even the simplest hospital EMR I've seen required a few hours to train.
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LOL -- that's probably 99.995% accurate.
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If I were a pharmacist, i would see the ever increasing AI built into CPOE to be an existential threat. As a physician, it's just annoying.
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Bob Wachter's recent article/series should be required reading for anyone debating the merits of CPOE:
https://medium.com/backchannel/how-...ve-a-patient-38-times-his-dosage-ded7b3688558
