It's Time to Rethink Computerized Physician Order Entry

Throughout history, physicians have been willing to grapple with injury, disease, and death - things which terrify the average person. It must be this willingness, more than knowledge or skill, that leads societies to confer great authority on physicians. Authority causes the suggestions, recommendations, and requests made by the physician to be taken as "orders" rather that what they actually are - suggestions, recommendations, and requests. Physician orders used to be considered sacrosanct; a nurse ignored a physician's order at her peril. No one ever openly questioned an order or a treatment choice.

To many, ordering by physicians appears to be analogous to other kinds of ordering e.g. a meal in a fast food joint or ordering from Amazon.com. I'll have one of these and one of those and, yes, I would like next-day delivery, thank you. Presto! Computerized Physician Order Entry (CPOE) is born! But it's not that simple. Discussion, review, and shared decision making often both precede and follow the act of placing an "order." During the process, various individuals and departments may be requested to collaborate or assume responsibility. Portions of a patient's care may be delegated. The primary provider no longer personally issues every order.

Ordering is therefore too narrow a concept to embrace the reality of delivering care. A broader definition is called for. An order is merely one form of request and it remains a request until it has entered the execution phase, begins to consume organizational resources, or cannot be interrupted. Prior to this "commit" point there are only requests. This differs from the fiscal view that an order is anything that would be billable if it were completed. The difference matters. A system designed to keep track of money will have a different emphasis than one designed to coordinated care and facilitate decision making.

There are several basic types of requests:

1. Request an informational message with/without acknowledgment to one or many recipients;

2. Request to record a state change (patient is placed in isolation, Dr. Smith is covering for Dr. Jones);

3. Request another to comment, suggest, recommend (consult), decide, act, participate, intervene, assume responsibility, monitor, study and interpret, test, deliver supplies or equipment, administer, remind, retrieve and report, etc.; and

4. Compound requests consisting of several requests, perhaps in a defined sequence.

Most importantly, only a subset of these requests fit the traditional concept of an order - an absolute, unalterable, command to a subordinate to carry out a specific action. Most requests are more general and less imperative. For example, consider writing an "order" to "call Dr. Smith and order or plead with him to cover for me tonight because I have an unexpected engagement." While physicians have traditionally written all sorts of stuff like this on "order sheets," they are not really orders at all. They are requests to others to, if they would be so kind, provide some assistance.

Does CPOE handle the full spectrum of requests that various members of the staff make to each other? I doubt it. Some CPOE applications treat things as fundamental as prescribing in illogical ways, such as requiring that the initial dose of a medication be delayed until the next time that routine meds are given - not so great for the stroke or myocardial infarction patient!

Many facilities that use CPOE, use separate applications for requesting and responding to consults, for e-prescribing, and most maintain paper order sheets for those requests that aren't handled by any of the computer systems. It is not enough for CPOE to be an electronic replacement for a supermarket checkout stand. That view does not address reality. Medicine needs a conceptual framework that addresses, in a coherent, coordinated way, the wide variety of requests that arise as we care for patients. That's why I say it's time to re-think CPOE.