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Computerized Provider Order Entry
Emily B. Barey

• OBJECTIVES
1. State two reasons why CPOE is different from other healthcare information
­technology implementations.
2. State at least three common barriers to a successful CPOE implementation.
3. State at least three strategies to ensure a successful CPOE implementation.
4. State at least two future possible directions of CPOE.
5. State three core competencies required of the nurse informaticist working
with CPOE.

• KEY WORDS
CPOE
ARRA
HITECH
Meaningful Use
Change management

agenda (The Leapfrog Group, 2010). Each consistently

INTRODUCTION
Much of the attention paid to Computerized Provider
Order Entry (CPOE) has historically been associated
with early adopters at academic medical centers such as
Brigham and Women’s Hospital and leading community
sites such as El Camino Hospital reporting on their expe-
rience with clinical information systems in the 1980s and
1990s. Then, in 2000–2001, through the publications of
the Institute of Medicine’s To Err is Human (Institute of
Medicine [IOM], 2000) and Crossing the Quality Chasm
(IOM, 2001) and the subsequent focus of The Agency for
Healthcare Research and Quality on preventing medical
errors this past decade, CPOE received renewed attention
as a patient safety tool. The private sector, simultaneously
through employer organizations such as the Leapfrog
Group for Patient Safety, has also pursued a similar
recommends the use of CPOE to improve healthcare
quality. Benefits often highlighted range from the simple
help of physician order legibility to the more complex
decision support related to allergy and interaction check-
ing, medication dosing guidance, and in some cases cul-
minating in an overall decrease in patient mortality and
significant financial return on investment (Kaushal et al.,
2006; Longhurst et al., 2010; Poissant, Pereira, Tamblyn, &
Kawasumi, 2005).
A new dimension of CPOE has emerged with the pas-
sage of The Health Information Technology for Economic
and Clinical Health Act of 2009 (HITECH). As part of the
American Recovery and Reinvestment Act of 2009 (ARRA),
the aim of HITECH is to promote the adoption and
meaningful use of health information technology (HIT).
Included in HITECH are financial incentives to physicians

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 402    P art 5 • A dvanced N ursing I nformatics in P ractice
and healthcare organizations that utilize electronic health
records (EHR), including CPOE. These incentives ini-
tially have come in the form of increased reimburse-
ment rates from the Centers for Medicaid and Medicare
Services (CMS), but will ultimately result in a penalty if
adoption and meaningful use of the EHR are not met.
The Department of Health and Human Services (DHHS)
has now published two sets of criteria and objectives for
the meaningful use of EHR technology. The first set was
published in July 2010, the second in September 2012.
A third set is expected to be published sometime in 2016.
The three stages are intended to promote data capture and
sharing across healthcare entities, advance clinical pro-
cesses, and improve clinical outcomes (DHHS, 2013).
This chapter discusses a brief history of CPOE and its
recently renewed significance on a national level with the
passage of HITECH. Benefits of CPOE have been long
established; however, the HITECH offers new incentives
to promote widespread adoption more rapidly. A suc-
cessful CPOE implementation methodology is critical to
fully realizing the vision of the HITECH. This chapter will
address common barriers to a successful implementation of
CPOE and strategies to overcome those barriers. A patient
safety framework will also be reviewed in order to avoid
any unintended consequences that arise as the result of a
new technology implementation. Finally, the chapter sets
the stage for the future of CPOE, including the required
core competencies of the nurse informaticist to leading this
type of implementation today and tomorrow.
The significance of CPOE cannot be underestimated.
Although CPOE implies a physician or a provider-centric
tool, the workflow and subsequent management of those
patient care orders involves the entire inter-disciplinary
team, with the nurse at the center as patient care coordi-
nator. CPOE is also often the foundation for standardizing
care delivery and best clinical practices, along with being
an important component of advanced decision support.
As such, in addition to the broader backdrop of patient
safety, quality, and now financial incentives, it is essential
to recognize the impact of CPOE on the work of the nurse
and the significance of the nursing informaticist in obtain-
ing a core competency in CPOE.
DEFINITION OF CPOE
CPOE is often used as an abbreviation to represent how
an EHR system requires an end user to electronically
enter patient care orders and requests. There have been
electronic order communication tools available in the past
that allowed for the transmission of lab, radiology, medi-
cation, and other types of orders to downstream ancillary
systems; however, they relied largely on the transcription
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of a handwritten physician note by a department secre-
tary, nurse, or pharmacist and offered limited rules check-
ing or clinical decision support (CDS) capacity.
The “P” in CPOE has most commonly stood for
Provider, but will also appear as Physician or Prescriber.
This is what makes CPOE different from basic electronic
order submission. The transcription step is removed, and
the provider places the order directly into the system. By
using Provider it is also implied that the user placing the
order is authorized to give or sign that order and leaves
room for other disciplines in addition to physicians who
have a scope of practice that supports CPOE, such as
advanced practice nurses and physician assistants.
CPOE is also different in that it is inherently tied to a
CDS system that enables the checking and presentation
of patient safety rules during ordering, such as drug–drug
interaction checking, duplicate checking, corollary orders,
and dose calculations (Tyler, 2009). The “E” is also some-
times replaced by an “M” and stands for computerized
physician order management or computerized provider
order management, further implying that these orders are
no longer once and done, but will require ongoing review
and updating in the context of rules, alerts, and other
feedback mechanisms an EHR may provide that paper and
pen cannot. Management of an order also implies that it
is more than simply entered, but also communicated to
other care team members, reviewed, and acted upon.
In 2005, Dr. Michael McCoy proposed three types of
CPOE: basic, intermediate, and advanced (McCoy, 2005).
Basic incorporates order entry with simple decision sup-
port features such as allergy or drug–drug interaction
checking. Intermediate level CPOE includes additional
relevant results display at the time of ordering and the abil-
ity for providers to save their order preferences. Dr. McCoy
considered advanced CPOE to represent advanced clinical
order management, and it is here that more sophisticated
decision support in the form of “guided ordering” or “men-
tored ordering” would be available (McCoy, 2005, p. 11).
The definition chosen for CPOE is important to clarify,
as it will impact the scope of the CPOE implementation
and the related design, build, testing, and training require-
ments. Will it be basic or advanced? Will it include physi-
cians only or all clinicians more broadly? The definition
and standards are also significant as healthcare organi-
zations are now required to benchmark themselves to
national HITECH Meaningful Use metrics.
IMPLEMENTATION
Implementing CPOE, in many ways, is not unlike other
health information technology projects. It requires a proj-
ect plan, with appropriate time to complete workflow
20-02-2015 18:18:39

analysis, build, testing, and training. Like other HIT proj-
ects, the most successful implementations have a change
management plan that facilitates end-user adoption of the
new technology. CPOE, however, is unlike other HIT proj-
ects in that it often impacts the healthcare organization
on a much broader and deeper scale than, for example,
activating a clinical data repository, Picture Archiving
and Communication System (PACS), or a clinical notes
dictation system. CPOE is at the heart of patient care and
cannot be done in isolation to one department or disci-
pline as it ultimately demands not only a new medium in
which providers will work—the EHR—but also a new way
in which to work. Babbott et al. discuss that physicians
working with a fully functioning EHR including CPOE
could be presented with multiple tasks ranging from pre-
ventative health reminders to required documentation,
and that although this may lead to a more accurate assess-
ment than on paper it calls into question if current prac-
tice patterns can sustain this “contemporary” approach
(2014, p. 4). CPOE has only recently become an accepted
tool as routine as using a stethoscope for new healthcare
professionals.
COMMON BARRIERS TO
SUCCESSFUL ADOPTION
Despite the recent, rapid expansion of CPOE in the wake
of Meaningful Use, a review of the literature suggests that
there are still segments of providers where the “digital
divide” persists and adoption remains low. Those at great-
est risk include small, primary care practices, frequently
owned by physicians and with some evidence suggesting
a greater proportion of patients that are Medicaid, minor-
ity, or uninsured (Ryan, Bishop, Shih, & Casalino, 2013).
These sites frequently do not have the practical knowledge
to implement a CPOE system, apply quality improvement
methods to achieve benefits from it, or sustain mainte-
nance. Critical access and smaller hospitals are also at risk
due to a low patient volume that limits the organization’s
ability to apply operational resources to a CPOE imple-
mentation, recruit and retain skilled IT personnel, and
difficulty finding a suitable vendor that can successfully
accommodate these limitations (Desroches, Worzala, &
Bates, 2013).
The literature also suggests that “four main driv-
ers influence a providers’ decision on electronic health
records: affordability; product availability; practice inte-
gration; and provider attitudes. HITECH addresses the
first three, but providers’ attitudes [that are] critical to
the success of the act, are beyond the legislation’s con-
trol” (Gold, McLaughlin, Devers, Berenson, & Bovbjerg,
2012). And that despite established benefits of an EHR; the
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implementation can still be disruptive and require a steep
learning curve for providers to use the features effectively
(Ryan, Bishop, Shih, & Casalino, 2013).
STRATEGIES FOR A SUCCESSFUL
ADOPTION
A number of studies and reports have been written about
successful implementation strategies for CPOE. Written in
2000, A Primer on Physician Order Entry cited executive
leadership, physician involvement, a multi-disciplinary
approach to implementation, good EHR system response
time, and flexible training strategies as the keys to a success-
ful CPOE implementation (Drazen, Kilbridge, Metzger, &
Turisco, 2000). A more recent study that focused on
supporting those provider practices most at risk for suc-
cessful CPOE adoption reinforced those strategies with
eight specific implementation tactics including building
relationships to gain the trust of providers that will sup-
port the change, hiring staff that understand the domain
of the physician practice, setting realistic expectations
and obtainable goals, ensuring there is enough physi-
cal space for hardware so that providers may work effec-
tively, aligning the organization’s vision with the goals of
the implementation, developing a business case to identify
the expected benefits of CPOE, planning for provider
practice redesign, and creating a sustainable support
model for ongoing improvement efforts (Torda, Han, &
Scholle, 2010).
Given the barriers to and strategies for successful
adoption of CPOE outlined here, the work of a nurse
informaticist in a CPOE implementation will draw on all
aspects of nursing informatics practice as defined by the
American Nurses Association, however, as a consultant
the nurse informaticist may add the greatest value to solv-
ing the complex issues of CPOE through expert domain
knowledge, change management theory and planning,
process improvement methods, and patient safety review
(ANA, 2008).
DOMAIN KNOWLEDGE
Nurses understand many of the physicians’ work pro-
cesses and along with nurse informaticists are in a unique
position to assess the impact of new CPOE workflows
through communication, coordination, and knowledge
sharing (Ghosh, Norton, & Skiba, 2006). Two observations
from nurse leaders highlight the importance of this role
for ensuring no interruption to patient care, effective care
team processes and generally aiding the provider using
CPOE for the first time.
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The first leader said: “the planning team spent a great
deal of time learning all that nurses did to actualize a
physician order prior to CPOE. We also recognized the
importance of focusing on the output of CPOE to ensure
that it supports effective nursing practice” (Ghosh et al.,
2006, p. 928). The second leader explained: “our nursing
staff was part of the initial phase roll out of CPOE. This
built in support system has been a critical factor in driving
physician adoption” (Ghosh et al., 2006, p. 928).
CHANGE MANAGEMENT
In addition to ensuring a reliable order management
workflow, nurses’ domain knowledge also enables the
nurse informaticist to plan and support an effective series
of change management activities. Change management
and communication activities should be a part of each
implementation phase starting as early as planning and
continuing past the activation of the new system; as proj-
ect milestones, each activity should build on each other
toward unifying providers and the entire care team, solidi-
fying their readiness for a new way of working with CPOE.
The requirement of a comprehensive change management
plan is well stated by Studer who completed an extensive
literature review of effectiveness of EHR implementations
and concluded that organizational factors must be consid-
ered before, during, and after the implementation in order
to promote successful adoption (2005).
One of those organizational factors is readiness for
change. “In practical terms, readiness for change requires
both a willingness and capacity to change” (Holt, Helfrich,
Hall & Weiner, 2010, p. 50). Holt et al. suggest three broad
dimensions of organizational readiness to be considered
when planning an implementation project and in select-
ing a method for assessing it. These include psychological
factors, structural factors, and the level of analysis (Holt
et al., 2010). Several instruments are available to assess
readiness to change and the nurse informaticist may help
identify the best tool by assessing those being asked to
change, the factors under which the change is being made,
and the level of impact the change will be felt by either the
individual or the organization (Holt et al., 2010).
The need for a sustained change management plan
after the implementation was supported in a survey of
providers using an EHR. The “high EMR cluster” of pro-
viders had a significant correlation to higher stress lev-
els and lower job satisfaction (Babbott et al., 2014, p. 4).
Achieving the expected benefits of CPOE is dependent
on a provider’s ability not only to survive but also thrive
in the “high EMR cluster.” The nurse informaticist may
apply basic usability theory and process improvement
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methods to identify areas of work redesign that may ease
the transition and promote realizing benefits sooner.
USABILITY, PATIENT SAFETY, AND
PROCESS IMPROVEMENT METHODS
Despite the many positive outcomes related to EHR
implementations, the literature does note negative, unin-
tended consequences of system implementations that
cannot be ignored (Ash et al., 2007; Han et al., 2005).
Along with reports of usability also being a barrier
to adoption of EHR and the expected increase in EHR
development and use as a result of HITECH, the Agency
for Healthcare Research and Quality (AHRQ) funded
research in 2009 and 2010 to establish a common set of
recommendations, use cases, policy, and research agenda
items related to the usability of EHR systems (AHRQ,
2010). AHRQ categorized the functions of an EHR into
four roles: memory aid, computational aid, decision sup-
port aid, and collaboration aid (Armijo, McDonnell, &
Werner, 2009). How well the EHR can support these
functions and a clinician using them in a complex care
environment is a direct result of the system’s design and
usability (Armijo et al., 2009).
Usability is a quality attribute that assesses how easy user
interfaces are to use (Nielsen, 2003). There are many qual-
ity attributes that represent usability, and for the purposes
of CPOE usability, those to focus on include learnability,
efficiency, errors, satisfaction, and utility (Nielsen, 2003).
Usability expert Jakob Nielsen stresses that it is better to
run several small tests in an iterative approach, where five
end users are typically enough to identify the most impor-
tant usability problems (2003). With this in mind, there are
three types of testing activities that will promote system
usability: a gap analysis between current and future state
content and workflows, shadowing a provider real-time
working in current state with the new CPOE system test-
ing future state and care team simulation. AHRQ further
recommends that these types of tests are organized around
a specific framework of use cases including acute episodes,
chronic conditions, preventative and health promotion,
and undifferentiated symptoms. The combination of mea-
suring these usability attributes through different types of
testing activities that are organized around common use
cases should capture the high-risk and high-volume work-
flows related to CPOE and EHR use broadly.
Any usability problems that arise from testing should
be seen as an opportunity to drive possible work redesign,
CPOE system enhancements, and training and change
management efforts. If problems cannot be solved, then
goals and expectations of the CPOE implementation must
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be recalibrated to reflect something more realistic includ-
ing the potential of not implementing a specific feature or
workflow if the risk to safe and reliable patient care may
be compromised.
Sustained process improvement methods post-live
implementation will further support new usability case
studies and successful adoption. The Plan-Do-Study-Act
or PDSA model as developed by Associates in Process
Improvement can be a helpful framework for guiding this
type of work (Langley, Nolan, Nolan, Norman, & Provost,
2009). The PDSA approach would facilitate assembling
a team to define the problem, set an improvement goal,
brainstorm possible solutions, choose and test a subset
of solutions in order to identify which solutions are most
effective, and then spread those changes to address the
problem broadly. The process may be iterative and starting
small and then expanding scope ensures both judicious
use of resources and acceptance of the change.
Although the primary goal of these activities is to
ensure a safe, reliable CPOE system technical build and
to anticipate and plan for the work redesign required of
providers, a secondary goal is equally important. These
activities also engage the providers and those end users
impacted by the changes made by CPOE in a way that
enables building relationships of trust with the informatics
and information technology team. This is accomplished by
identifying and meeting the provider and care team needs
that surface during the testing and improvement work,
and if unable to meet the needs clearly communicating a
risk mitigation plan. The work also simultaneously devel-
ops the core competencies required to not only configure
and maintain a CPOE system technically, but also to lead
and manage professionally through this enormous change
for the entire healthcare organization. The cumulative
benefits, and subsequent risk mitigation, of usability test-
ing and post-live PDSA efforts make the investment well
worth the expense for guiding the CPOE implementation
toward healthcare transformation and away from simple
automation of current state practice.
FUTURE DIRECTIONS
There is no doubt that CPOE will be an important feature
and function of EHRs for the foreseeable future. As noted
previously, recent, renewed attention to the adoption of
CPOE at a national level with the passage of ARRA has
solidified CPOE’s position as significant to the delivery
of healthcare of the future. The increased number of pro-
viders using CPOE alone will change the course of future
development in this area, not to mention advances in soft-
ware, hardware, and interoperability standards.
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As coordinated care becomes the gold standard for
healthcare delivery, pharmacists and nurses are working
to their full scope of practice and partnering with physi-
cians to facilitate key CPOE processes such as medication
reconciliation and orders management. Pharmacists and
pharmacy techs are collecting medication history, dis-
pensing discharge prescriptions to ensure continuity of
care and educating patients on medication management.
Nurses and other inter-disciplinary team members such
as respiratory therapists and nutritionists are now not
only clarifying orders and implementing prescribed inter-
ventions, but are also making recommendations through
order entry as pended, protocoled, or suggested sets that
a physician may accept or decline. This collaboration will
only continue to grow and will support both improved
provider productivity with CPOE and greater accuracy in
the plan of care for a patient.
Increasing patient engagement is another core compo-
nent to healthcare reform and may include a new role for
patients in the future of CPOE. Although medication rec-
onciliation has historically been the domain of providers, a
recent pilot study conducted by the VA Boston Healthcare
System enabled patients to electronically verify their medi-
cation list post-discharge. This virtual medication reconcili-
ation avoided potential adverse drug events and reinforced
the patient’s desire to partner directly with their physician
in all aspects of their care (Heyworth et al., 2014).
The focus of CPOE software development has been ori-
ented to improving basic usability and addressing specific
workflow concerns, such as medication reconciliation.
In the future, the focus will be on making CPOE systems
smarter and able to better anticipate the providers’ next
action based on past patterns of use. In addition, clinical
decision support will continue to become more robust and
patient specific, but with it will be a more elegant manage-
ment of alerting to avoid alert fatigue.
Hardware platforms for personal computing are an
exciting area to watch for the future of CPOE. Providers
will be able to choose from a wide range of devices in
size and portability that will be increasingly enabled for
touch screen and tailored to the unique information needs
of a specialty, such as intensive care, surgery, or oncol-
ogy. There will be continued improvement of integration
between telecommunication systems and EHR software
that will facilitate increased remote alerting, monitoring,
and access capabilities.
As interoperability standards between EHR systems
improve, it is quite possible that resurgence in a “best of
breed” vendor approach to EHR software modules could
occur. It would require a significant expansion of data
exchange standards beyond medication, allergy, and prob-
lem lists, but it is not unfathomable, considering the leaps
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 406    P art 5 • A dvanced N ursing I nformatics in P ractice
in HIT standardization in the past five years alone. In the
meantime, it is certain that interoperability will expand
the provider’s accountability for considering and recon-
ciling patient historical data as EHR systems are already
passing discreet medication, allergy, and problem list data
to be consumed downstream by other EHRs and the pro-
viders using them.
Research related to the impact of CPOE adoption on
this new scale, along with the use of electronic health
records broadly by setting and type of provider will be
critical to guiding the future of CPOE, and the nurse infor-
maticist has much to contribute to shaping that future as
leaders of health information technology implementations
(Hogan & Kissam, 2010).
CORE COMPETENCIES OF THE
NURSE INFORMATACIST IN CPOE
Sensmeier summarized the demand for nursing infor-
matics professionals in 2006 and quoted the American
Medical Informatics Association (AMIA) Chair, Charles
Safran, M.D., as stating that “every hospital and care setting
needs one [nurse informaticist] in order to meet the gov-
ernment’s vision for EHRs” (2006, p. 169). This is further
reinforced in the 20th Annual HIMSS Leadership Survey
where “half of healthcare IT professionals indicated that a
focus on clinical systems will be their organizations’ top
IT priority in the next year, with a specific focus on EMR
and CPOE technology” (Health Information Management
Systems Society [HIMSS], 2009, p. 7). A significant barrier
identified by the survey was a lack of IT staffing, particu-
larly in application level support and process/workflow
design (HIMSS, 2009).
Application level knowledge represents the ability to
assemble the building blocks of a clinical information sys-
tem in the most effective way to meet the needs of the end
user. This skill will primarily rely on the nurse informata-
cist’s ability to assess, plan, and implement. In the case of
CPOE, this will require not only technical competency for
the purposes of designing and building the workflows to
deliver patient care orders into the application, but also
content management knowledge to standardize those
orders and reinforce them with evidence-based practice.
More broadly, application level knowledge also includes
the ability to assess the integration points and impact of a
particular application like CPOE with other applications
like a results interface or pharmacy information system.
As discussed, the nurse informatacist as consultant will
also possess the domain knowledge of CPOE workflows
and clinical process that is essential for successfully trans-
lating and aligning the needs of the end user, the patient,
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and the healthcare organization into the application, and
leveraging its features and functions to meet those needs.
As no single nurse informaticist can know everything
about all of an organization’s processes or physician prac-
tice, workflow analysis skills draw on the nurse’s underly-
ing ability to interview clients for their history, complete
an assessment, and collaborate across disciplines to meet
a common goal. These are skills that would have been
learned in nursing school for the purposes of patient
care, and here scale for the purposes of ensuring the best
outcomes for the organization utilizing the CPOE being
implemented. For example, a nurse would never imple-
ment a plan of care for a patient simply based on diagnosis
alone. So too a nurse informaticist would never implement
CPOE simply based on one provider or one department.
The nurse informaticist as consultant can also assess
the need for and establish a change management plan for
CPOE. These skills are also learned by nurses early in their
clinical careers, as they relate to providing patients with
education about their plan of care. This may include antic-
ipatory guidance for changes large and small to a patient’s
lifestyle, daily routine, relationships, and perception of
themselves. The nurse’s ability to establish a healthy, trust-
ing relationship with the client is at the core of success-
ful patient education. Preparing an organization for the
changes related to CPOE is at its core fundamentally not
that different; however, the scale is significantly bigger and
broader as the learning styles, motivators, and metrics of
success for the CPOE implementation will vary widely
across providers, patients, the inter-disciplinary team, and
the organization itself. Subsequent “coping ­mechanisms”
for the CPOE changes will also vary by organization based
on culture, infrastructure, available resources, and the
ability to apply those resources. The nurse informatacist
working with CPOE is competent in assessing an indi-
vidual’s and an organization’s readiness to change, can
employ basic usability and process improvement methods
to anticipate the impact of the change and lead through
the change in a positive, constructive way.
Ensuring a usable system that promotes patient safety
and provider adoption is another primary requirement for
the nurse informaticist implementing CPOE. Familiarity
with the heuristics of usability along with the ability to
assess common high-risk and high-volume use cases for
unintended consequences will ensure that benefits of the
implementation are realized reliably and without causing
undue harm.
National healthcare policy review has often been
reserved to the scope of practice of nurse leaders in man-
agement or academia. The expert nurse in CPOE, how-
ever, can no longer isolate him- or herself from the of
work government on healthcare information technology.
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As stated previously, the implications of healthcare reform
and HITECH are now more than ever tightly intertwined
with the daily care of patients and the clinical informa-
tion systems that support that care delivery. While an
advanced degree in healthcare policy is not necessary,
the competent nurse informaticist should understand the
regulatory and compliance landscape, and its impact on
clinical processes and applications as this will always be an
influence on his or her future work.
CONCLUSION
CPOE remains one of the most challenging areas within
healthcare IT today, and yet it has the promise of signifi-
cant benefits to both the patient and the provider, making
it an area of potential great professional reward. CPOE
systems have improved over the years and will only con-
tinue to become more user-friendly and sophisticated in
their clinical decision support capabilities as the demand
increases from broader adoption. Cultural barriers to
CPOE implementation will also shift as adoption becomes
required to demonstrate meaningful use of an EHR.
With core competencies of systems knowledge, workflow
analysis, change management, usability theory, process
improvement methods, human factors, and healthcare
policy, the nurse informaticist will be well positioned to
support CPOE implementations today and shape the sys-
tems of tomorrow.
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