Nurse Order Entry – an alternative to CPOE?

Getting physicians to enter their own orders on computerized systems has and continues to be a challenge to those in the health informatics field. Computerized physician order entry (CPOE) is often used as a measure of success. Given how the health care systems in North America are structured, getting physicians on-board and using information systems is required. Physicians hold the power in our system. I’m not saying this is a bad thing – it’s just a reality.

A recent paper published in the Journal of Medical Internet Research (JMIR) titled “Physician order entry or nurse order entry? Comparison of two implementation strategies for a computerized order entry system aimed at reducing dosing medication errors” presents some new information on the issue.

In this article, the authors compared physician only entry with a nurse and physician entry process to reduce medication errors on a neonatal ward. Basically, what the study found was that use of a clinical decision support system by both physicians alone or physicians with nurses entering the orders reduced medication errors. While there is an added step in the process when the nurse enters the order, this may be an acceptable trade-off if it can decrease physician data entry work while increasing overall use of electronic tools.

Two things struck me as I read this article. First, given that physicians are the most expensive and precious resource in the system, why are the efforts aimed at increasing the workload in terms of data entry? Shouldn’t the system, from an efficiency and optimization perspective, be looking at means of maximizing the physician’s time toward the things we need them to do, namely making decisions around diagnosis and treatment? If I remember my theory of constraints properly, then health systems should be doing everything possible to maximize each physician’s time such that it is spent on decision making rather than information gathering, data entry, or other process related work. If that is the case, then I suspect that our hospitals and offices should be re-organized to achieve this operational efficiency. One possible solution could be to have physicians sitting at a terminal whereby the physician holds each interaction via video-conferencing of some sort. Other health professionals can be the “arms and legs” and have everything queued up and ready for the technology mediated interaction. Hey, I don’t know about you, but that’s starting to sound like telemedicine, doesn’t it?

The second thing that struck me was that if physicians are resistant to CPOE, are they making themselves vulnerable to becoming displaced in the system in the long-term? An argument could be made that nurses are also highly qualified resources in the system which are being under-utilized and therefore more opportunities should be afforded to maximize their time and training. With the relative reluctance (general stereotype) of physicians to embrace CPOE, could nurses be the health professional who does the providing of care? As we begin to codify and standardize medical practice and decision making, then physicians start to lose their power in the system. To me, this reminds me of some of the examples in Christensen’s books on disruptive innovation. Innovations allow those with less training and skill to do more while the most highly skilled focus on those truly unique cases which involve high levels of uncertainty and complexity.

Getting back to the article, I found the article to be interesting in providing some data on the viability of using nurses as an intermediary towards CPOE. There are some methodological issues with the study, but the overall conclusions seem to be valid and reasonable. I wonder if a nurse order entry alternative could work within a North American context.