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February 11, 2010

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Jay R Fisher

Shiela, CMS has given some broad guidance to this question via FAQ 10134 on 11/12/2010. Here's the text:

"Any licensed healthcare professional can enter orders into the medical record for purposes of including the order in the numerator for the measure of the CPOE objective if they can enter the order per state, local, and professional guidelines. The order must be entered by someone who could exercise clinical judgment in the case that the entry generates any alerts about possible interactions or other clinical decision support aides. This necessitates that CPOE occurs when the order first becomes part of the patient's medical record and before any action can be taken on the order. Each provider will have to evaluate on a case-by-case basis whether a given situation is entered according to state, local, and professional guidelines, allows for clinical judgment before the medication is given, and is the first time the order becomes part of the patient's medical record."

Sheila Hagan, RN,CNO

I am trying to find out what CMS defines CPOE as and who they include in CPOE... RN's, LPN's. Would like a definite yes or no from CMS

Jay Fisher

Brian raises an interesting question. There is at least one pracical consideration. In an ambulatory setting, the calculation of CPOE percentage is based on:

1)Unique Patient denominator (i.e., if you see a patient multiple times in a reporting period, that patient only counts once); and
2)Instance of CPOE numerator (i.e., once a valid CPOE order has been entered for a unique patient, the counter increments and any subsequent orders for that unique patient do not improve your CPOE percentage).

So ... if the initial script was done on a unique patient via CPOE, subsequent orders would not be of benefit, unless the "refills" were done in a subsequent reporting period.

Brian

In an outpatient setting does this order need to occur at face to face visit? We handle refills and call in meds regularly without seeing patient, will this count to the numerator and denominator for CPOE requirements?

Jay Fisher

Shafik:

Final Rule simplified things a bit for us. First, you only need deal with medication orders. Second, you may count IP and ED, if you are a hospital. Third, the calculation of the measure (hitting a 30% CPOE threshhold), must be within the capabilities of your EHR, if it is to be certified. Here's the language of the rule:

"More than 30 percent of all unique patients with at least one medication in their medication list seen by the EP or admitted to the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period have at least medication one order entered using CPOE"

So, in answer to your question, I don't see how the existance, or absence of order sets would matter, since both the numerator, and the denominator are based on Medication orders only.

Shafik

Do we need to implement order-set to achieve the CPOE requirements, e.g. system shall load all orders with single click on order-set template, these template can be setup or customized by users or we can go in each section and order each of them separate will work too.

John Rosing

Jay, Last month I wrote David Eddinger at CMS to ask if use of a "scribe" would be acceptable to CMS from the standpoint of the CMS Conditions of Participation. Granted, his interest and expertise is with the CoP, not HITECH. Yet his reply is instructive. Here is my question and his answer: From: John R. Rosing [mailto:johnrosing@pattonhc.com] Sent: Monday, January 25, 2010 11:27 AM To: Eddinger, David W. (CMS/CMSO) Subject: CPOE Rules David, we understand that some organizations are dealing with CPOE- resistant physicians by offering them a "computer scribe" service. This service provides them with someone dedicated to round with them with a tablet PC or Computer on Wheels who enters orders while the physician is present (so he/she can respond to alerts, etc.) This is how one community hospital was able to agree to the goal of 100% CPOE, provide the safety features of CPOE, as well as keep the nursing staff happy (they REALLY didn't want to have a dual system of paper and electronic orders after go live). The expectation is that the scribe would enter the orders in a planned/“hold” state, but the physician must log in, review, and sign them prior to them being initiated (implemented). While orders are in this “hold” state they cannot be seen or acted upon by staff. These orders differ from verbal significantly in that they are not processed until the physician reviews and signs them. They exist in a planned state until the physician logs on, opens them, reviews them and signs them. Do you see any CoP regulatory problem with this solution? John, I discussed this with our team. We agree with your assessment. If the scribe activities are handled as you state, they would not be considered verbal orders. As long as the physician truly reviews the document, and revises as needed, prior to authentication, and entering into the hospitals order system, we see no regulatory or quality issues. David W. Eddinger, RN, MPH Captain, US Public Health Service Technical Director Hospital Survey and Certification CMS - Division of Acute Care David.Eddinger@cms.hhs.gov The information provided in this email is only intended to be general summary information to the public. It is not intended to take the place of statute, regulations or official CMS policy.

Jay Fisher

Brian Younger posed the following question:

"For the 10% CPOE requirement for hospitals, are "nursing orders" (e.g. an RN on 4 South is concerned her patient might fall out of bed, orders a fall assessment, and as a result orders siderails for the patient's bed - all based on her authority as a nurse)included?"

There are two aspects to Brian's question, I think. First, "Do we count orders placed by nurses?" Page 1856 of the Federal Register provides some insight to this. It states that "authorizing provider" includes RN's, PA's and NP's. Based on this, it seems nurse orders should be included in both the numerator and denominator.

The second part to Brian's question might well be "Do orders for Nursing activities qualify?" The same Federal Register page refers to "medical orders", "other providers", and "other auxiliary services", which seem to infer that orders for nursing activities should be included as well.

Paul Roemer

It wouldn't surprise me if they add that as a Stage 2 or 3 requirement along with on-line order entry of labs.

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