CDS & CPOE ease provider stress, encourage guideline adherence

Computerized provider order entry (CPOE) and clinical decision support (CDS) improve order set usability and decrease providers’ cognitive workload while increasing adherence to established clinical guidelines, according to research published in the September issue of Pediatrics.

Seattle Children’s Hospital first implemented CPOE in 2003 and applied software design methods to create standards for order set content and development. These systematically developed order sets replaced order sets developed through an “ad hoc” method, in which no clear standard for development existed.

Jeffrey Avansino, MD, and Michael G. Leu, MD, both of Seattle’s Children’s Hospital, compared the systematically developed order sets and ad hoc order sets by having seven surgeons complete each in the context of two clinical scenarios, one in which they were treating a child with perforated appendicitis and the other a child with nonperforated appendicitis. The surgeons’ actions were videotaped and they completed two surveys to grade usability of and cognitive workload associated with the order sets.  

The surgeons unanimously preferred using the systematically developed order sets, giving them better grades for both usability and cognitive workload. Orders generated from the systematically developed sets were also more likely to adhere to clinical guidelines, although completing both order sets took similar amounts of time.

Based on their observations, the researchers posited that effective clinical support eases provider stress because they are able to use it confidently without having to second guess decisions about their order choices.  

“Enabling CDS through order sets has advantages in that the clinicians do not have to stop what they are doing to find the guideline, and they do not have to interpret the guideline to successfully execute it, supporting clinician belief that they can receive up-to-date information more quickly,” Avansino and Leu wrote.

Despite the advantages CDS offers, there could be unintended consequences to its widespread adoption. As an analogy, students learning the practice of medicine with CDS may end up like cooks who know how to make a tasty meal, but don’t know what makes it tasty.

“We are concerned about the potential of these systems to limit resident training, creating an environment for ‘cookbook medicine’ resulting from prechecked orders,” Avansino and Leu wrote. “It can be argued that this method impairs the residents' ability to actively learn the concepts important for caring for patients with clinical diagnoses such as perforated appendicitis.”