Pediatric Informatics: Computer Applications in Child Health (Health ...

108 W.H. Drummond et al.
traditionally ordered in grams. In children, this medication is most often ordered
in milligrams, although it may be dispensed in 1 or 2 g vials. CPOE systems must
be aware of these conversions so that the provider can dose medications in familiar
units without introducing missing leading “0,” extraneous trailing “0,” decimal
point and human calculation errors. Pediatric CPOE systems should be capable of
calculating the appropriate dose and rounding for the dispensable form.
8.3.5.4 Clinical Decision Support
Robust clinical decision support is a desired component of any CPOE implementation.
Well designed and fully integrated “decision support” improves both physician
choices and hospital financial performance. 71, 72 Most current CPOE systems do not
offer advanced clinical decision support. For Pediatrics, even simple dose range
checking utilities may not be part of the standard package. Due to changing tolerance
to medications with chronologic and gestational age and growth in children,
dose range tables are significantly more complex than in adult patients.
8.3.5.5 Mandatory Detail
CPOE systems force hospital-based providers to make explicit decisions about
issues that are neither their responsibility nor their area of expertise. For example,
using CPOE, a physician cannot simply order an “OG tube” and trust the nurse to
select the appropriate size for the infant or child from the unit stocks. Instead, the
physician is required to make a decision that is in the scope of practice for a nurse
and order an OG tube of a specific size.
The ordering physician must know whether or not the CT scan requires contrast;
previously this was in the scope of practice for the board-certified radiologist.
Simple procedures such as ordering Erythromycin may now require an in depth
knowledge of its various salt forms (e.g. Erythromycin Stearate, Erythromycin Estolate,
Erythromycin Ethylsuccinate, Erythromycin Propionate, or Erythromycin Thyocinate).
Many such decisions were previously absorbed by the team-based knowledge.
The doctor ordered an OG tube, and the nurse decided, based on her practice
experience and visual judgment of her baby’s size and condition that “8 French”
was the appropriate size. Similarly, the pharmacist interpreted the physician order
and chose the Erythromycin salt from the hospital pharmacy’s standard stocks,
based on standard pharmacy procedures. With CPOE, front end clinicians have to
make these decisions. Lack of sub-domain knowledge may result in delays, errors,
inefficiencies, and frustrated caregivers.
8.3.5.6 Volume of Orders
The critical care environment is a challenge to any order entry system. Rapid
prescribing and administration of emergency shock and trauma medications