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

268 K.B. Johnson and C.G.M. Weigle
guidelines (differential allowances for dosing intervals: “three times a day” vs
“every 8 h”), preferred forms and routes of administration (“oral liquids” vs “intravenous
infusions”) and the drug information provided with dispensed doses (readable
instructions vs package inserts). These differences often have a significant impact on
user interfaces for ACPOE and inpatient CPOE systems. For example, ACPOE systems
often allow a prescription to be written using tablets, milliliters, or other units,
and round doses to support easy administration at home, while inpatient systems
(designed for health care providers) may use more sophisticated dosing guidelines
and terminology. The differential needs for ordering certain types of medications in
inpatient and outpatient settings, including total parenteral nutrition, intravenous
infusions, and specifically timed sequences of medications (such as chemotherapy)
make current ACPOE and inpatient CPOE interfaces noninterchangeable (even
though users might prefer a single universal interface for all prescriptions).
ACPOE for tests and procedures is more complex than inpatient ordering of
similar tests or procedures. The “captive audience” of inpatient settings allows
tracking of tests/procedures (that are usually carried out within the hospital) and
review (as part of inpatient clinician responsibility) of order fulfillment on patients
prior to discharge. In ambulatory settings (aside from immunization administration
and point-of-care testing), tests and procedures are performed at outside facilities
(that may provide services for many ambulatory practices). Ambulatory orders for
testing will be fulfilled after the patient encounter is over and the patient has left the
office. Routing of test/procedure information (date and location of test, completed,
missed or rescheduled appointment, test result or interpretation) may be complex,
and tracking a test/procedure or its result may be vulnerable to being missed.
In organizations where ACPOE is part of a larger EHR system that serves
both inpatient and ambulatory settings, there are typically benefits of electronic
linkage of patient information (to shared laboratory and radiology information
systems) across clinical settings (that may facilitate clinical follow-up of test
results), but there may also be challenges with regard to regulatory issues on
referrals. Small group practices (including many pediatric practices) still using
paper records will most likely adopt freestanding (standalone) EHR systems with
or without an ACPOE system (unconnected to large organizations). Relaxation of
Stark and “anti-kickback” regulations to create a safe harbor for larger organizations
to provide information technology (such as interoperable EHRs) to referring
physicians (to increase EHR adoption) 19 may help to realize the benefits.
19.3 General Considerations in ACPOE Adoption
Although numerous studies support the use of ACPOE system, less than one third
of practices have integrated this technology into their workflow. There are many
reasons for this low adoption rate, including: 20
Early adopter experience—may catalyze or impede adoption
Legacy systems