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SAFER Computerized Provider Order Entry with Decision Support (Office of the National Coordinator)

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SAFER
Safety Assurance Factors
for EHR Resilience
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Self-Assessment
Computerized Provider Order
Entry with Decision Support
General Instructions
for the SAFER Self-Assessment Guides
The SAFER Guides are designed to help
healthcare organizations conduct self-assessments
to optimize the safety and safe use of electronic
health records (EHRs) in the following areas.
▪ High Priority Practices
▪ Organizational Responsibilities
▪ Contingency Planning
▪ System Configuration
▪ System Interfaces
▪ Patient Identification
▪ Computerized Provider Order Entry
with Decision Support
▪ Test Results Reporting and Follow-up
▪ Clinician Communication
Each of the nine SAFER Guides begins with a Checklist
of recommended practices. The downloadable SAFER
Guides provide fillable circles that can be used to indicate
the extent to which each recommended practice has been
implemented. Following the Checklist, a Practice Worksheet
gives a rationale for and examples of how to implement
each recommended practice, as well as likely sources of
input into assessment of each practice, and fillable fields to
record team members and follow-up action. In addition to
the downloadable version, the content of each SAFER
Guide, with interactive references and supporting materials,
can also be viewed on ONC’s website at www.healthit.gov/
SAFERGuide.
The SAFER Guides are based on the best evidence
available at this time (2016), including a literature review,
expert opinion, and field testing at a wide range of
healthcare organizations, from small ambulatory practices to
large health systems. The recommended practices in the
SAFER Guides are intended to be useful for all EHR users.
However, every organization faces unique circumstances
and will implement a particular practice differently. As a
result, some of the specific examples in the SAFER Guides
for recommended practices may not be applicable to every
organization.
The SAFER Guides are designed in part to help deal with
safety concerns created by the continuously changing
landscape that healthcare organizations face. Therefore,
changes in technology, practice standards, regulations and
policy should be taken into account when using the SAFER
Guides. Periodic self-assessments using the SAFER Guides
may also help organizations identify areas in which it is
particularly important to address the implications of change
for the safety and safe use of EHRs. Ultimately, the goal is
to improve the overall safety of our health care system.
The SAFER Guides are not intended to be used for legal
compliance purposes, and implementation of a
recommended practice does not guarantee compliance with
HIPAA, the HIPAA Security Rule, Medicare or Medicaid
Conditions of Participation, or any other laws or regulations.
The SAFER Guides are for informational purposes only and
are not intended to be an exhaustive or definitive source.
They do not constitute legal advice. Users of the SAFER
Guides are encouraged to consult with their own legal
counsel regarding compliance with Medicare or Medicaid
program requirements, HIPAA, and any other laws.
For additional, general information on Medicare and Medicaid
program requirements, please visit the Centers for Medicare
& Medicaid Services website at www.cms.gov. For more
information on HIPAA, please visit the HHS Office for Civil
Rights website at www.hhs.gov/ocr.
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SAFER
Safety Assurance Factors
for EHR Resilience
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Self-Assessment
Computerized Provider Order
Entry with Decision Support
Introduction
The Computerized Provider Order Entry with Decision
Support SAFER Guide identifies recommended safety
practices associated with computerized provider order entry
(CPOE) and clinical decision support (CDS). Completing
this self-assessment in collaboration with a multi-
disciplinary team will help an organization optimize the
safety and safe use of CPOE with CDS in the EHR. The
implementation and use of CPOE with CDS is complex and
fragile, requiring careful planning, implementation, and
maintenance to function properly. In the EHR-enabled
healthcare environment, providers rely on technology to
support and manage the complex processes related to
CPOE with CDS, and this reliance creates potential safety
risks that can be minimized by the adoption of the
recommended practices in this guide.
The use of CPOE with CDS can improve medication safety
as well as ensure that providers who electronically order
diagnostic tests and consultations remain in the
communication loop.
1, 2, 3, 4, 5, 6, 7, 8, 9, 10
However, certain
CPOE-related practices can create safety risks.
11, 12, 13, 14, 15,
16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30
For example, partial
adoption of CPOE, or a lack of CPOE monitoring (e.g.,
incomplete data entry, excessive use of free text), can
create hazardous conditions.
CDS, whether stand-alone or integrated within an EHR, is
designed to aid the clinical decision-making process at the
point of care. The current scope of CDS focuses primarily
on medications, laboratory testing, radiology procedures,
and clinical references literature.
31
Substantial evidence
suggests that well-designed CDS not only
enhances the quality of care, but directly improves patient
safety by decreasing common errors and preventing
omissions or missed opportunities that result in patient
harm.
3, 32, 33, 34, 35
In spite of this, poorly implemented EHR
systems have been shown to introduce errors that
adversely affect care.
11, 15, 20, 25, 36, 37, 38, 39, 40
Completing the self-assessment in the Computerized
Provider Order Entry with Decision Support SAFER Guide
requires the engagement of people both within and
outside of the organization (e.g., EHR technology
developers, diagnostic services providers). Because this
guide is designed to help organizations prioritize EHR-
related safety concerns, clinician leadership in the
organization should be engaged in assessing whether
and how any particular recommended practice affects the
organization’s ability to deliver safe, high quality care.
41
Collaboration between clinicians and staff members while
completing the self-assessment in this guide will enable
an accurate snapshot of the organization’s CPOE and
CDS status, in terms of safety. Even more importantly,
collaboration should lead to a consensus about the
organization’s future path to optimize EHR-related safety
and quality: setting priorities among the recommended
practices not yet addressed, ensuring a plan is in place to
maintain recommended practices already in place,
dedicating the required resources to make necessary
improvements, and working together to mitigate the
CPOE-related safety risks introduced by the EHR.
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Safety Assurance Factors
for EHR Resilience
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Self-Assessment
Computerized Provider Order
Entry with Decision Support
Table of Contents
1
2
4
5
8
General Instructions
Introduction
About the Checklist
Checklist
Team Worksheet
About the Recommended
Practice Worksheets
Recommended Practice
Worksheets
References
9
The SAFER Self-Assessment Guides were developed by health IT safety researchers and informatics experts:
Joan Ash, PhD, MLS, MS, MBA, Professor and Vice Chair, Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon
Health & Science University;
Hardeep Singh, MD, MPH, Associate Professor of Medicine at the Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of
Medicine and Chief of the Health Policy, Quality and Informatics Program at the Houston VA HSR&D Center of Excellence, and Director of the Houston
VA Patient Safety Center of Inquiry; and
Dean Sittig, PhD, University of Texas School of Biomedical Informatics at Houston, UT–Memorial Hermann Center for Healthcare Quality & Safety.
This guide was developed under the contract Unintended Consequences of Health IT and Health Information Exchange, Task Order HHSP23337003T/HHSP23320095655WC.
The ONC composite mark is a mark of the U.S. Department of Health and Human Services. The contents of the publication or project are solely the responsibility of the authors and do not necessarily represent the
official views of the U.S. Department of Health and Human Services, Office of the National Coordinator for Health Information Technology.
10
39
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About the Checklist
>Practice Worksheets
>Table of Contents
>About the Checklist
>Team Worksheet
>About the Practice Worksheets
The Checklist is structured as a quick way to enter and print your self-assesment.
Your selection on the checklist will automatically update the related section of the
corresponding Recommended Practice Worksheet.
The Domain associated with the Recommended Practice(s) appears at
the top of the column.
The Recommended
Practices(s) for the
topic appear below
the associated
Domain.
Select the level of
implementation
achieved by your
organization for each
Recommended
Practice.
Your Implementation
Status will be
reflected on the
Recommended
Practice Worksheet in
this PDF.
To the right of each Recommended Practice is a link
to the Recommended Practice Worksheet in this PDF.
The Worksheet provides guidance on implementing
the Practice.
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Checklist
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practices for Domain 1 — Safe Health IT
1.1
Coded allergen and reaction information (or "no
known allergies" [NKA]) are entered and updated
in the EHR prior to any order entry.
Worksheet 1.1
Implementation Status
Fully
in all areas
Partially
in some areas
Not
implemented
reset
1.2
Evidence-based order sets are available in the
EHR for common tasks and conditions and are
updated regularly.
Worksheet 1.2
1.3
User-entered orderable items are matched to, or can
be looked up from, a list of standard terms.
Worksheet 1.3
1.4
The EHR can facilitate both cancellation and
acknowledgment of receipt of orders for laboratory,
radiology, and pharmacy.
Worksheet 1.4
1.5
CDS alerts are displayed in the relevant clinical
context.
Worksheet 1.5
1.6
CDS incorporates current best practices and
guidelines from authoritative sources (e.g.,
national organizations, medical specialty
professional associations).
Worksheet 1.6
Recommended Practices for Domain 2 — Using Health IT Safely
2.1
Clinicians are trained and tested on CPOE
operations before being issued login credentials.
Worksheet 2.1
Implementation Status
Fully
in all areas
Partially
in some areas
Not
implemented
reset
2.2
Clinicians are engaged in implementing, reviewing,
and updating CDS.
Worksheet 2.2
2.3
CPOE is used for ordering all medications,
diagnostic tests, and procedures for which CPOE is
available.
Worksheet 2.3
2.4
There is minimal use of free-text order entry.
Orders are entered and stored in standardized,
coded form.
Worksheet 2.4
2.5
Order entry information is electronically
communicated (e.g., through the computer or
mobile messaging) to the people responsible
for carrying out the order.
Worksheet 2.5
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Checklist
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practices for Domain 2 — Using Health IT Safely
Implement
Fully Par
2.6
Interruptive alerts (e.g., pop-ups at the time of
ordering) are used with discretion and only for
high risk, high priority conditions.
Worksheet 2.6
ation Status
in all areas
tially
in some areas
Not
implemented
reset
2.7
Drug-allergy interaction checking occurs during the
entry of new medication orders and new allergies.
Worksheet 2.7
2.8
Duplicate order checking occurs for high risk
medication, diagnostic tests, and procedure
orders (excluding "as needed" [PRN]
medications).
Worksheet 2.8
2.9
Drug-condition checking occurs for important
interactions between drugs and selected conditions.
Worksheet 2.9
2.10
Drug-patient age checking occurs for important age-
related medication issues.
Worksheet 2.10
2.11
Dose range checking (e.g., maximum single dose or
daily dose) occurs before medication orders are
submitted for dispensing.
Worksheet 2.11
2.12
A process is in place to review interactions so that
only the most significant interaction-related alerts, as
determined by the organization, are presented to
clinicians.
Worksheet 2.12
2.13
Clinicians are required to re-enter their password, or
a unique PIN, to “sign” (authenticate) an order.
Worksheet 2.13
2.14
When appropriate, corollary (or consequent) orders
are automatically suggested and linked together with
the original order such that changes are reflected
when the original order is rescheduled, renewed, or
discontinued.
Worksheet 2.14
2.15
Users can access authoritative clinical reference
materials directly from the EHR, including
organization-specific information when available.
Worksheet 2.15
2.16
CPOE and CDS functionality are tested to ensure
proper operation before go-live and with test patients
in the production system before clinical use.
Worksheet 2.16
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with Decision Support
Checklist
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practices for Domain 2 — Using Health IT Safely
2.17
Questions presented to the user by CPOE or CDS
are unambiguous.
Worksheet 2.17
Implementation Status
Fully
in all areas
Partially
in some areas
Not
implemented
reset
2.18
CPOE and CDS implementation and use are
supported by usability testing based on best
practices from human factors engineering.
Worksheet 2.18
2.19
Critical patient information is visible during the order
entry process.
Worksheet 2.19
2.20
The clinician is informed during the ordering process
when additional steps are needed to complete the
order being requested.
Worksheet 2.20
2.21
Use of abbreviations and acronyms is minimized and
standardized.
Worksheet 2.21
2.22
Additional safeguards (e.g., double checking by a
second specialist) are implemented in the EHR
before high risk medications are prescribed.
Worksheet 2.22
Recommended Practices for Domain 3 — Monitoring Safety
3.1
Key metrics related to CPOE and CDS (e.g.,
override rates) are defined, monitored, and acted on
to optimize safety and use.
Worksheet 3.1
Implementation Status
Fully
in all areas
Partially
in some areas
Not
implemented
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reset
reset
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Computerized Provider Order Entry
with Decision Support
Team Worksheet
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
reset page
A multi-disciplinary team should complete this self-assessment and evaluate potential health IT-related patient safety risks
addressed by this specific SAFER Guide within the context of your particular healthcare organization.
This Team Worksheet is intended to help organizations document
the names and roles of the self-assessment team, as well as
individual team members’ activities. Typically, team members will
be drawn from a number of different areas within your
organization, and in some instances, from external sources. The
suggested Sources of Input section in each Recommended
Practice Worksheet identifies the types of expertise or services to
consider engaging. It may be particularly useful to engage specific
clinician and other leaders with accountability for safety practices
identified in this guide.
The Worksheet includes fillable boxes that allow you to document
relevant information. The Assessment Team Leader box allows
documentation of the person or persons responsible for ensuring
that the self-assessment is completed. The section labeled
Assessment Team Members enables you to record the names of
individuals, departments, or other organizations that contributed
to the self-assessment. The date that the self-assessment is
completed can be recorded in the Assessment Completion Date
section and can also serve as a reminder for periodic
reassessments. The section labeled Assessment Team Notes is
intended to be used, as needed, to record important
considerations or conclusions arrived at through the assessment
process. This section can also be used to track important factors
such as pending software updates, vacant key leadership
positions, resource needs, and challenges and barriers to
completing the self-assessment or implementing the
Recommended Practices in this SAFER Guide.
Assessment Team Leader
Assessment Completion Date
Assessment Team Members
Assessment Team Notes
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Computerized Provider Order Entry
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About the Recommended
Practice Worksheets
>Table of Contents
>About the Checklist
>Team Worksheet
>About the Practice Worksheets
>Practice Worksheets
Each Recommended Practice Worksheet provides guidance on implementing a specific
Recommended Practice, and allows you to enter and print information about your self-assessment.
The Rationale section
provides guidance
about "why" the
safety activities
are needed.
Enter any notes
about your self-
assessment.
Enter any follow-up
activities required.
Enter the name of
the personal
responsible for the
follow-up activities.
The Suggested
Sources of Input
section indicates
categories of
personnel
who can provide
information to help
evaluate your level of
implementation.
The Examples
section lists
potentially useful
practices or
scenarios to inform
your assessment and
implementation of the
specific
Recommended
Practice.
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Recommended Practice 1.1
Worksheet
Domain 1 —
Safe Health IT
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
Implementation Status
1.1
Coded allergen and reaction information (or "no known
allergies" [NKA]) are entered and updated in the EHR prior
to any order entry.
42
Checklist
Rationale for Practice or Risk Assessment
One of the main purposes of CDS is automated drug-allergy
checking, which requires coded entry of allergies in the EHR.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ Users are reminded to enter patients’ allergies or “no known
allergies” before entering any medication orders.
▪ A standard, controlled vocabulary of allergens and reactions (e.g.,
SNOMED-CT) is available and used.
▪ There is a defined hierarchy of authority to edit or remove allergy-
related information from a patient’s EHR.
▪ The EHR system permits entry of medication intolerances,
distinguished from true allergies.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
reset page
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Recommended Practice 1.2
Worksheet
Domain 1 —
Safe Health IT
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
Implementation Status
1.2
Evidence-based order sets are available in the EHR for
common tasks and conditions and are updated
regularly.
43
Checklist
Rationale for Practice or Risk Assessment
Order sets minimize errors of omission through
standardization. Requiring clinicians to enter each of the
individual orders for routine clinical practices increases the
risk of overlooking one or more items.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Pharmacy
Examples of Potentially Useful Practices/Scenarios
▪ Order sets for medications are developed on the basis of Institute
for Safe Medication Practices (ISMP) guidelines.
44
Similar
standard formatting approaches are used for developing
diagnostic test- and procedure-related order sets.
▪ Order sets exist for the ten most common clinical conditions (e.g.,
management of chest pain), procedures (e.g., insulin
administration and monitoring), and clinical services (e.g.,
admission to labor and delivery).
45
▪ Clinical content is developed or modified based on evidence from
authoritative sources (e.g., the AHRQ CDS Initiative, specialists
within the organization).
▪
▪
EHR developer-provided clinical content is based on authoritative
sources and is reviewed for accuracy on a regular basis, and the
EHR’s software is upgraded whenever those sources are
updated.
Order sets for medications include complete pre-written
medication orders (order sentences) that include dose (unless the
dose should be modified based on patient data, such as blood
pressure, creatinine clearance, or blood glucose), dose form when
necessary, route of administration, frequency, and a PRN flag and
indication, if appropriate.
42
▪ Pre-written medication orders use doses that are weight-based,
when appropriate.
▪ Personalized order sets should be used sparingly. If an
organization permits them, there is an annual review process
(e.g., clinical quality committee or medical director approval).
45
▪ Medications requiring complex dosing guidelines (e.g., insulin
sliding scale) are standardized and available electronically.
▪ The CPOE list of orderable items (i.e., medication dictionary or
orderable catalog) includes all formulary medications to reduce
the necessity of entering free-text orders.
▪ The CPOE list of orderable items includes acceptable, non-
formulary medications, which are clearly marked, that users can
order for out-of-formulary fulfillment.
▪ Prescribing systems for children use weight-based dosing
recommendations, age-appropriate dosing calculators and dose-
range checking, and pediatric-specific drug-drug interaction
alerts.
46
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
reset page
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Recommended Practice 1.3
Worksheet
Domain 1 —
Safe Health IT
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
Implementation Status
1.3
User-entered orderable items are matched to, or can be
looked up from, a list of standard terms.
47
Checklist
Rationale for Practice or Risk Assessment
CDS is important to patient safety. CDS can be supported
by orders of standardized items, but not on free-text
orders.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Pharmacy
Examples of Potentially Useful Practices/Scenarios
▪ Users' orders are matched to a codified set of orderable
items (e.g., medications, laboratory and radiology tests).
▪ The EHR's search facility should support various word
orders (e.g., “abdominal ultrasound” or “ultrasound,
abdominal”), various names (e.g., generic, brand,
synonym), and should be able to be browsed
alphabetically.
48
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
reset page
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Recommended Practice 1.4
Worksheet
Domain 1 —
Safe Health IT
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
Implementation Status
1.4
The EHR can facilitate both cancellation and acknowledgment
of receipt of orders for laboratory, radiology, and pharmacy.
Checklist
Rationale for Practice or Risk Assessment
Communication errors, especially related to medication
orders and diagnostic services, are frequent
occurrences. Order tracking can reduce these errors.
Suggested Sources of Input
Diagnostic services EHR
developer
Health IT support staff
Pharmacy
Examples of Potentially Useful Practices/Scenarios
▪ The user can look up whether the lab has received the
specimen for testing or not.
▪ When medication orders are cancelled, information is
received and acted on appropriately by the responsible
pharmacy.
49, 50
▪ The two-way interfaces that facilitate order tracking are
tested pre- and post-go-live.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Recommended Practice 1.5
Worksheet
Domain 1 —
Safe Health IT
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
Implementation Status
1.5
CDS alerts are displayed in the relevant clinical
context.
40, 51, 52, 53, 54, 55, 56, 57, 58
Checklist
Rationale for Practice or Risk Assessment
CDS to improve diagnostic or therapeutic decision
making should be accessible in real time at the point
of care; otherwise, the advice generated may be
useless or underutilized.
59
Risks include information
overload and clinician dissatisfaction.
3, 33, 34
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Health IT support staff
Examples of Potentially Useful Practices/Scenarios
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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▪ A process is in place to identify and remove alerts that do
not make sense in the particular clinical context. In some
cases, the process may require communication with the
EHR developer.
▪ Ambulatory alerts for cancer screening protocols should not
be presented during the inpatient stay.
60, 61
The discharge
time period may be more appropriate for this type of CDS.
▪ Alerts for diabetic foot screening should not be presented
for patients with bilateral lower extremity amputations.
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Recommended Practice 1.6
Worksheet
Domain 1 —
Safe Health IT
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
Implementation Status
1.6
CDS incorporates current best practices and guidelines
from authoritative sources (e.g., national organizations,
medical specialty professional associations).
62
Checklist
Rationale for Practice or Risk Assessment
Out of date or incorrect knowledge provided by
the CDS system may be harmful.
3, 33, 34
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Health IT support staff
Examples of Potentially Useful Practices/Scenarios
▪ For organizations that rely on EHR developer-provided
CDS, a process is in place to ensure that CDS is based on
authoritative sources and is regularly updated.
▪ The evidence supporting CDS is reviewed and approved by
EHR users before adoption.
▪ Authoritative sources such as AHRQ’s CDS Initiative and
professional associations are used to develop CDS content.
For example:
▪ Colon cancer screening reminders follow U.S. Preventive
Services Task Force guidelines.
63
▪ Vaccination reminders use the latest recommendations from the
Advisory Committee on Immunization Practices.
64
▪ Consider the “Choosing Wisely” guidelines to reduce
unnecessary tests and procedures.
65, 66, 67
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Recommended Practice 2.1
Worksheet
Domain 2 —
Using Health IT Safely
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
Implementation Status
2.1
Clinicians are trained and tested on CPOE operations
before being issued login credentials.
50
Checklist
Rationale for Practice or Risk Assessment
CPOE is a complex tool. To maximize its safe and
effective use, clinicians must be trained rigorously and
should not be expected to “learn the basics on the
job.”
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
Pharmacy
EHR developer
Health IT support staff
Examples of Potentially Useful Practices/Scenarios
▪ Incentives such as continuing education (e.g., CME, CEU)
credits are awarded to clinicians who have been trained
on CPOE.
▪ Clinicians are required to demonstrate basic CPOE skills
before getting their login credentials.
68
▪ The organization evaluates whether specialized CPOE
training should be required in high risk areas.
▪ Training is reinforced periodically, particularly with system
changes and upgrades.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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SAFER
Self-Assessment
Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.2
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Recommended Practice
Implementation Status
2.2
Clinicians are engaged in implementing, reviewing,
and updating CDS.
62, 69, 70, 71, 72, 73
Checklist
Rationale for Practice or Risk Assessment
Failure to include clinicians in decisions that affect their
clinical work environment, their decision making
capabilities, or how their decisions are communicated and
recorded significantly increases the risk of hazardous
events. CDS systems can be optimized through
monitoring of use, overrides, and clinician satisfaction.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
Diagnostic services
Pharmacy
Examples of Potentially Useful Practices/Scenarios
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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▪ Clinicians are involved in developing and maintaining CDS
content consistent with updated guidelines and algorithms.
There is a process that involves clinicians in managing,
evaluating, and prioritizing CDS updates.
62, 72, 73, 74, 75
▪ Developing and maintaining high quality CDS interventions
is difficult and time consuming.
41
The organization should
incentivize, or otherwise reward, clinicians for their time
spent working on CDS-related activities.
▪ Clinician-provided feedback is reviewed and used for
refinement and maintenance of CDS and the relevant
clinical content.
62, 71, 72, 73, 75
▪
▪
Clinician overrides (i.e., decisions not to follow a computer-
generated suggestion) for high priority CDS elements are
logged and available for review and reporting.
76, 77, 78
For EHR developer-provided or -controlled CDS, a process
is in place to communicate the need for CDS
improvements with the developer.
▪ Compendia CDS and clinical terminology updates should
be done on a frequent and regular basis. Doing this
enables prescribers to have access to the most up-to-date
information at all times.
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Self-Assessment
Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.3
Worksheet
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Recommended Practice
Implementation Status
2.3
CPOE is used for ordering all medications, diagnostic
tests, and procedures for which CPOE is available.
43
Checklist
Rationale for Practice or Risk Assessment
While full use of CPOE with advanced CDS has
been shown to reduce errors,
59
partial use of CPOE
can introduce errors.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
Diagnostic services
EHR developer
Health IT support staff
Pharmacy
Examples of Potentially Useful Practices/Scenarios
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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▪ Except in unusual situations, providers are required to enter
their orders into the CPOE system. This includes orders for
controlled substances.
▪ Exceptions (e.g., emergency orders in resuscitation
situations) are clearly defined, and processes are in place
and followed for their proper documentation in the EHR.
▪ Recommendations from The Joint Commission are followed
when submitting orders to RNs by text messaging. This is
acceptable as long as the texting platform has:
79
▪ A secure sign-on process
▪ Encrypted messaging
▪ Delivery and read receipts
▪ Date and time stamps
▪ Customized message retention time frames
▪ A specified contact list for individuals authorized to receive and
record orders
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Self-Assessment
Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.4
Worksheet
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> Practice Worksheets
Implementation Status
Recommended Practice
2.4
There is minimal use of free-text order entry. Orders are
entered and stored in standardized, coded form.
43, 80, 81
Checklist
Rationale for Practice or Risk Assessment
Free-text data can introduce errors if it is inconsistent with
structured data or is not used or communicated properly.
50
Free-text orders cannot be effectively supported with CDS.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Health IT support staff
Examples of Potentially Useful Practices/Scenarios
▪ When medications are entered using standardized, coded
terms, corresponding narrative text is minimized. Processes
are in place to ensure timely use and review of any narrative
text.
▪ The organization takes specific safety precautions whenever
full free-text ordering is allowed.
▪ When medications must be ordered using free text, as
constrained by organizational policy, a pharmacist reviews
the order to identify and address any drug-drug or drug-
allergy interactions.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Self-Assessment
Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.5
Worksheet
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> Practice Worksheets
Recommended Practice
Implementation Status
Rationale for Practice or Risk Assessment
For effective CPOE, orders must be electronically
communicated. An automated process minimizes lapses
in communication.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Health IT support staff
Examples of Potentially Useful Practices/Scenarios
▪ In-patient nurses are notified via the EHR when new results
or orders are entered into the system for one of their
patients (e.g., when they login to the system an alert tells
them that new orders are available, or they are sent an
informative page or text message).
83
▪ In the ambulatory setting, clinical workflow is evaluated and
optimized to ensure that nursing and other support staff
responsible for carrying out orders are alerted to the
presence of new orders. Examples of alerts could be a task
in-box, messages on the edge of the screen, alerts at log
on, text messages, or pages.
▪ Orders that are not acknowledged by the individual
responsible for carrying them out within appropriately
defined time periods are automatically escalated to a
supervisor.
84
▪ Workflow is evaluated to ensure that all electronic orders go
to the intended recipient and that person documents their
actions in the EHR.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Order entry information is electronically communicated (e.g.,
through the computer or mobile messaging) to the people
responsible for carrying out the order.
82
Checklist
2.5
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Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.6
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Recommended Practice
Implementation Status
2.6
Interruptive alerts (e.g., pop-ups at the time of ordering)
are used with discretion and only for high risk, high priority
conditions.
40, 51, 52, 53, 54, 55, 56, 72, 85, 86
Checklist
Rationale for Practice or Risk Assessment
Excessive use of interruptive alerts creates clinician
dissatisfaction and reduces their effectiveness,
causing clinicians to miss important alerts.
31
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer Health
IT support staff
Examples of Potentially Useful Practices/Scenarios
▪ For lower priority conditions, passive alerts that do not force
an interruption of workflow are available.
54
▪ High risk, high priority conditions that justify interruptive
alerts are identified by clinicians and are subject to review.
▪ Interruptive alerts at the point of care are used only after
considering other available options.
87
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Partially in some areas
SAFER
Self-Assessment
Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.7
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Recommended Practice
Implementation Status
2.7
Drug-allergy interaction checking occurs during the entry of
new medication orders and new allergies.
59, 80, 88
Checklist
Rationale for Practice or Risk Assessment
Interaction checking minimizes the risk of adverse
drug events related to allergies.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ Allergy checking occurs for all current medications
whenever a new allergy is entered into the system.
▪ Testing of high risk drug-allergy pair interactions should be
done at initial EHR implementation and with periodic EHR
upgrades to the medication and allergy database. Specific
pairs selected for testing should be those most relevant to
the care setting. For example, checking an ACE inhibitor
prescription for the allergic reaction of ACE inhibitor-
induced angioedema.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Partially in some areas
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Self-Assessment
Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.8
Worksheet
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Recommended Practice
Implementation Status
2.8
Duplicate order checking occurs for high risk medication,
diagnostic tests, and procedure orders (excluding "as
needed" [PRN] medications).
59, 80, 89
Checklist
Rationale for Practice or Risk Assessment
Duplicate order checking reduces the risk of inadvertent
drug overdoses and unnecessary tests and procedures.
59, 80
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ Therapeutic duplication checking that occurs before new
medication orders are submitted (e.g., two orders for the
same or two different beta-blockers are placed) is carefully
implemented and monitored. Note that there are situations
where it is clinically indicated to prescribe duplicate
therapies. For example, duplicate alerts should NOT fire for
an order for an IV bolus, followed by an order for a
continuous drip of the same medication.
▪ There are rules to determine how and when diagnostic tests
or procedures receive duplicate checking before they are
ordered.
90
▪ Duplicate checking does not include PRN (i.e., as needed)
medication orders.
▪ PRN orders should not include overlapping criteria (e.g., for
pain 1-3, give aspirin AND for pain 2-4, give Vicodin).
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Self-Assessment
Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.9
Worksheet
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Recommended Practice
Implementation Status
2.9
Drug-condition checking occurs for important interactions
between drugs and selected conditions.
59
Checklist
Rationale for Practice or Risk Assessment
Electronic drug-condition checking reduces the risk of
preventable adverse drug events related to specific
conditions.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ Drug-condition interaction checking occurs when new
medications are ordered or new conditions are
identified (e.g., Accutane or tetracycline prescribed for
a pregnant woman).
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Self-Assessment
Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.10
Worksheet
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Recommended Practice
2.10
Drug-patient age checking occurs for important age-related
medication issues.
15, 91
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
Drug-patient age checking reduces the risk of preventable
age-related adverse drug events.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ Drug-patient age interaction checking occurs when new
medication orders are submitted for dispensing (e.g.,
medications contraindicated in the elderly).
▪ Changes in frequency, dose, or therapeutic substitutions
are suggested for pediatric patients.
92
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.11
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Recommended Practice
2.11
Dose range checking (e.g., maximum single dose or daily
dose) occurs before medication orders are submitted for
dispensing.
59, 93
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
Dose range checking reduces the risk of medication
overdose.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ Renal dose adjustment suggestions and information
on the patient’s renal status are clearly displayed
prospectively for relevant medications. In cases where
actual dose adjustments are not possible within the
existing software, EHR developers should provide
reference dosing guidelines either within the EHR or
through info button links.
▪ Patient context (e.g., age, renal function) dynamically
changes the dosing or administration timing defaults
prospectively.
▪ Maximum single dose and maximum daily dose are
independently checked.
▪ Dose limits are appropriate for age, weight, and body
surface area.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Partially in some areas
SAFER
Self-Assessment
Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.12
Worksheet
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Recommended Practice
Implementation Status
2.12
A process is in place to review interactions so that only the
most significant interaction-related alerts, as determined by
the organization, are presented to clinicians.
53, 54
Checklist
Rationale for Practice or Risk Assessment
Tiered alerting by severity (significance) is associated
with higher compliance rates for drug-drug interaction
alerts.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ Less significant alerts are presented as information
only, rather than as interruptive alerts.
53
▪ Alerts that are displayed are modifiable (e.g., show
only the most severe interactions versus all
interactions) based on feedback from the users and
monitoring of user behavior (e.g., alert override
rates).
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Partially in some areas
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Self-Assessment
Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.13
Worksheet
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Recommended Practice
Implementation Status
2.13
Clinicians are required to re-enter their password, or a unique
PIN, to “sign” (authenticate) an order.
Checklist
Rationale for Practice or Risk Assessment
Explicit order authentication reduces the risk of
inadvertently entering orders under the wrong identity
when someone else is logged in. It gives users an
additional opportunity to confirm that the orders they
entered are correct, and prevents them from
inadvertently signing orders they did not intend to sign.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ An explicit re-authentication process occurs for orders in
addition to the original login for access to the EHR.
▪ Providers should be shown a summary view of orders
before signing.
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Partially in some areas
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Self-Assessment
Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.14
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Recommended Practice
Implementation Status
2.14
When appropriate, corollary (or consequent) orders are
automatically suggested and linked together with the original
order such that changes are reflected when the original order
is rescheduled, renewed, or discontinued.
94
Checklist
Rationale for Practice or Risk Assessment
Automatically suggested, linked orders reduce
order inconsistencies by managing closely
associated orders in tandem.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ Examples include: prothrombin time monitoring when
warfarin is prescribed, or drug level measurements with
Vancomycin or aminoglycoside orders.
94
▪ Corollary orders are deleted whenever the main order is
deleted (e.g., if a colonoscopy is cancelled, the bowel
prep is also cancelled).
Assessment Notes
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Person Responsible for Follow-up Action
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Partially in some areas
SAFER
Self-Assessment
Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.15
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Recommended Practice
2.15
Users can access authoritative clinical reference materials
directly from the EHR, including organization-specific
information when available.
47, 62, 71, 72, 74, 95
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
Ready access to information can reduce the risk of
errors. CDS to improve diagnostic or therapeutic
decision making should be accessible in real time
at the point of care; otherwise, the advice
generated may be useless or underutilized.
59
Suggested Sources of Input
EHR developer
Health IT support staff
Examples of Potentially Useful Practices/Scenarios
▪ Relevant reference materials should be accessible
through info buttons or similar functionality in the order
entry screen/module. Examples include: medication
monographs (such as Micromedex), dosing calculators,
diagnostic guides, laboratory reference materials, image
atlases, anatomical diagrams, patient education
materials, and disease-specific treatment guidelines.
96
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.16
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Recommended Practice
Implementation Status
2.16
CPOE and CDS functionality are tested to ensure proper
operation before go-live and with test patients in the production
system before clinical use.
97
Checklist
Rationale for Practice or Risk Assessment
Appropriate testing reduces the risk of errors
associated with inappropriate CPOE or CDS system
behavior.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Health IT support staff
Examples of Potentially Useful Practices/Scenarios
▪ A CPOE evaluation tool (e.g., the Leapfrog Group's
CPOE "flight simulator" for hospitals) is used to
evaluate the safety and effectiveness of CPOE and
CDS functionality.
98, 99, 100
▪ CDS rules should be tested in the live environment
after any CDS-related change and after major EHR
software upgrades. This testing should be done for
both new rules and existing rules (i.e., regression
testing).
101
▪ CDS interventions are evaluated to ensure correct
firing of alters and reminders.
102
Assessment Notes
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Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.17
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Recommended Practice
2.17
Questions presented to the user by CPOE or CDS are
unambiguous.
57, 59
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
Misunderstanding queries posed by the system can
lead to risks of errors and adverse events.
103
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer Health
IT support staff
Examples of Potentially Useful Practices/Scenarios
▪ There are policies and procedures to evaluate the clarity of
questions posed to users.
▪ Questions should be kept simple and focused. For example,
“Is IV contrast contraindicated?” may be confusing. It might
be better to ask, "Is IV contrast safe to administer? Yes,
safe. No, not safe."
▪ Avoid negatively and poorly worded questions (e.g., “Do you
want to cancel this alert? Yes, No, Cancel.”).
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.18
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Recommended Practice
Implementation Status
2.18
CPOE and CDS implementation and use are supported by
usability testing based on best practices from human
factors engineering.
104, 105
Checklist
Rationale for Practice or Risk Assessment
Risks of untested usability include decreased clinician
efficiency and clinician dissatisfaction, as well as errors
and adverse events due to unintended consequences of
CDS use.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
Diagnostic services
EHR developer
Health IT support staff
Pharmacy
Examples of Potentially Useful Practices/Scenarios
▪ Major CDS and CPOE changes and interventions
are tested with representative end users.
104
▪ Clinician-reported hazards associated with CPOE and
CDS due to poor usability are regularly communicated to
a team charged with reviewing complaints and relaying
validated hazards to the creator of the CPOE or CDS for
management. Regular review and follow-up of validated
issues and solutions should occur.
Assessment Notes
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with Decision Support
Recommended Practice 2.19
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Recommended Practice
Implementation Status
2.19
Critical patient information is visible during the order
entry process.
106
Checklist
Rationale for Practice or Risk Assessment
Ensuring that critical data are visible in the EHR
minimizes errors related to misidentification or failing
to account for common clinical issues.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ Pertinent clinical information (e.g., age, weight, allergies,
pregnancy status, creatinine clearance/GFR) and
identifying patient information is easily accessible from the
ordering screen (e.g., in a patient header bar, on the
ordering screen, from a hide/show panel). If screen
resolution allows, it is preferable that the information be
accessed without scrolling.
106
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.20
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Recommended Practice
Implementation Status
2.20
The clinician is informed during the ordering process when
additional steps are needed to complete the order being
requested.
Checklist
Rationale for Practice or Risk Assessment
Clinicians may not be aware that an order will not be
completed without additional steps, leading to delays in
performing the order.
Suggested Sources of Input
Diagnostic services EHR
developer
Pharmacy
Examples of Potentially Useful Practices/Scenarios
▪ Clinicians are informed when non-formulary medications
require additional pre-approval.
▪ Clinicians are informed when “send out” tests require special
forms or procedures.
▪ The mode of informing clinicians or their team members of
incomplete orders could include passive notifications (e.g.,
an informative icon).
Assessment Notes
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Person Responsible for Follow-up Action
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Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.21
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Recommended Practice
2.21
Use of abbreviations and acronyms is minimized and
standardized.
107, 108, 109
Checklist
Implementation Status
Rationale for Practice or Risk Assessment
Acronyms and abbreviations are a source of errors in
both paper and electronic records. Minimizing and
standardizing use of acronyms and abbreviations
reduces the risk of errors related to misunderstanding.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Examples of Potentially Useful Practices/Scenarios
▪ Organizational policies on the use of abbreviations and
acronyms incorporate, and are consistent with, their
use in EHRs.
▪ Use of abbreviations and acronyms is consistent with
industry best practices.
▪ Abbreviations such as "qd" or "qid" are avoided.
Assessment Notes
Follow-up Actions
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Computerized Provider Order Entry
with Decision Support
Recommended Practice 2.22
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Recommended Practice
Implementation Status
2.22
Additional safeguards (e.g., double checking by a second
specialist) are implemented in the EHR before high risk
medications are prescribed.
Checklist
Rationale for Practice or Risk Assessment
Medication errors are the most common type of
error that reach patients and cause harm. For high
risk medications, additional safeguards are
justified to reduce the likelihood of harm.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Pharmacy
Examples of Potentially Useful Practices/Scenarios
▪ A clinician- or specialist-driven process is in place to
identify high risk medications that justify additional
safeguards and integrate those safeguards into the
EHR.
▪ Chemotherapy agents require special authorization and
are displayed in a visually distinct way (e.g., different
color, italics).
▪ "TALLman lettering" is used to reduce CPOE errors
from orthographically similar medication names (i.e.,
look-alike or sound-alike medication names; for
example, acetaZOLAMIDE and acetoHEXAMIDE).
110,
111, 112
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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Recommended Practice 3.1
Worksheet
Domain 3 —
Monitoring Safety
> Table of Contents > About the Checklist > Team Worksheet > About the Practice Worksheets
> Practice Worksheets
Recommended Practice
Implementation Status
3.1
Key metrics related to CPOE and CDS (e.g.,
override rates) are defined, monitored, and
acted on to optimize safety and use.
40, 43, 113
Checklist
Rationale for Practice or Risk Assessment
Well-designed and correctly used CPOE and CDS can
reduce the most common errors that harm patients.
Monitoring and oversight of the performance and clinician
use of CPOE and CDS functionality allows optimization
of a powerful driver of improved patient safety in an EHR-
enabled healthcare system.
Suggested Sources of Input
Clinicians, support staff, and/or
clinical administration
EHR developer
Health IT support staff
Examples of Potentially Useful Practices/Scenarios
▪ Key CPOE and CDS safety indicators are monitored and
reported to leadership on a periodic basis. Examples
include:
▪ Rates of preventable ADEs
▪ CPOE use rate
▪ Frequency (i.e., volume) of orders that generate an alert
▪ Override rate (i.e., percent of alerts that are overridden) in
comparison to alert volume
▪ Median turnaround time for STAT laboratory or radiology
results
▪ Percent of all orders requiring modification by someone other
than the ordering provider
▪ Alerts with the highest percent of overrides (note: these
should be evaluated periodically for effectiveness and turned
off if deemed unacceptable)
▪ Usage of evidence-based order sets
▪ Clinician satisfaction with CDS alert functionality
▪ Results of any CPOE evaluation tool
Assessment Notes
Follow-up Actions
Person Responsible for Follow-up Action
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References
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