"We have no better measure right now in this country for medication errors," Binder explained. Medication error is the "No. 1 patient safety problem by far," she continued. "We use CPOE as a proxy measure."

From the provider side, CPOE can be a big help – or, as some learned years ago, an untenable burden.

Graham Hughes, MD, chief medical officer of analytics firm SAS, was at GE Healthcare during those heady days of the mid-2000s, and previously designed and developed CPOE systems.

"I've lived it and I have the scars," Hughes quipped.

Today, what Hughes describes as the "PlayStation-Xbox generation" of physicians enter practice wondering why the level of automation has been so poor, said Hughes. "The difficulty with CPOE has been making it part of a physician's natural workflow," he suggested.

Longtime medical informatics professional Howard Landa, MD, tried to implement CPOE at Loma Linda University Medical Center in California in 2001, two years before the Cedars debacle. He brought it up on one unit, then took it down shortly thereafter because physicians complained of having to do too much work.

[See also: CPOE remains a challenge for many, surveys show.]

"We weren't accounting for the workflows," said Landa, now the chief medical information officer for Alameda County Medical Center in Oakland, Calif.
Landa, vice chairman of the Association of Medical Directors of Information Systems, knows today that there is a balance between facilitating workflow and disrupting it.

"We tried to do too much without understanding the integration of decision support into the workflow," Landa said of earlier CPOE efforts. "All that does is frustrate."

He believes CPOE has improved markedly in the last few years after a long period of stagnation. Landa used a Technicon Data Systems CPOE system as an intern at New York University in 1983.

"Between then and the early 2000s, you didn't see much difference," he said. There was little in the way of clinical decision support or workflow support for order entry, he said.

"I look at CPOE as a piece of decision support," said Landa. "Rules and alerts require CPOE." He added, "It is hard to do meaningful use without an aggressive CPOE program."

Hughes said that there is kind of a spectrum of alert fatigue. System designers have begun to distinguish between subtle guidance and "you need to act now" kind of guidance.

"There is becoming stratification of alerts," he said. And context matters. For example, test results often are abnormal in patients in intensive care, so it is almost counterproductive for a CPOE to keep flagging abnormal values in an ICU, he noted.

"I would say were in the second, maybe third generation of CPOE systems, we have a lot more refining to do," Hughes said. "There's a huge amount of opportunity for innovation still ahead."