109
Chapter 4
Order/CPOE
The power to command has never meant the power to remain mysterious.
Ferdinand Foch
This chapter analyzes workflow number 2: Order/Computerized Physician Order
Entry (CPOE) from the same two perspectives as the previous Prescribe/eRx
workflow: processes and data elements.
Initially, we isolate the Order workow from the higher-level diagram
(dataflow diagram [DFD] 0), and using top-down analysis we decompose it into
lower-level processes: DFD 2.x.
We identify similarities with the Prescribe workflow, and this allows us
to reuse, with some changes, most of the Prescribe processes in the Order
workflow. Still, there are enough differences between eRx and CPOE to justify a
two-chapter approach. The similarities and differences will help us define DFD 2
and its lower subprocesses and activities.
Using the dataows from the DFD 2.x, we uncover the discrete data elements
required by the Order workflow to perform its functions. Dataflows may relate to
external actors or to the Medications database. We identify both the data struc-
tures involved in the interactions with the external actors and the data elements
used by the evolving logical model.
110 ◾  Electronic Health Record: A Systems Analysis of the Medications Domain
Processes
DFD 2 Order Workflow
First, let us isolate the Order workow from the Medications system:
Healthcare Medications Order
From DFD 0: Medications system (Figure2.3), we cut and paste workflow number
2 with its external entities, data stores, and other processes attached (Figure4.1).
The Order workflow is similar to Prescribe workow in many aspects (1–3). In
terms of processes, an ordering clinician may need to:
Review patient data
Select a new drug
Select an existing drug (and Modify, Stop, Hold, or Renew)
Select a dose
Communicate with other external actors
Consider Formulary information
Consider CDS (clinical decision support) recommendations
Sign and distribute order
The seven processes in the column in Figure4.2 (Communicate, Review
Patient Data, Select Drug, Select Dose, Consider Formulary, CDS, and Sign) with
some minor differences are actually common to all the clinical workflows related
to the medications domain—Prescribe, Order, Dispense and Administer—and
we consider reusing processes from the previous chapter as much as possible. In
Patient ID, Order
Patient parameters, CDS, Formulary
CDS
Patient parameters
Patient ID, Order
Patient parameters
ORDERING
CLINICIAN
PHARMACY
2
Order
5
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CLINICAL REPOSITORY
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Order
Figure 4.1 Order workflow: Isolated from DFD 0.
Order/CPOE ◾  111
addition, the Order workflow has two specific processes to be detailed further in
this chapter:
Use Order Set
Reconcile Meds
Let us examine the differences between the Prescribe and Order workflows
(Table4.1).
There are a couple of preconditions to DFD 2 that must be satisfied before the
system may proceed with the Order workflow:
1. Clinician is uniquely identified.
2. Clinician is authorized to use system in lieu of ordering medications.
3. Patient is uniquely identified.
4. All system’s activities are logged.
Communicate
Select Drug
Review Patient
Data
Reconcile
Meds
Select Dose
Use Order
Set
CDS
Sign
Consider
Formulary
Figure 4.2 Common processes: Order, Prescribe, Dispense, and Administer.
112 ◾  Electronic Health Record: A Systems Analysis of the Medications Domain
The Order workflow is decomposed into eight main processes (bubbles):
2.1 Communicate Order
2.2 Review Patient Data
2.3 Select Drug
2.4 Select Dose
2.5 Consider Formulary
2.6 Sign Order
2.7 Use Order Set
2.8 Reconcile Meds
If we compare the Order workflow (Figure4.3) with the Prescribe workflow
from Chapter 3 (Figure3.2), we can see several differences:
Patient and PBM (pharmacy benefit management)external actors in
Prescribeare not participating in the Order workflow. The Patient is not
planned to interact directly with the Order workflow.
The role of PBM in the Prescribe workflow is represented by the hospital
PHARMACY in the Order workow.
There are a couple of new actors (ORDER SET REPOSITORY and RULES
REPOSITORY) and two new processes: 2.7 Use Order Set and 2.8 Reconcile
Meds. The other six processes, 2.1–2.6, are reused, with some minor changes
from DFD 1.x Prescribe into DFD 2.x Order.
Even though several processes mentioned use it, CDS does not appear on DFD
2.x. As workflow number 5, it should not appear on a lower DFD. Still, we
define the dataflows to and from CDS related to Order workflow, as we will
see that several Order processes use CDS on medications. Details about the
CDS can be found in Chapter 8.
Let us proceed with the top-down analysis of the Order workow and decom-
pose DFD 2 into its children processes: the DFD 2.x.
Table4.1 Differences between Prescribe and Order Workflows
Prescribe/eRx Order/CPOE
Setting Private practice, outpatient Inpatient, ambulatory
Pharmacy Community, mail, independent Hospital pharmacy
Formulary PBM Hospital pharmacy
Complexity Simple Complex
Order set Rare Common
Meds reconciliation Rare Common
Need to cosign Rare Common
Order/CPOE ◾  113
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