CPOE Workflows

This document defines eight core workflows for the Computerized Provider Order Entry (CPOE) module. Each workflow includes process steps, actors, decision points, integration hooks, exception handling, and the paperless transformation achieved by the HIS.

Regulatory context: UAE Federal Decree-Law No. 30/2021 (controlled substances), MOH Unified Electronic Platform (UEP), NABIDH/Malaffi HIE connectivity, UAE PDPL data protection. See 05-integrations.md for technical detail.

WF-CPOE-001: Medication Order Entry

Process Flow

Actor: Physician (Attending, Resident, NP/PA) Trigger: Active encounter in progress — inpatient admission, ED visit, or outpatient appointment Pre-conditions: Patient identified (Emirates ID / MRN), encounter open, allergy list reviewed

1. Physician opens CPOE from the patient chart and searches for medication by generic name, brand name, indication, or clinical problem.
2. System displays results prioritised by: - Formulary status (preferred → non-preferred → not on formulary) - Provider's prescribing history - Evidence-based order sets for the patient's active diagnoses
3. Physician selects medication and strength.
4. System auto-populates a default dose based on: - Patient age: Paediatric dosing for patients < 18 years (mg/kg) - Patient weight: Weight-based dosing when available - Renal function: eGFR-adjusted dose if CrCl < 60 mL/min - Indication: Diagnosis-specific dosing ranges
5. Clinical Decision Support (CDS) fires sequentially: - a. Drug–allergy interaction check → if alert, display severity-graded warning - b. Drug–drug interaction check → if alert, display interaction with recommended action - c. Dose-range validation → if out of range, require justification - d. Duplicate therapy check → if same class active, display active medication - e. Renal dosing check → if eGFR-adjusted dose differs, suggest adjustment - f. Formulary check → if non-formulary, display Tier 1 alternatives with cost comparison
6. Physician enters / confirms order details: dose, route, frequency, duration, PRN indication (if applicable), priority (Routine / STAT / ASAP / Today), special instructions.
7. System validates completeness and displays order summary.
8. Physician signs order electronically (Tier 2 Advanced E-Signature per Federal Decree-Law No. 46/2021).
9. If the medication is a controlled substance → route to WF-CPOE-008 for UEP submission before transmission.
10. System transmits signed order to:
    • Pharmacy Information System (HL7 ORM^O01 or FHIR MedicationRequest)
    • Medication Administration Record (MAR)
    • Patient's active orders list
    • Billing / charge capture
11. System receives pharmacy acknowledgement and updates order status.

Data Modified:

• medication_orders — INSERT
• clinical_alerts — INSERT (one row per CDS alert fired)
• order_audit_log — INSERT
• pending_pharmacy_queue — INSERT

Integration Points

Exception Handling

• Network failure during transmission: Order saved locally in retry queue; exponential backoff (30 s → 1 min → 2 min → 5 min); after 4 failures, alert user and flag for manual escalation to pharmacy.
• Hard-stop CDS alert (contraindicated): Order cannot proceed; physician must select an alternative or obtain co-signature from a second attending.
• Formulary restriction: Display preferred alternatives; allow non-formulary ordering with justification and prior-authorisation trigger if insured.
• Patient allergy list incomplete: System displays warning — "Allergy review required" — and requires physician attestation before signing.

Paperless Transformation

Remaining Paper Touchpoints: Patient may receive printed discharge medication instructions if they opt out of portal access.

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• Medication order exists with order_status = 'active' and valid e-signature
• Pharmacy queue contains pending order for pharmacist verification
• MAR schedule generated with administration times
• All CDS alerts logged with provider response (accepted/overridden)

SLA and Timing

State Transition Diagram

WF-CPOE-002: Laboratory Order Entry

Process Flow

Actor: Physician (Attending, Resident, NP/PA) Trigger: Clinical need during active encounter Pre-conditions: Patient identified, encounter open

1. Physician opens Lab Orders panel and searches by test name, LOINC code, CPT code, or clinical indication.
2. System displays results grouped by: - Individual tests (Chemistry, Haematology, Microbiology, etc.) - Lab panels (BMP, CMP, CBC, Lipid Panel, LFTs) - Provider favourites and diagnosis-based order sets
3. Physician selects one or more tests.
4. CDS checks fire: - a. Duplicate test detection — alert if same test performed within look-back window (CBC: 24 h, HbA1c: 90 days, Lipid Panel: 30 days) - b. Pregnancy screening — for females of child-bearing age, alert if radiation-associated order or teratogenic medication context - c. Insurance / prior-authorisation check — display coverage status and required ICD-10-AM codes
5. Physician enters order details: collection date/time, priority (STAT / Today / Routine), specimen type (auto-selected, overridable), clinical indication (ICD-10-AM), fasting requirement, special instructions.
6. System validates and physician signs order electronically.
7. System transmits to LIS via HL7 ORM^O01.
8. LIS assigns specimen barcode and notifies nursing / phlebotomy.
9. Specimen collected → scanned → transported → received in lab.
10. Results transmitted back via HL7 ORU^R01 and displayed in patient chart.

Data Modified:

• laboratory_orders — INSERT
• clinical_alerts — INSERT (if CDS fired)
• order_audit_log — INSERT

Integration Points

Exception Handling

• Duplicate test within window: Soft-stop alert; physician can override with documented clinical reason.
• STAT lab not collected within 30 min: Escalation alert to charge nurse.
• Critical result received: System flags result, sends push notification to ordering provider, requires acknowledgement within 30 minutes (DOH/DHA critical result policy).
• Specimen rejected by lab: LIS sends rejection message; nursing re-collection triggered.

Paperless Transformation

Remaining Paper Touchpoints: None — fully digital from order to result.

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• Lab order exists with order_status = 'active' and valid e-signature
• LIS has received order and assigned specimen barcode
• Nursing/phlebotomy notified for specimen collection
• Charge captured for billing

SLA and Timing

State Transition Diagram

WF-CPOE-003: Imaging / Radiology Order Entry

Process Flow

Actor: Physician (Attending, Resident, NP/PA) Trigger: Clinical need during active encounter Pre-conditions: Patient identified, encounter open

1. Physician searches by imaging modality + body part (e.g., "CT head without contrast").
2. System displays matching exams with ACR Appropriateness Criteria scores where available.
3. Physician selects exam.
4. CDS checks fire: - a. Appropriateness criteria — if "usually not appropriate", display recommendation and evidence - b. Contrast safety — if contrast-enhanced: check eGFR (iodinated: CIN risk if < 60), check allergy list (iodine, gadolinium) - c. Pregnancy screening — for radiation-based studies in females of child-bearing age - d. Cumulative radiation dose — alert if projected annual dose exceeds threshold (> 50 mSv)
5. Physician enters order details: exam protocol (with/without contrast, specific views), clinical indication (ICD-10-AM + free-text clinical question), priority, scheduled date/time, portable vs. department, pregnancy status attestation.
6. System validates and physician signs order electronically.
7. System transmits to RIS via HL7 ORM^O01; DICOM modality worklist updated.
8. RIS schedules exam; patient transported or portable imaging arranged.
9. Images acquired, stored in PACS.
10. Radiologist interprets and signs report.
11. Report transmitted back via HL7 ORU^R01 and displayed in patient chart.

Data Modified:

• imaging_orders — INSERT
• clinical_alerts — INSERT (if CDS fired)
• order_audit_log — INSERT

Integration Points

Exception Handling

• Appropriateness criteria override: Require free-text justification; logged in order_audit_log.
• eGFR unavailable: System flags "Renal function unknown — obtain serum creatinine before contrast study"; order held pending result.
• STAT imaging not performed within target: Escalation to radiology charge technologist.
• Critical finding on imaging: Radiologist sends critical result notification; ordering provider must acknowledge within 30 minutes.

Paperless Transformation

Remaining Paper Touchpoints: Patients may receive printed imaging reports for external referral if the receiving facility is not on NABIDH/Malaffi.

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• Imaging order exists with order_status = 'active'
• RIS has received order and added to scheduling worklist
• DICOM modality worklist updated for imaging equipment
• Radiation dose projection recorded if applicable

SLA and Timing

State Transition Diagram

WF-CPOE-004: Order Modification

Process Flow

Actor: Ordering provider (original) or covering provider with appropriate privileges Trigger: Clinical reassessment, pharmacist clarification, or lab/imaging result prompting change Pre-conditions: Active order exists in medication_orders, laboratory_orders, or imaging_orders

1. Provider opens the active order from the patient's orders list.
2. Provider selects "Modify Order".
3. System displays current order details and editable fields.
4. Provider modifies field(s): dose, frequency, route, duration, priority, special instructions.
5. System re-runs CDS checks on the modified values (drug–allergy, DDI, dose-range, renal dosing, formulary).
6. If CDS alerts fire, provider responds (accept recommendation, override with reason, or cancel modification).
7. Provider reviews modified order summary.
8. Provider re-signs order electronically (new Tier 2 e-signature required for any dose/frequency/route change).
9. System: - Updates the order record with modification details and new signature - Inserts an audit log entry capturing old values, new values, modifier, and timestamp - Transmits updated order to downstream systems (Pharmacy, LIS, RIS as applicable) - Updates MAR if medication order was modified
10. Downstream system acknowledges modified order.

Data Modified:

• medication_orders / laboratory_orders / imaging_orders — UPDATE
• order_audit_log — INSERT (with action = 'Modified', old/new values captured)
• pending_pharmacy_queue — UPDATE (if medication order)

Integration Points

Exception Handling

• Order already dispensed/collected: Pharmacist / lab notified; may require new order instead of modification.
• Modification by non-ordering provider: System checks covering-provider relationship; if not authorised, modification blocked with escalation to ordering provider.
• Controlled substance modification: Any change to a CDa/CDb medication triggers re-submission to MOH UEP (WF-CPOE-008).

Paperless Transformation

Remaining Paper Touchpoints: None.

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• Order record updated with new field values and fresh e-signature
• Audit log captures old values, new values, and modification reason
• Downstream system has received and acknowledged the modified order
• MAR schedule regenerated if medication timing changed

SLA and Timing

Note: Order Modification transitions the parent order through the Modified → Active path in the state diagrams defined in WF-CPOE-001 (Medication), WF-CPOE-002 (Lab), and WF-CPOE-003 (Imaging). No separate state diagram is required.

WF-CPOE-005: Order Cancellation / Discontinuation

Process Flow

Actor: Ordering provider or pharmacist (for safety-related cancellation) Trigger: Clinical reassessment, adverse reaction, patient discharge, or duplicate order identified Pre-conditions: Active order exists

1. Provider opens the active order and selects "Cancel" or "Discontinue". - Cancel: Order has not yet been acted upon (not dispensed, not collected, not performed). - Discontinue: Order is active and doses have been administered or tests performed; stop future actions.
2. System prompts for: - Reason for cancellation / discontinuation (required — dropdown + free text) - Effective date/time (immediate or future)
3. Provider confirms and signs electronically.
4. System updates order status: - Cancel → order_status = 'cancelled' - Discontinue → order_status = 'discontinued', discontinue_datetime set
5. Downstream notifications: - Pharmacy: cancel pending dispense / update MAR to stop future doses - LIS: cancel pending collection - RIS: cancel scheduled exam - NABIDH / Malaffi: send cancellation message
6. MAR updated: future scheduled administrations removed.
7. Audit log entry captured.

Data Modified:

• medication_orders / laboratory_orders / imaging_orders — UPDATE (status)
• order_audit_log — INSERT (action = 'Cancelled' or 'Discontinued')
• pending_pharmacy_queue — UPDATE (status = 'Cancelled')

Exception Handling

• Medication already administered: Cannot cancel; only discontinue to stop future doses.
• Specimen already collected: LIS notified to cancel processing if not yet started; if in-process, result will be delivered normally.
• Controlled substance cancellation: Cancellation reported to MOH UEP; inventory adjustment triggered in PIS.

Paperless Transformation

Remaining Paper Touchpoints: None.

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• Order status set to cancelled or discontinued with reason and e-signature
• No future actions scheduled for this order (MAR cleared, collection cancelled, exam cancelled)
• Downstream systems notified and acknowledged
• Audit trail complete with cancellation reason

SLA and Timing

Note: Cancellation and discontinuation transition the parent order to terminal states (Cancelled, Discontinued) in the state diagrams defined in WF-CPOE-001, WF-CPOE-002, and WF-CPOE-003. No separate state diagram is required.

WF-CPOE-006: Verbal / Telephone Order Entry

Process Flow

Actor: Nurse or Unit Clerk (enters order), Physician (authorises verbally, co-signs within 24 hours) Trigger: Physician verbally communicates an order during an emergency, procedure, or telephone call Pre-conditions: Active encounter; receiving person has verbal-order entry privilege

1. Nurse / clerk opens CPOE and selects "Verbal Order" or "Telephone Order" mode.
2. System displays a prominent banner: "VERBAL ORDER — requires co-signature within 24 hours".
3. Nurse / clerk enters the order details as dictated by the physician, using read-back verification: - Medication/test/imaging details - Dose, route, frequency (for medications) - Priority - Clinical indication
4. System runs CDS checks (same as WF-CPOE-001/002/003).
5. Nurse / clerk enters: - Name of ordering physician (selected from provider list) - Read-back verification attestation checkbox
6. Nurse / clerk signs the order entry (Tier 1 Simple E-Signature).
7. System creates the order with order_source = 'verbal' or 'telephone' and cosign_required = TRUE.
8. Order is transmitted to downstream systems immediately (same as regular order).
9. System generates a co-signature task assigned to the ordering physician.
10. Physician must open and co-sign the order within 24 hours (Tier 2 Advanced E-Signature).
11. If not co-signed within 24 hours → escalation: notification to department chair and compliance.

Restrictions:

• Controlled substances (CDa): Verbal orders not permitted for CDa medications (Federal Decree-Law 30/2021). CDb verbal orders permitted in emergencies with 24 h co-signature.
• High-risk medications (chemotherapy, anticoagulants): Verbal orders discouraged; system displays strong advisory.

Data Modified:

• medication_orders / laboratory_orders / imaging_orders — INSERT (with order_source, cosign_required, entered_by)
• order_audit_log — INSERT
• cosign_tasks — INSERT

Exception Handling

• CDa verbal order attempt: Hard block — system does not allow verbal order entry for CDa medications.
• Co-signature overdue: Automated reminders at 12 h, 18 h, 23 h; escalation at 24 h.
• Order entered incorrectly: Physician modifies or cancels during co-signature review (triggers WF-CPOE-004 or WF-CPOE-005).

Paperless Transformation

Remaining Paper Touchpoints: None.

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• Order is active and transmitted to downstream systems immediately
• Co-signature task exists with 24-hour deadline assigned to ordering physician
• Read-back verification attestation recorded in audit log
• CDa verbal orders blocked; CDb verbal orders flagged with emergency documentation

SLA and Timing

State Transition Diagram

WF-CPOE-007: Order Set Execution

Process Flow

Actor: Physician (Attending, Resident, NP/PA) Trigger: Diagnosis or clinical scenario matching a pre-built order set (e.g., "Sepsis Workup", "Chest Pain Admission", "Post-Op Total Knee Replacement") Pre-conditions: Active encounter; order set active in order_sets master data

1. Physician opens Order Sets and searches by diagnosis, clinical problem, or order set name.
2. System displays matching order sets with: - Description and clinical rationale - Date last reviewed / approved by P&T committee - List of included orders (medications, labs, imaging, nursing, dietary)
3. Physician selects an order set.
4. System expands the order set into individual order lines, each pre-populated with default values.
5. Physician reviews and customises: - Deselect items not needed (checkbox per item) - Modify doses, frequencies, or timing for individual items - Conditional items activate based on patient criteria (e.g., "If eGFR < 30, add dose adjustment")
6. CDS checks fire per individual order item (same rules as standalone orders).
7. Physician reviews the composite order summary.
8. Physician signs all orders with a single electronic signature (batch signing).
9. System creates individual order records for each selected item.
10. Orders transmitted to respective downstream systems (PIS, LIS, RIS) as individual messages.
11. Time-sequenced orders scheduled according to order set timing rules (e.g., "Lab at T+4h", "Imaging at T+24h").

Data Modified:

• medication_orders / laboratory_orders / imaging_orders — INSERT (multiple)
• order_set_executions — INSERT (linking execution to order set template)
• clinical_alerts — INSERT (per-item CDS alerts)
• order_audit_log — INSERT (per order, referencing order set)

Exception Handling

• CDS alert on one item in set: Alert displayed inline; physician can override, modify, or deselect that item without affecting other orders.
• All items deselected: System warns "No orders selected" — order set not executed.
• Outdated order set: If order set has not been reviewed within 12 months, system displays advisory; clinical pharmacist notification triggered.

Paperless Transformation

Remaining Paper Touchpoints: None.

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• Individual order records created for each selected item
• Order set execution logged with template reference and customisation details
• All items transmitted to appropriate downstream systems
• Time-sequenced orders scheduled according to timing rules

SLA and Timing

State Transition Diagram

WF-CPOE-008: Controlled Substance Ordering (UAE-Specific)

Process Flow

Actor: Physician with MOH Controlled Substance Authorisation Trigger: Order for a medication classified as CDa (Narcotic or Psychotropic) or CDb per Federal Decree-Law No. 30/2021 Pre-conditions: Active encounter; physician's controlled substance prescribing privilege verified; patient Emirates ID on file

UAE Regulatory Authority: Federal Decree-Law No. 30/2021; Ministerial Decree No. 379/2019 (UEP mandate). See reference-data/compliance/uae-regulations.md §Controlled Substances for full schedule mapping.

1. Physician initiates medication order (enters WF-CPOE-001 steps 1–6).
2. System detects the selected medication's controlled_class (CDa-Narcotic, CDa-Psychotropic, or CDb) from medication_master.
3. Pre-checks: - a. Verify physician has MOH controlled substance authorisation → if not, hard block. - b. Check encounter type: if telehealth → hard block (telehealth prescribing of controlled substances prohibited in UAE). - c. Self-prescribing check: if ordering_provider_id matches patient → hard block (Art. 82). - d. Enforce maximum supply duration: CDa ≤ 30 days; CDb ≤ 90 days.
4. UEP Integration (Unified Electronic Platform): - System submits prescription to MOH UEP via REST API. - UEP performs:
   • Patient eligibility verification (Emirates ID)
   • Prescriber authorisation verification
   • Duplicate prescription detection across all UAE facilities
   • Quantity limit validation
   • UEP returns: uep_prescription_id + approval status.
5. CDa-specific requirements (Schedules 1–6): - System generates a serialised special prescription number (special_prescription_number). - Qualified e-signature required (Tier 3 per Federal Decree-Law 46/2021). - Dual verification by pharmacist required before dispensing.
6. CDb-specific requirements (Schedules 7–8): - Standard prescription form with controlled substance notation. - Advanced e-signature (Tier 2) required. - Pharmacist verification required.
7. System records uep_prescription_id, uep_submission_status, and uep_submission_datetime on the order.
8. Order transmitted to Pharmacy with controlled substance metadata.
9. Pharmacist performs independent dual verification (CDa) or standard verification (CDb).
10. Dispensing confirmation reported back to UEP.
11. All transactions logged in controlled_substance_inventory for MOH reporting.

Data Modified:

• medication_orders — INSERT (with controlled substance columns: controlled_class, uae_legal_schedule, uep_prescription_id, special_prescription_number, dual_verification_by)
• controlled_substance_inventory — INSERT (transaction_type = 'dispensing')
• order_audit_log — INSERT
• clinical_alerts — INSERT (if duplicate detected by UEP)

Integration Points

Exception Handling

• UEP unavailable: Order queued; system retries with exponential backoff. If unavailable > 30 min, alert compliance officer. CDa orders cannot be dispensed without UEP approval. CDb 72 h emergency supply permitted with documented follow-up.
• UEP duplicate detection: Provider reviews existing prescription details; if clinically justified, override with documented reason.
• Pharmacist dual verification denied: Order returned to prescriber with pharmacist notes; prescriber must modify or cancel.
• Inventory discrepancy: Auto-alert to pharmacy director and compliance; investigation workflow triggered.

Paperless Transformation

Remaining Paper Touchpoints: MOH-witnessed destruction of expired controlled substances may still require a paper destruction certificate with physical witness signatures (pending digital destruction workflow in UEP).

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• UEP prescription ID recorded on order
• CDa orders have serialised special prescription number and Tier 3 e-signature
• Pharmacy notified with all controlled substance metadata for dual verification (CDa) or standard verification (CDb)
• Dispensing confirmation reported back to UEP
• Inventory transaction logged for MOH reporting

SLA and Timing

State Transition Diagram

Cross-Workflow Reference

Related Modules

• PIS (Pharmacy Information System): Receives all medication orders; manages dispensing and MAR
• LIS (Laboratory Information System): Receives lab orders; returns results
• RIS (Radiology Information System): Receives imaging orders; returns reports
• EHR & Patient Management: Patient demographics, allergy list, problem list, encounter context
• Scheduling: Encounter management; bed/OR scheduling
• Billing & Claims: Charge capture triggered by signed orders
• Policy & Contract Management: Formulary and coverage data for CDS checks