Transcript CPOE Issues and Controversies

CPOE
Issues and Controversies
Kenneth L. Geoly, M.D.
Medical Director, Clinical Informatics
Inova Health System
Computerized
Physician Order Entry (CPOE)
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What is it...
What it is NOT...
What might it be...
Computerized
Physician Order Entry (CPOE)
What is it?
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The definition for CPOE as it is being promulgated for patient
safety is:
The use of an institutional computerized health record by
physicians to electronically enter their orders.
There are THREE major reasons to support this initiative - they
all refer to the IN-PATIENT environment
Reasons for CPOE
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Order Communication
 Clarity of Orders
 Ease of Identifying the Ordering Physician
Standardization of Care
 Clinically validated order sets for
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Clinical diagnoses
Procedures
Situations (post-op order sets)
Alerts and Reminders (Real Time Decision Support)
 Drug Safety Database (Conflict Checking)
 Clinically validated rules
Computerized
Physician Order Entry (CPOE)
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What it is NOT
There are multiple definitions for Electronic Medical
Records (EMR’s)
 In-Patient
 Office-Based
These both (OP & IP) are clinical data repositories
(CDR’s) BUT
Their use is frequently distinctly different - especially
in our area
Computerized
Physician Order Entry (CPOE)
What it is NOT (contd)
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The Office-Based EMR is per force an out growth of the basic physician
billing system. Purchased by private physician practices. Most offices
do not have them.
Most of the orders are for meds (Rx’s), labs and procedures
 usually not done in the physicians’ offices
 results are frequently manually (occasionally electronically) entered
into the system if they are entered at all.
These EMR systems are designed to track Rx’s, labs and procedures
both for clinical continuity and billing purposes and for some, to serve
as repositories of office notes
Few have real time decision support
There are usually no issues with order communication
Computerized
Physician Order Entry (CPOE)
What it Might Be
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Only when the out patient environment is electronically merged
with the in-patient environment (Universities, Mayo, fully
integrated IDN’s) does the office (clinic) based EMR become
part of a true institution based CDR and thereby a part of a
CPOE initiative
Otherwise office based EMR’s are not what Leapfrog had in
mind as benefiting from CPOE
Today’s discussion will focus on the in-patient CPOE
Computerized
Physician Order Entry (CPOE)
Issues
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IOM Report and the Leapfrog Group
 Assumptions of Value
Actual Value
Vendor Selection
Physician Acceptance and Use
Implementation
Expectations - from all sides
ROI - real and virtual
CPOE: Issues
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IOM Report (yada yada yada…)
Leapfrog Group
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Defined use of CPOE as one of the three major initiatives which
might improve medical errors
Based their data on university application of the process
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Residents, Health Care Extenders, Full time MD’s, Hospitalists
However, since pressures will still be present, CPOE is being
fostered as necessary in all in-patient clinical environments
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May affect payment, insurance status, etc
Will require that visiting attendings utilize the CPOE system
Less than 10% of all hospitals currently have it
Physician acceptance will be an issue
Best to do it proactively than reactively
Note
Actual Value of CPOE
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Order Communication
 Clarity of Orders
 Ease of Identifying the Ordering Physician
Standardization of Care
 Clinically validated order sets for
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Clinical diagnoses
Procedures
Situations (post-op order sets)
Alerts and Reminders (Real Time Decision Support)
 Drug Safety Database (Conflict Checking)
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Drug-Drug, Drug-Lab, Drug-Disease, Allergies, etc
Clinically validated rules for care
Order Communication
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Clarity of Orders
 A large percentage of written physician orders are
not clear
 100% of electronic orders are…
Physician Identification
 Between 20 and 50% of Physician signatures are
illegible
 Electronic Identification is absolute (almost…)
 Worse with larger medical staffs
Pharmacy Workflow Facilitation
MD
Unit Sec.
Nurse
Pharmacy
Notify Nurse
Rx Enters
the Order
Locate Chart
If Stat
Write Order
Flag Chart
Return Chart to
Rack
Periodically
Review
Chart Rack
Check Order
Completeness
Enters Order
in Computer
Notifies
Rx
Notify Nurse
Check Order
Completeness
Notifies
Rx
Rx Verifies
Order
Med Sent
to Floor
Standardization of Care
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Rules and order sets must be clinically and locally
validated (medical staff must approve of them before
use)
Provide a clinically validated care path for the
situations to which they refer
Most Physicians are opposed at first (“cookbook
medicine”) but rapidly become comfortable with these
order sets as they use them
Real Time Decision Support
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Pharmacy Rules (alerts) appear if there are conflicts
 Drug-Drug; Drug-Lab; Allergy; Maximum Dose
 Must be aware that the more granular these rules are, the
more they will be ignored by the users
 Rules must appear only for the most frequent and serious
situations
Other rules which are disease situation specific (Digoxin and K+;
ABX and Kidney Function)
Vendor Selection
Facts of Life...
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Many Vendors have their own CPOE modules
Most Health Care companies already have an existing Health
Care Information System (HIS)
Therefore, unless the time has come to change the HIS, even
though another Vendor’s CPOE module might be better than the
one for the existing HIS, most health care systems will be using
the one from the system they now use
What to Look for
Ease of Use
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CPOE WILL delay rounding time for visiting MD’s at first. Expect
months of grousing
The module’s must be intuitive and reflect how MD’s currently write
orders
Electronic Signature must be available by groups of orders
Order Sets must be easy to find and use
Most vendors will have already had significant input as to the use from
previous physician client consultation and this can be invaluable but...
Obtaining local physician input on the ease of use is essential
What to Look for
Options on Order Communication to Nursing
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How does a nurse or pharmacist know that an order has been
written
Nursing and Pharmacy Must Be involved in selecting the
method of communication
Most Vendors will offer flexible ways to communicate to the
nurse / pharmacist that electronic orders have been written
 Unit Secretary alerts
 Nursing Alerts - Real time
 Log-in alerts
What to Look for
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Ease of Insertion of Rules and Reminders
Most Vendors already have this
 At various stages of development
Need to have these tailorable by institution
 Density is an issue
 Adding or subtracting rules should be easy
What to Look for
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Remote Access
Big selling point for physicians
 can modify orders from home and office
 minimizes the medical record delinquencies
Need to be able to have MD’s write and sign orders
remotely
Physician Acceptance and Use
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Community Based Physicians are per force
spending less time in the hospitals
CPOE will be viewed by many as a waste of their
time and put in place mostly for the hospital’s benefit
(“…now they want us to be unit secretaries…”)
There must be significant local physician (not only the
leadership) input at multiple levels in developing and
tailoring the system before it goes live
Physician Acceptance and Use
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Physician Input:
 Screen Flow (how the orders are actually put in)
 Decision Support (which rules go in and which do not)
 Order Set Creation (best done by department or section and
validated by medical staff)
Find a Physician Champion to help implement it
Provide adequate education and support weeks before a unit
implements CPOE
Provide 24/7 support on the unit for weeks after go live
Wireless Computing will also help (usually not PDA’s)
Implementation
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Vendor Involvement
 Other Customers’ Experience will be helpful
Necessary Committees
 Representation from IS, Nursing, Pharmacy and Medical Staff
 Steering Committee
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Screen Flow
Order Sets
Decision Support
Dedicated Analyst
Project Plan with fixed (realistic) time line (six months to a year from inception to
completion of first unit)
One unit at a time
 support team, education, process development
 100% conversion by unit
Expectations
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Expect at first:
 physician resistance
 slow starting and high frustration levels
 communication issues
Expect ultimately:
 clearer orders with ease of MD ID
 improved nursing and MD satisfaction
 better patient safety and clinical care
Be Patient!
Expectations
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Do Not Expect - at first:
 Immediate Acceptance
 Significant measurable ROI
 Smooth Implementation
 The
more units come on line, the easier it will be
ROI
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Many Vendors already have an order communication
module in place (for nursing and pharmacy)
These systems may therefore provide the CPOE
module as part of this order communication module
If it must be bought separately, prices vary
Implementation costs will vary but are probably close
to .5 to 1M overall
 Mostly Staffing and support
ROI
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There will be no appreciable measurable ROI for a health care
system
The virtual ROI’s are:
 CPOE will probably be mandatory
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If the health care system doesn’t have it, there will probably be
financial penalties (California)
Improved patient safety will result in:
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Reduction in Medical Errors
Shorter Lengths of Stay (B&W’s study)
Fewer Law Suits
Better Care (Better Reputations)
Questions...