The Relationship B etween Organizational D ynamics & C omputerized P hysician O rder E ntry

1. The Relationship BetweenOrganizational Dynamics &Computerized Physician Order Entry Tom Rosenal MD FRCPC Health Informatics Institute Algoma University 2011 Aug 27

2. Overview • Problems in decision-making in healthcare • Orders as a proxy for decisions • Electronic Health Records (EHRs) & decisions • Order entry as a solution • Why so difficult to implement CPOE? • Organizational structure, dynamics & culture • The Calgary experience 2

3. Is there a Problem in Healthcare Delivery? • Adverse events 8% admissions, ⅓ preventable, 1/6 fatal • Baker, Norton, Ghali et al, Canadian Adverse Events Study 2004 • Error rates 3-16% • Jha, Bates et al 2010, inpts, developed countries • Where in the process of care do errors arise? 3

4. Problems with Medication Safety

5. Orders Examples • Penicillin 500 mg IV q8h • Mammogram every 2 years for age 50-69 • Consult ostomy nurse Key aspects • Implies an action • Final result of a clinical decision • Communicates to team • Documents plan 5

6. Elements of an EHR Relation to Orders 1. Record of Past Events 2. Clinical Decision Support 3. Document Plan of Care Past orders Support to clinician when ordering Active orders Map

7. Why do we need EHRs? • Make optimal decisions • Organize information • Reduce cognitive load • Overcome limitations of paper • Space • Time • Interaction with clinician Applies to patients & populations 7

8. The Evolution of Ordering 2. Paper, pre-printed “Standing orders” 1. Paper, handwritten 3. Electronic orders 8

9. Computerized Physician Order Entry CPOE or Computerized Provider Order Entry 9

10. Quality-oriented, designed orders 10

11. So why not implement CPOE everywhere ASAP? • Expensive in time & money & upkeep • New kinds of errors may be worse than old – unintended consequences • Resistance to change by clinicians • Many attempts have failed • Canada – Lapointe • U.S. – Han, Shabot 11

12. Reasons for Failure to Launch • Inadequate technology • Insufficient resources • People, time, money • Goals misaligned admin – clinicians - academicians • Vendor - health care organization misaligned • Organizational culture 12

13. Elements of Organizational Culture • Shared vision of organization, individuals, goals, values • Focus (internal, external) • Processes (communication, decision making) • Degree centralization • Behaviour (risk aversion, consistency) • Capacity for change • Size, structure, heterogeneity, age, external constraints & opportunities • Documented vs. tacit 13

14. Organizational Culture • Ideology or shared beliefs that bind values to action • Myers 1982 • The fabric of the organization • Watkins & Marsick1992 • Context influencing patient safety project effectiveness • Shekelle, Bates, Greenhalgh et al 2011 • External factors • Organization structural characteristics • Teamwork, leadership, and patient safety culture • Management tools 14

15. Calgary Health Region Acute Care EHR Pt Care Info System Activated June 2009 15

16. Calgary Organizational Levers

17. Calgary Acute Care component of EHR Increasing Chance of Success • Goal: Improved care, greater capacity • Design by clinicians for clinicians • Owned by clinicians • Alignment between administration & clinicians • Leverage organizational culture • Not a technology project • Alignment of stars

18. Engagement: Clinicians In Charge • Task-oriented agendas during physician-friendly times • Encourage multi-disciplinary participation • Review on-line prototype progress at all meetings • Encourage between meeting access to evolving prototype (homework) • Know when to escalate issues out of committee • Remuneration • Make it fun Cookies 18

19. Clinical Ownership Medical Advisory Board policy 100% of all possible orders directly entered within 18 months of activation. Late 2004. Medical Department Heads Calgary Health Region 19

20. Role of the MD Super User • Help physician colleagues to optimize their use of system • Lists • Orders • Preferences & Filters • Workflow • Value-add (billing reports etc.) • Report and Escalate Issues to Project Team • Gather ideas for system improvements • Reduce irritation & stress 20

21. Project Outcomes • Well-accepted by physicians • Highly used • Revealed & reduced practice variation where measured (even sans EHR) • Model for other (not IT) projects • Platform for new interventions • Reducing postop delirium • Improving glucose management 21

22. Calgary CPOE Rates over Time 20,000 Orders/day 22

23. What We Did Less Well • Computer-based learning poorly designed & targeted • Design of nursing documentation less slick than orders • Initial blood culture orders led to poor technique • Engagement of regional quality group poor • Noncritical repairs & enhancements too slow • Clinical impact measurement minimal 23

24. Questions & Discussion ? Tom.Rosenal@AlbertaHealthServices.ca 24

25. Extra Slides

26. 1. Alignment of Clinical & Administrative Leadership • PCIS project prominent on Regional Balanced Scorecard. Metrics: • # & kind of clinician involvement • Project milestone achievements • Alignment to Regional Patient Safety • High Impact Pan-departmental Order Sets (HIPOS) • Clin Decision Supp committee of clinicians, safety staff & IM/IT set priorities for alerts, some order sets & impact reports. • Jointly planned focus on key clinical processes • Combined clinical & operational governance • Steering Committee all dept directors & heads co-chaired by exec physician & VP Advanced Tech • Clinical Design Team of 35 clinicians with many working groups • Clinical portfolio-based Clinical Adoption Councils & Unit Councils

27. Alignment: Revealing the cracks • PCIS is a catalyst. • PCIS makes many processes and workflows visible. • PCIS shows need for policy but does not determine it. • PCIS reveals opportunities. Sometimes there is time to take advantage of them. E.g. • When is tid? • Where do you keep the vital signs sheet? • What data is sufficient to uniquely identify a person?

28. Policy Pt identification & booking 100% CPOE within 18 months post-implementation - MAB Real time charting meds - PPC Orders entered by unit clerks verified before sent to performing dept – PPC Exceptions to Use of Enterprise System Policy – Steering proposed Hybrid chart clarity Projected impact Labs attributed to right pt Reduced Med errors Reduced Med errors Reduced Med errors Better Inter-dept communication Ease finding scattered pt data Examples of PCIS-related policy impact on quality

29. Alignment: PCIS – Policy body linkages • Medical Advisory Board • Health records • Professional Practices Council • Professional Practices Informatics • Executive leadership • Information Management Steering • Clinical Informatics • PCIS Steering • PCIS Clinical Design • PCIS Core clinical Design • PCIS Adoption • Clinical Documentation

30. Alignment: PCIS - Content linkages • Order set physician designate for each clinical dept appointed by dept head • Shared order set content led by local experts with communication to all affected depts • Content display guided by Clinical Decision Support Committee • Order sets • Alerts • Web content

31. 2. Effective, Early Engagement of Clinicians • System selection committee by 11 influential • Physicians (incl Chair of MAB, President of Medical Staff) • Nurses • Allied health staff • Clinical Design Team • Multi-disciplinary clinician 12 MD, 12 RN, 6 Allied Health, 6 others • Cross-departmental • Cross-site • Order set creation • 12 physicians designated by dept heads 2 years before order entry • Coordinated authors • Focus on concrete decisions • Product viewed at each meeting in real time design • Clinicians encouraged to think through processes out loud • Early awareness • Frequent presenters at rounds • Item at standing committee meetings • Informal networking • Engage clinicians via discussions with operations leaders

32. Engagement – Project clinician responsibilities • Prepare PCIS for safe & efficient use • Design of interface • Validation & design of order sets • Intelligent deployment of alerts • Automated measure of system impact • Address required workflow change • Learn from other sites using PCIS • Estimate device needs within budget constraints • Ensure appropriate training • Engage broad clinician community • Recruitment of clinicians to project • Formal communication in multiple venues • Informal communication • Segment clinicians by diffusion theory to focus engagement • Support clinicians at activation • Remove barriers • Support staff during & after activation • Super-user strategy • Act as canaries

33. Engagement: Not Everyone Can Attend Meetings – Portal access

34. 3. Unique Relationship Between Physicians & Institution • Our physicians are no different than yours… • Most are not employed by the Region, thus not “mandate-able” • Clinical depts designated a paid physician to project team • Nearly every dept (11) • 0.1 to 0.7 FTE • Project & designates met Dept Heads & Directors regularly • Reinforce their role • Communicate • Linked with regional QI physicians • Informally to project • On Clinical Decision Support Comm • Focused on positive impact • Quality of care • Quality of life of clinicians • Segmented clinicians using technology diffusion theory • Home-baked cookies at clinician meetings

35. Evidence that EHRs improve healthcare • Kaiser Permanente • Joan Ash, Dean Sittig • Veteran’s Administration • Ken Kizer, Jonathan Perlin, Paul Nichol • Harvard • David Bates, Atul Gawande, Lucian Leape • Intermountain Health Care • Brent James • Alberta • Medicine quality care: Jayna Holroyd-Leduc, Karmon Heimle • Cardiac APPPROACH registry: Merrill Knudtson, Bill Ghali • Orthopedics access: Cy Frank • Denmark GPs • Denis Protti But also unintended (bad) consequences 35

36. The 10 Commandments of Clinician Adoption • Commit to the right goal: to improve outcomes • View the system as clinical tool, not novel technology • Ensure ownership by medical leaders for the implementation’s success and establish a longer term clinical informatics culture • Design system capabilities physicians find enticing. • Groom an army of practicing physician super users • Market: Implement a physician engagement & communications model that works. • Design training methods to resonate with physicians. • Order Management is as Important as Order Entry • Reflect clinical impact back to the physician community. • Attend to Organizational Morale & build future capacity

37. How to Cross the Gap Infrastructure – Calgary • Shared vision • From Unit Clerk to CEO • Escalating & viral communication – outreach to existing venues • Clinical working groups • Involve naysayers • Committed organizational leadership • MAB policy on 100% possible order entry • Highest priority during activation • Weekly meetings site leaders 2 months pre-activation • Reasonably effective clinical community • Project begins in 7th year of regionalization • Reasonably robust info system • Previous system (~1990) near-disaster 37

38. CDS: Medical Knowledge

39. Structured & Filtered Lab Data IHI Trigger tool in action: INR

40. Clinical Summary Tab

41. Structured Order Review

42. Filtered Order Review

43. Structured Order Entry

44. Faster Structured Order Entry

45. Faster Structured Order Entry

46. Structured Order Entry – Order Set

47. Hospitalist Admission Set (detail)

48. Relevant Labs & Auto-calculation

49. Drug-Allergy Alert

50. Knowledge bases