Conversion to CPOE – Evidence Based Medicine

1. Conversion to CPOE – Evidence Based Medicine Mike Gorczynski, D.O. Director Medical Informatics Aurora Health Care Regional User Group 10:00am May 1, 2007 M:\MIKEGSKI\Demos\RUG Order Sets May 2007.ppt

2. Who is Aurora Health Care? • Integrated Delivery Network • 13 Hospitals (40-600 beds) • 120 Outpatient Clinics • 140 Retail Pharmacies • Long Term Care • Home Health Services • Hospice Services • Laboratory Services • One of the nation’s “Most Wired” hospitals in 2004 & 2005 & 2006 • Private, non-profit, teaching organization: • 684 employed physicians • 3,200 physicians on staff • 27,000 employees • $2.9 billion annual revenue • 0.5 million IP days/year • 2.3 million OP visits/year • 0.25 million ED visits/year • 0.3 million Home Care visits/year • 5.6 million retail Rx/year

4. EMR Applications at Aurora • Hospital “Core” systems implemented from 2000-07 • Patient Access (Registration & Scheduling) • PowerChart Orders, Results, Charges • Radiology, Surgery, Emergency Dept • Pharmacy • Interfaces: Lab, Transcription, Dietary, Digital Imaging • “Advanced” product implementations under way • PowerChart Office in Clinics (75% done) • Multidisciplinary Clinical Documentation & eMAR (85% done) • Barcode Medication Administration (new) • CPOE (Pilot = May 2006, rollout Feb 2007)

5. Computer Physician Order Entry The Vision • 1995 - Computer-based Patient Records (CPR), including CPOE The Urgency • 1999 - Institute of Medicine - “To Err is Human” The Impact • reduce morbidity, mortality, and costs The Challenge • engage physicians in computer dialog without adversely impacting productivity productivity engage

6. Order Sets  Choose a strategy • Hospital-specific • Region-specific • Enterprise standard with boundaries • Enterprise standard

7. Evidence based medicine will guide development of system wide order sets.

8. Aurora Health Care CPOE Physician Champion Council Aurora Board 1.Approve the strategic approach to safety 2.Approve goals 3. Strategic monitoring of Patient Safety Program and team recommendations 1. Communicate Vision, and implementation plans to each Medical Department 2. Assist soliciting participation in Evidence-based Order Sets Development process. 3. Enthusiastic user and vocal champion 4. Along with lead hospital administrators, identify challenges and plan change management tactics Quality Committee 1. Oversight of Care Management and Patient Safety strategies 2. Participate in development of strategic approaches to quality and safety 3. Review and approval of specific goals and objectives 4. Direct successful accomplishment of goals and objectives Care Management/ Quality Council 1. Benchmarking 2. Data management 3. Performance measures 4. Facilitate project teams 5. Education CM/Q Staff Clinical Informatics SubCommittee 1. Provide direction for Clinical Information technology efforts to ensure business objectives for CM, Patient Safety, and clinical process improvement 2. Identify and sponsor projects that promise value, identify barriers, and suggest measures of success 1. Communicate Vision, and implementation plans to each Medical Department 2. Assist soliciting participation in Evidence-based Order Sets Development process. 3. Enthusiastic user and vocal champion 4. Along with lead hospital administrators, identify challenges and plan change management tactics CPOE Physician Champion Council 1/17/03

9. Expectations Attend meetings Communicate with all relevant medical staff Communicate back to IS Use CPOE when your hospital is implemented Compensation for your time

10. Communications • System Leadership 21 • Physician 198 • Regional/Hospital Leaders 36 • Care Management/Quality 19 • Other 12 TOTAL 286

11. Recruit Clinical Subject Domain Expertsaka“Medical Facilitators” “Believe” in EBM and in CPOE Respected by medical staff Review literature when necessary Encourage participation by all members of medical staff

12. The Standard Aurora Process Zynx Templates and Evidence Existing Order Sets Internally developed EBM citations Evidence-Based Development Session Rendering for CPOE and ePPO Expert Panels Departments Review All Physicians Invited Expert Medical Facilitators Selected Pharmacists, Nurses, Care Managers Invited

14. Guides to Order Sets Topic Selection • It is a problem... • …that is commonly occurring • ...for which the interventions ordered vary widely • ... though uncommon, has a widely accepted though complex medical management approach • ... for which interventions ordered require time-consuming human-computer interactions • ... where there is a goal to improve a minimum service level • ... for which there is a high likelihood of achieving consensus regarding medical management • ... for which scientific rationale exists

15. Order Set Development Guidelines • Orderables compliant with 90 – 10 rule • Mandatory, default, or optional • Comments on orders • Links to evidence – Zynx and non-Zynx • Suggestions for interruptive alerts • Support system Care Management initiatives • Support regulatory requirements and CMS requirements

16. Links to evidence from within patient chart Links to evidence g

17. Zynx Summary and rationale g

18. Clinical Decision Support - CPOE

19. …Tell me why your Tx varies…

20. Keeping track of order sets

21. Some statistics… ~200 standardized Order Sets All UniqueSessions Number of Drs participating 73 165 Number of Nurses 33 69 Number of Pharmacists 11 70 Number of CM 17 41 TOTALS 134 345

22. Physician-specific statistics… Physicians participating OS development 73 Supporting physician leaders 200 TOTALS “informed” and/or participatory273 (38%) Physicians comprising 85% of admissions 722 Therefore, 273 of 722 “busiest” physicians are well-informed and/or have particpated (38%) .

23. Do’s... • Do get pharmacy input for every session, they are INVALUABLE • Do recruit physicians with a 1:1 conversation • Do explain “critical mass” as sum of {system + personal} • Do figure out who in your organization will do the work • Do encourage suggestions for Comments, Alerts, and Horizontals • Do keep track of sessions with detailed instrument • Do develop a migratory deployment plan

25. CPOE Full House Go-Live • All departments beyond pilot Units (Peds, OB, ED, Anesthesiology) • February 12, 2007 • Exempt: Milwaukee Cardio Group, Interventional Radiology • Exempt providers still expected to electronically sign verbal orders

26. In Wisconsin, measures are important…

27. 33%ile 50%ile 85%ile 90%ile

28. Utilization is underestimated by: • Exempt physicians (imminent retirement, locums) • Orders that spawn increases to denominator (e.g. range orders, sliding scales) • Learning curve data included in cumulative stats

29. Assuring Safety and Quality • AMCO Benefits Measures • CMS, Premier Measures • Medication Orders Monitoring • IS Issues Database • Incident Reports

30. AMCO Benefits Measures - TBD * Data will be indexed by number of discharges

31. CMS Premier Measures

32. Medication Orders Monitoring Summary pharmacy interventions logged: Drug dose 35 Start and Stop dates 14 Duplicate Drugs 13 Allergies 7 TPN problems 7 Drug Interactions 6 Others 39 Totals 121 (38 days  3.1 per day) Benchmark = 170 (90 days 1.8 per day)

33. IS Issues Database Discontinue PowerPlan on Pt XXX (2) Orders placed on wrong visit (2) RPh needs to change time of Rx order PCA ordered on hold x 24 hrs RT documentation not adequately descriptive

34. The Vision – did we achieve it? Success – a negotiated entity • Utilization or • Clinical transformation

35. The Vision The most important outcome for Aurora’s first sites is that we be successful. Success is most tightly linked to utilization by physicians.

36. Utilization versus Clinical Transformation Utilization • Change behavior without adversely impacting productivity • Legibility • Remote ordering capability in context of clinical data Transformation • Order Sets preferable to no Order Sets • EBM OS’s preferable to OS without EBM • Standardization – even in absence of EBM leads to improved outcomes

37. Order Sets Usage (2/12 – 4/10/07) 157 8%opportunity to move to standards 143 N = 3798

38. Usage Distribution of System OS’s 2/12 – 4/10/2007