420 likes | 808 Views
The Good News
E N D
1. MISSION: IMPOSSIBLEThe Use of Technology in Promoting Physician Adoption of CPOE Massachusetts Hospital CPOE Initiative: Physician Involvement and Governance
2. The Good News & The Bad News
3. Implementing CPOE is not as difficult as you think…
4. It’s Worse.
5. The Good News You have plenty of company: CPOE adoption is growing nationally
As more community hospitals implement, a growing base of “on-the-ground” experience is available to draw from
With planning, persistence and agility the CPOE implementation mission is Possible.
6. Critical Elements of Success Securing physician acceptance requires strong hospital and medical staff leadership
Recognition that CPOE is Not an “IT Project”
CPOE implementation throws a spotlight on many imperfect clinical practices
Keeping the implementation moving involves deciding which battles to take on
7. Establishing a Vision for CPOE
8. The Migration from Paper to Electronic Don’t use CPOE as a first clinical application
Have results and other clinical data needed for decision making readily available on-line
10. Rapid vs. Gradual Deployment Deploying too quickly may not allow for changes in workflow adaptation, and result in implosion
Allowing voluntary adoption will result in stagnation beyond early adopters
The right balance is critical to achieve the “tipping point”
11. Choosing a Pilot Unit Consistent patient and physician population (e.g. minimal “boarders”)
Willing physicians and nurses
Frequent team feedback sessions
12. Dealing with Integration Issues Bidirectional pharmacy system integration is critical
Back-end integration also highly desirable for Lab and Radiology
Other ancillary areas: e.g. Dietary, Blood Bank
13. Workflow Analysis The devil really is in the details
Over-analysis of workflow is impossible
Ask staff what their processes are, but then watch them to learn what they really do
Workflow analysis must be done for every nursing unit
No matter how uniform your care unit practices are, minor variations will exist and can cause major unanticipated issues with CPOE
14. Workflow Analysis Map the current state out, then validate it
Use the “future state” map as an educational tool
Include ancillary departments in the workflow analysis as well
15. Order Notification Going from paper to electronic is unsettling for nursing staff too
Orders may be received and acknowledged in Pharmacy before the nurse even knows about them
Paper printouts provide security, but can become a crutch you can’t take away later
“Heads-up” computer display of new orders is preferable
16. Order Notification Examples Lab order “add-on’s”
Consults and other orders without an electronic back-end system
17. Training Be flexible when offering options for physician training
Clinical Support Team available by page or phone for training
Reach out to physicians who don’t sign up:
Emails, memos from Chief, schedule time through practice manager
Access to CPOE provided after training is completed
18. “At The Elbow” Implementation Support
19. Clinical Support Team Visible Clinical Support Team (CST) staff on unit 24x7 during initial 3 weeks
Offer help and assistance to MDs without being confrontational
Log issues and discuss with technical team during daily status meetings
Support is gradually “weaned” over 4-6 weeks
21. Ongoing Education Adoption and skill level will vary widely across individual physicians
Multi-mode approach to ongoing training:
Department meetings to share information
Ready availability of ongoing support
Feedback button in CPOE
“Tip of the Week”
22. Tip of the Week CPOM "Tip of the Week"
ISSUE: Chem-6 does not contain a creatinine; it will be replaced with Chem-7
TIP: Our nephrologists have pointed out that there have been some clinical problems due to use of the Chem 6 (Na, K, Cl, bicarb, BUN, glu) because it does not contain a creatinine. Therefore, on 11/7, Chem 6 will be replaced in CPOM with Chem-7 (which is a Chem-6 plus creatinine).
ISSUE: Ordering heparin and warfarin
TIP: When heparin and warfarin are ordered, it is usually necessary to order lab tests (PT/INR or PTT) and instructions to nursing (e.g., "Notify doctor for INR above x") at the same time. In CPOM, heparin and warfarin have their own order sets, which make this easy. These order sets, currently called "Warfarin Anticoag Protocol", "Heparin Initiation" and "Heparin Maintenance" should be used when ordering these drugs. At present, these order sets are found on the Order Set tab in the "General" list -- see the attachment for a picture. Very soon, it will also be possible to find these order sets on the Med/IV tab main "common list". Please use the heparin and warfarin order sets when ordering these drugs -- it takes just a little bit of 'getting used to' but works much better than ordering the drugs "alone".
If you have questions about using CPOM, page the CPOM Clinical Support Team. To reach them, use pager # 72900 or search on "CPOM" in the Partners Paging Directory and select "Clinical Support Team".
23. Hardware: No Waiting for CPOE
24. Hardware – How Much is Enough? Monitor # of physicians on each unit during peak ordering times (don’t guess!)
Account for other users (nursing, case management)
Space may be the biggest constraint
Enlist nurse managers to help prioritize use of workstations for CPOE during peak ordering times
Laptops, tablets, PDAs
25. Example Hardware Map
26. Addressing Usability Issues with Agility
27. Order Set Design & Development Use pre-existing order sets (OS) where available as a template
Think “usability” and efficiency
Consistent organization across OS (e.g. “ADCVANDISL”)
Minimize clicks (e.g. pre-checked default values)
Monitor use of OS vs Ad Hoc orders
Does the volume of non-OS orders warrant adding these to existing OS’s?
Maximize use of “Quick Pick” or “Common Lists”
28. Drugs by Classification Example
31. Quick Orders Example
36. Clinical Decision Support Achieving the right balance takes trial-and-error
Begin with a minimalist approach, and add DS incrementally
Avoid “Alert Fatigue”:
Physicians will click-through frequent alerts without reading them
37. Degrees of Decision Support
38. Change Control and Enhancements Establish a multi-disciplinary group to manage CPOE content changes and enhancements
Stick to a defined process
40. Remote Ordering Placing orders from the office or from home
Placing orders on patients who haven’t been admitted yet – “suspended orders”
Requires careful workflow analysis with nursing. They “activate” the orders.
41. Mobility Wireless Computers On Wheels (COWs) useful for team rounding
Pen-based tablets
Utility will vary with CPOE vendor software
Most users find them still too heavy to carry around
PDAs: Screen real estate too small for most CPOE applications
42. Other Technology Enhancements Rapid Sign-On and Access to CPOE
Single Sign-On
User logs in once, all applications are accessible without additional log-ins
Balancing HIPAA Privacy/Security and Clinician Workflow
43. Good Luck on Your CPOE Mission!