CPOE Issues and Controversies

1. CPOEIssues and Controversies Kenneth L. Geoly, M.D. Medical Director, Clinical Informatics Inova Health System

2. Computerized Physician Order Entry (CPOE) • What is it... • What it is NOT... • What might it be...

3. Computerized Physician Order Entry (CPOE) What is it? • 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

4. Reasons for CPOE • Order Communication • Clarity of Orders • Ease of Identifying the Ordering Physician • Standardization of Care • Clinically validated order sets for • Clinical diagnoses • Procedures • Situations (post-op order sets) • Alerts and Reminders (Real Time Decision Support) • Drug Safety Database (Conflict Checking) • Clinically validated rules

5. Computerized Physician Order Entry (CPOE) 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

6. Computerized Physician Order Entry (CPOE) What it is NOT (contd) • 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

7. Computerized Physician Order Entry (CPOE) What it Might Be • 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

8. Computerized Physician Order Entry (CPOE) Issues • 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

9. CPOE: Issues • IOM Report (yada yada yada…) • Leapfrog Group • 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 • 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 • 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

10. Note

11. Actual Value of CPOE • Order Communication • Clarity of Orders • Ease of Identifying the Ordering Physician • Standardization of Care • Clinically validated order sets for • Clinical diagnoses • Procedures • Situations (post-op order sets) • Alerts and Reminders (Real Time Decision Support) • Drug Safety Database (Conflict Checking) • Drug-Drug, Drug-Lab, Drug-Disease, Allergies, etc • Clinically validated rules for care

12. Order Communication • 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

13. Pharmacy Workflow Facilitation

14. MD Unit Sec. Nurse Pharmacy With CPOE Locate Chart Rx Enters the Order If Stat Notify Nurse Write Order Periodically Review Chart Rack Rx Verifies Order Flag Chart Check Order Completeness Check Order Completeness Return Chart to Rack Notifies Rx Enters Order in Computer Med Sent to Floor Notifies Rx Notify Nurse

15. Standardization of Care • 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

16. Real Time Decision Support • 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)

17. Vendor Selection Facts of Life... • 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

18. What to Look for Ease of Use • 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

19. What to Look for Options on Order Communication to Nursing • 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

20. What to Look for 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

21. What to Look for 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

22. Physician Acceptance and Use • 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

23. Physician Acceptance and Use • 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)

24. Implementation • Vendor Involvement • Other Customers’ Experience will be helpful • Necessary Committees • Representation from IS, Nursing, Pharmacy and Medical Staff • Steering Committee • 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

25. Expectations • 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!

26. Expectations • Do Not Expect - at first: • Immediate Acceptance • Significant measurable ROI • Smooth Implementation • The more units come on line, the easier it will be

27. ROI • 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

28. ROI • There will be no appreciable measurable ROI for a health care system • The virtual ROI’s are: • CPOE will probably be mandatory • If the health care system doesn’t have it, there will probably be financial penalties (California) • Improved patient safety will result in: • Reduction in Medical Errors • Shorter Lengths of Stay (B&W’s study) • Fewer Law Suits • Better Care (Better Reputations)

29. Questions...