CPOE Issues and Controversies

Kenneth L. Geoly, M.D. Medical Director, Clinical Informatics Inova Health System

Computerized Physician Order Entry (CPOE)

  

What is it... What it is NOT... What might it be...

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 IN-

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) (post-

Alerts and Reminders (Real Time Decision Support)  Drug Safety Database (Conflict Checking)  Clinically validated rules

Computerized Physician Order Entry (CPOE)



What it is NOT There are multiple definitions for Electronic Medical Records (EMRs)  In-Patient In Office-Based OfficeThese both (OP & IP) are clinical data repositories (CDRs) BUT Their use is frequently distinctly different - especially in our area

Computerized Physician Order Entry (CPOE)

What it is NOT (contd)


 

The Office-Based EMR is per force an out growth of the basic physician Officebilling system. Purchased by private physician practices. Most offices do not have them. Most of the orders are for meds (Rxs), 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 Rxs, 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


Only when the out patient environment is electronically merged with the in-patient environment (Universities, Mayo, fully inintegrated IDNs) 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 EMRs are not what Leapfrog had in mind as benefiting from CPOE Todays discussion will focus on the in-patient CPOE in-

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

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 MDs, Hospitalists

However, since pressures will still be present, CPOE is being fostered as necessary in all in-patient clinical environments in    

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



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) (post-

Alerts and Reminders (Real Time Decision Support)  Drug Safety Database (Conflict Checking)


DrugDrug-Drug, Drug-Lab, Drug-Disease, Allergies, etc DrugDrug-

Clinically validated rules for care

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

Pharmacy Workflow Facilitation

MD
Locate Chart

Unit Sec.

Nurse

Pharmacy

If Stat Write Order Periodically Review Chart Rack Check Order Completeness Enters Order in Computer Notifies Rx Notify Nurse Check Order Completeness Notify Nurse

Rx Enters the Order

Flag Chart Return Chart to Rack

Rx Verifies Order

Notifies Rx

Med Sent to Floor

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

Real Time Decision Support



Pharmacy Rules (alerts) appear if there are conflicts  Drug-Drug; Drug-Lab; Allergy; Maximum Dose DrugDrug 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...
 

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 Vendors 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


  

CPOE WILL delay rounding time for visiting MDs at first. Expect months of grousing The modules must be intuitive and reflect how MDs 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


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 Log-

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

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 MDs write and sign orders remotely

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 hospitals 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



 

 

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 PDAs)

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

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!

Expectations


Do Not Expect - at first:  Immediate Acceptance  Significant measurable ROI  Smooth Implementation


The more units come on line, the easier it will be

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

ROI


There will be no appreciable measurable ROI for a health care system The virtual ROIs are:  CPOE will probably be mandatory


If the health care system doesnt have it, there will probably be financial penalties (California) Reduction in Medical Errors Shorter Lengths of Stay (B&Ws study) Fewer Law Suits Better Care (Better Reputations)

Improved patient safety will result in:

   

Questions...