Spotlight on Work Flow June 1, 2010
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Getting the most out of CPOE

Mercy Medical Center prioritizes physician adoption, satisfaction and improved patient care in selection and implementation of CPOE.

Ten years after the landmark Institute of Medicine report "To Err is Human," the nation's healthcare system finds itself at a crossroads. One of the central recommendations to come from this report was to leverage technology, namely computerized physician order entry (CPOE), to decrease medical errors and the financial costs attendant to them. Despite this report and many others like it, the industry has failed to capitalize on the promise of better outcomes and lower costs through order automation.

Numerous studies have reported opportunities to reduce errors by greater than 80 percent through CPOE. Yet barely one-third of all hospitals have purchased some form of CPOE, and fewer than 10 percent of physicians actually make use of the system to enter their orders. The challenges are magnified in community hospitals where physicians typically are not employed by the hospital, have independent practices in the community, admit patients to multiple hospitals and spend limited time at the hospital each day.

Mercy Medical Center, a community hospital located in Cedar Rapids, Iowa, is taking on the challenge of implementing CPOE with a unique approach to encourage use among its staff of 400 affiliated physicians. Averaging more than 10,500 admissions and 300,000 ambulatory visits a year, Mercy Medical Center is a typically sized community hospital with an atypical approach to technology acquisition. Mercy has long believed in an IT strategy that provides mutual benefit to the hospital and its affiliated physicians who face mounting pressures on their schedules and declining reimbursements. Mercy proceeded with a strategy that prioritized physician adoption and satisfaction as a precursor to implementing CPOE, and adopted a solution that will ultimately support both increased quality outcomes and meaningful-use compliance.

With each additional application connected to the PatientKeeper portal, Mercy has driven physician adoption of technology without changing the way physicians practice medicine.

The benefits of CPOE

CPOE systems have been lauded for their ability to prevent medical errors, improve outcomes and reduce healthcare costs. It is estimated that more than 1 million serious medication errors occur every year in U.S. hospitals, including administration of the wrong drug, drug overdoses, drug interactions and drug allergies. Adverse drug events (ADEs) and other errors result in increased morbidity, mortality and financial costs to the healthcare system. A single ADE can contribute an average of $2,000 to the cost of a hospitalization, resulting in over $7.5 billion in hospital costs nationwide. CPOE is often cited as a way to avoid these events through improved legibility, avoiding transcription error, interaction alerts and through enforcing the practice of evidence-based medicine.

The paradox of physician adoption of CPOE In February of 2009, the federal government introduced the concept of meaningful use of certified EHR technology as part of the HITECH Act. Requiring CPOE as a central objective in stage 1 of the meaningful-use objectives has resuscitated interest in these systems by vendors and hospitals alike; however, its less than stellar adoption history remains as a steep challenge.

While the case for CPOE is fairly well established, there are many shortcomings that physicians often attribute to these systems. Foremost among them is the negative impact on physicians' time. Although often touted as being time-neutral, traditional CPOE systems rarely achieve that baseline requirement. Overly complex user interfaces and navigation challenges require physicians to click through too many screens and provide additional, non-clinical information. The learning curve for CPOE systems is steep, particularly for physicians who practice in multiple locations and are required to learn different systems. The net result of these shortcomings is a negative impact on a physician's income. When one considers that a 10 percent decrease in physician productivity results in a 20 percent decrease in income, any extra time spent negotiating cumbersome systems can quickly try physicians' patience and place their admitting relationship with the hospital at risk.

Traditional CPOE systems also suffer from a general belief that they actually challenge a physician's ability to practice medicine. Whether fighting "alert fatigue" or the insistence that overly complex order sets represent "cookbook medicine," traditional CPOE is often seen as an impediment to their practice of medicine rather than supportive of their work flow. CPOE can also change valuable communication patterns that exist between other caregivers. Conversations with nurses - as well as ancillary department staff, such as pharmacists and lab technicians - are eliminated or minimized by traditional CPOE systems; these conversations can result in valuable feedback and sometimes even necessary order revisions. Given that most systems are designed to support ancillary rather than physician work flows, the conflict between system implementation and physician adoption should not come as a surprise.

Regardless of the reasons for the failure of CPOE, hospitals must reconsider this functionality as part of the meaningful-use objectives, which require real physician adoption within a few short years. New and unique approaches to CPOE will be required to increase physician adoption and help hospitals maximize their HITECH stimulus incentives.

Mercy's approach to technology

Three years ago, Mercy began implementing a plan to preserve its investments in core hospital information systems while simultaneously addressing concerns about usability. By investing in the PatientKeeper Physician Portal to integrate disparate technologies, Mercy was able to improve access to patient information and drive adoption of technology to levels that did not previously exist. With each additional application connected to the PatientKeeper portal, Mercy has driven physician adoption of technology without changing the way physicians practice medicine.

Mercy has decided to build on this success by taking the same approach to selecting and implementing PatientKeeper CPOE. In doing so, Mercy has avoided a common and costly requirement to replace back-end, ancillary systems. Rather than implementing a system that attempts to meet the needs of all departments, Mercy was able to focus on a CPOE solution that meets the needs of their physicians first and foremost while integrating with existing departmental systems.

The tenets of successful CPOE

Mercy is taking a unique approach to CPOE that focuses on driving physician adoption and saving physicians' time. This approach is predicated on the following key tenets:

  • Routing orders to existing departmental systems. Many CPOE vendors require an expensive replacement of all ancillary systems; however, Mercy wanted to leverage their existing IT infrastructure by routing orders to existing departmental systems. This approach enabled Mercy to create a more efficient front end for physicians that supports their work flow while providing a less expensive and quicker implementation.
  • Allowing physicians to continue to rely on the expertise of other clinicians. Many CPOE systems expose physicians to the universe of decision-support rules at the point of care (including critical and non-critical alerts). These systems force physicians to provide additional clinical expertise that is currently provided by clinical pharmacologists, radiologists, nurses and other clinicians. This ultimately slows down physicians, inhibits CPOE adoption and does little to improve clinical quality.
  • Tailoring order sets to individual physicians and incorporating evidence-based medicine where available. Waiting for agreement on standard order sets as an implementation requirement is unnecessary and can result in physician rejection of CPOE. Instead, Mercy wanted to use personalized order sets to reflect the way individual physicians practice medicine and to make the entry of orders quick and easy. As the system collects data on actual ordering practices, the hospital will begin to incorporate and/or modify evidence-based order sets as appropriate.
  • Utilizing mobile and desktop computing platforms simultaneously. Organizations that have implemented CPOE often experience an increase in verbal orders that take longer to place electronically. The process of finding a workstation, signing in, and getting to the point in the system to actually place a simple order can take several minutes in the best-case scenario. Mercy wanted to provide physicians with the option of using a smart phone to enter simple orders, thereby reducing verbal orders and eliminating the associated compliance issues.
  • Supporting hybrid paper and electronic processes. While most hospitals want to immediately transition to a completely electronic work flow, Mercy is aware that order entry should support a hybrid paper and electronic process at least in the short term. Providing technology that physicians will use, built around their current work flow, may be the fastest way to achieve meaningful use. Mercy does not want to force physicians to change their work flow or wait until all back-end departmental systems are automated before implementing CPOE. Further, Mercy plans to approach the rollout of CPOE incrementally while moving toward the goal of 100 percent adoption throughout the organization over time.

With a focus on these tenets, Mercy has elected to prioritize the implementation of a CPOE system that will provide physicians with a win-win opportunity to save time and ultimately provide better patient care.

For more information on PatientKeeper solutions, click here.

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