Computer Provider Order EntryCPOE

The First Step in Computerized Decision Support

Bruce Slater, MD, MPH 263-8242 - Pager 9015

DGIM Primary Care Conference 4/14/2004

Learning Objectives

• Be able to – describe what CPOE is– describe proven advantages of CPOE– describe what is expected of attending

physicians using CPOE– articulate advantages of CPOE for physicians at

UWHC

Financial Support

• No outside support

Introduction

• Definitions– Clinical Decision Support (CDS)– Not Continuing Medical Education (CME)– Computer-based Patient Record (CbPR)– Clinical Data Repository – CDR (WISCR-IT)

Background

• CPOE is the infrastructure for CDS

• Why aren’t we there yet?

• Security, Standards and Simplicity

• What it can’t do

The CbPRS as CarCockpit

Lubricants

AcceleratorBrake

Fuel to Engine

Transmission

Driver

Car Part Function CbPR Part FunctionDashboard Status Display Screen Status

Steering/Pedals Control Keyboard/Mouse Control

Fuel&Engine Propulsion CDR Clinical Data

Accelerator Move forward Reminders Do things

Brake Stop Alerts Don’t do things

Transmission Transfers power Standards Transmits messages

Lubricants Reduces friction Terminologies Reduces misunderstanding

Driver In Charge Provider In Charge

How it works – 1

CPOE

Action 2000Orders

WISCR-IT CDR

A2K terminal(HUC)

MD-on WebBrowser

Paper Orders

Med OrdersRxTFC Accuscan

Intermediate Document

MD-paper orders

CPOE

How it works – 2Personal Computer

The Network

http

Web Browser

Java Virtual Machine

CPOE

Screen Painter

Form Printer

Dialog Boxes

WISCR-IT

How it works – 3

How it works – 4

How it works – 5

How it works - 6

Evidence-based Informatics - 1

• Tierney, et al. JAMA 1993– Financial

• Total Charges – $6964 v $6077 12.7% less (p=.02)• Test Charges - $1852 v $1621 12.5% less (p=.006)• Drug Charges - $1181 v $1001 15.3% less (p=.008)

– Time• Minutes writing orders 25.5 v 58.5 more (p<.001)• 5.7 minutes less writing “scut cards” (p=.02)

– Acceptance• 52% of housestaff users thought it made work easier

Evidence-based Informatics - 2

• Kuperman, et al. Annals 2003– Review article

• Time entering orders – 3 studies summarized– Shu 2001 – (9% v 2.1%) minus 2% = 5% more time

– Bates 1994 – (10.5% v 5.3%) minus 2.7% = 4.5% more time

– Overhage 2001 – 6.2% overall p=NS. Experienced users neutral.

• Drug monitoring and preventive care– Overage 1997 – 46.3% v 21.9% p<.001

• Lab Orders– Tierney 1990 – 13-14% fewer tests and charges p<.05

Evidence-based Informatics - 3

• Kuperman, et al. Annals 2003 (continued)– Medication Errors

• Bates 1998 – 55% fewer non-intercepted serious med error, p=.01 17% less ADEs p>.2

• Shojania 1998 – 32% fewer Vanco orders p=.04

• Bates 1999 – 81% fewer non-missing dose errors

• Evans 1998 – 86% fewer Antibiotic ADEs, 94% fewer mismatches, also fewer excess doses

Evidence-based Informatics - 4

• Mekhjian 2002– Process variables

• Med turn-around time 64% reduction p<.0001

• Radiology completion time 43% reduction p<.05

• Lab result reporting time 25% reduction p=.001

• Un-countersigned orders reduced 34%

• Length of stay decreased .2 days in acute hospital, no change in cancer hospital

The Leapfrog Group

• 145 large healthcare purchasers • “Safety Leap” forward in health care quality• Pay (more) for (higher) performance• Consumer education and report cards• First 3 Safety standards

– CPOE– Evidence-based hospital referral– ICU physician staffing

The Institute Of Medicine

• To Err is Human – 48,000-98,000 lives/year

• Exact figure is controversial, but not idea

• 17-29 Billion in cost per year

• Under-use, Overuse and Misuse

• System problem NOT “bad apples”

• Systems can be designed to make it easier to do the right thing than the wrong thing

CPOE at UWHC

• Workflow, workflow, workflow

• “Wetware” more important that hardware or software.

• Rollout schedule – pilot until all bugs out

• No firm schedule for subsequent units

• Swarming support 24/7 for 6 weeks

• Daily status meeting, weekly feedback

“Microscope Effect”

• Nursing sign-off and acknowledgement

• Multiple wrist band printing

• Nurses feel “monitored”

• Height not measured

• Verbal order policy ‘misunderstanding’

Inpatient before Outpatient

• Error prevention more crucial

• Costs higher

• Costs accrue to bottom line

• Hospital infrastructure ready

• Less diverse infrastructure

• More experience around the country

What we have found so far

• Positive Issues for Attendings– Orders available

quicker– Able to see all orders– Able to check orders

offsite– Able to check if certain

labs ordered instead of paging houseofficer

• Positive Issues for Housestaff– Speeds up intern work

– Charts more available

– Less call back

– Antibiotics hung quicker

Challenges

– Some decrease of communication between physicians and nurses

– Mixed environment (paper/CPOE) unsatisfying to HUC and RN, they prefer all CPOE!

– CPOE process will force difficult issues to be addressed before implementation can proceed

– Some errors introduced during transition– Pharmacy work load has increased

Obstacles expected but not seen

• Response time was not too slow• Software was not difficult to

understand • There were not excessive warnings• Orders were not hard to find• CPOE does not prevent any order

being written

Cedars-Sinai Medical Center

• 877 Bed hospital in Los Angeles• 1800 physicians – mostly attendings• CPOE part of system removed after 4 months due

to “revolt” of 400 physicians• 2 week pilot in OB in July, 2 weeks per floor• Human factors, workflow not adequately

considered.• Software had “functionality issues”• Inadequate education of physician users

What is Expected of Attendings

• Ask residents about non-formulary medications written

• Ask residents about DNR/DNI order changes• Encourage residents to use CPOE as intended and

not “work around it”• Listen to residents comments and concerns about

CPOE and let me know• Let me know of your own comments or concerns

Questions and Comments

Bruce Slater 263-8242 - Pager 9015