A Clinical Case A Clinical Case for Physician for Physician

Adoption of Adoption of CPOECPOE

Maulin Shah, MDMaulin Shah, MD

Providence and CPOEProvidence and CPOE

St. Vincent HospitalSt. Vincent Hospital Portland Medical CenterPortland Medical Center

Providence and CPOEProvidence and CPOE

PPMC live with CPOE since 2006PPMC live with CPOE since 2006

Still primarily used by hospitalists and Still primarily used by hospitalists and residentsresidents

Small community physician adoption overallSmall community physician adoption overall

PSVMC to go live in about a year (2010)PSVMC to go live in about a year (2010)

How to drive community How to drive community physician adoption of physician adoption of

CPOE?CPOE? Establish executive and clinical leadership Establish executive and clinical leadership

buy-in of importance of CPOE and its buy-in of importance of CPOE and its clinical clinical benefitsbenefits

Create a culture of excellence in quality Create a culture of excellence in quality that can be messaged to community that can be messaged to community providersproviders

Physicians that have the Physicians that have the impressioimpression that n that CPOE will benefit patient care are more CPOE will benefit patient care are more likely to adopt itlikely to adopt it

Expect some community Expect some community resistance!resistance!

Is benefit for patients or for the hospital’s Is benefit for patients or for the hospital’s bottom line?bottom line?

Are physicians being demoted into clerical Are physicians being demoted into clerical positions?positions?

Efficiency of writing orders will go down for Efficiency of writing orders will go down for at least some time, with little perceived at least some time, with little perceived direct benefit to the physiciandirect benefit to the physician

Speak to the patients heart – bring the use of Speak to the patients heart – bring the use of CPOE back to patient care improvements!CPOE back to patient care improvements!

How to convince How to convince physicians?physicians?

Speak their language – use clinical trials Speak their language – use clinical trials where possiblewhere possible

Patient outcomes measure are best, but not Patient outcomes measure are best, but not mandatorymandatory

Remember, you are trying to establish a Remember, you are trying to establish a culture where there is uniform acceptance culture where there is uniform acceptance and the and the impression impression that CPOE improves that CPOE improves patient carepatient care

Talking points in favor of Talking points in favor of CPOECPOE

1.1. Reduction of medication errorsReduction of medication errors

2.2. Improved adherence to evidence-based Improved adherence to evidence-based guidelinesguidelines

3.3. Improved efficiency and delivery of patient Improved efficiency and delivery of patient carecare

Medication ErrorsMedication Errors

Defined as is “an error in the process of Defined as is “an error in the process of ordering, dispensing, or administering a ordering, dispensing, or administering a medication, regardless if an injury medication, regardless if an injury occurred” occurred”

Preventable ADE: Subset of medication Preventable ADE: Subset of medication errors that result in injuryerrors that result in injury

Most interventions target Preventable Most interventions target Preventable ADE’sADE’s

Reducing Medication Reducing Medication ErrorsErrors

1.1. Providing most up-to-date information Providing most up-to-date information about patient at the time of order entryabout patient at the time of order entry

2.2. Alerts to most common drug errors.Alerts to most common drug errors.a)a) Common alerts – drug-dug, drug-allergy, etc.Common alerts – drug-dug, drug-allergy, etc.

b)b) Advanced alerting – disease, age, or lab Advanced alerting – disease, age, or lab specific alertingspecific alerting

Reducing ADE’s is hard to Reducing ADE’s is hard to measuremeasure

Infrequent when compared to overall number Infrequent when compared to overall number of ordersof orders

Poorly documented and measured before Poorly documented and measured before CPOE implementationCPOE implementation

But can show reduction in errors quite But can show reduction in errors quite dramaticallydramatically

66% reduction in errors with CPOE on 66% reduction in errors with CPOE on average of studies, but only trend towards average of studies, but only trend towards reduction on ADEreduction on ADE

Digression 1: CPOE Digression 1: CPOE StudiesStudies

Mostly done at academic centers with home Mostly done at academic centers with home grown systems, large development shops, grown systems, large development shops, and large numbers of resident physiciansand large numbers of resident physicians

Translation to community context less Translation to community context less convincing, though some studies show convincing, though some studies show trends in improvement similar to larger trends in improvement similar to larger studies, but usually of less magnitudestudies, but usually of less magnitude

Digression 2: Electronic Digression 2: Electronic medical management medical management

already in placealready in place PSVMC has CDSS for pharmacists for PSVMC has CDSS for pharmacists for

medication managementmedication management

Will CPOE have as large a benefit, when Will CPOE have as large a benefit, when much of the benefit might have already much of the benefit might have already been realized with pharmacy information been realized with pharmacy information system?system?

Guideline AdherenceGuideline Adherence

Many evidence based guidelines, but poorly Many evidence based guidelines, but poorly adhered toadhered to

One of the most striking benefits of CPOE One of the most striking benefits of CPOE on patient outcomes is study on impact of on patient outcomes is study on impact of clinical alerting on VTE prophylaxisclinical alerting on VTE prophylaxis

41% reduction in VTE (true patient 41% reduction in VTE (true patient outcomes, not just process measure!) outcomes, not just process measure!)

Efficiency in CareEfficiency in Care

Careful with this argument – remember to Careful with this argument – remember to couch in terms of patient carecouch in terms of patient care

Argument is that when a medication or Argument is that when a medication or treatment or study is conducted more treatment or study is conducted more rapidly and reliably, then patients benefitrapidly and reliably, then patients benefit

Can make some argument in less callbacks Can make some argument in less callbacks to physician, less transcription errors, etc.to physician, less transcription errors, etc.

SummarySummary

Get executive and leadership buy inGet executive and leadership buy in

Create concrete messaging showing the Create concrete messaging showing the benefit of CPOE in patient care that can be benefit of CPOE in patient care that can be delivered to physiciansdelivered to physicians

Create a culture of excellence and Create a culture of excellence and expectation that all will be done to improve expectation that all will be done to improve patient quality – of which CPOE is just one patient quality – of which CPOE is just one componentcomponent