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CPOE Deployment Marks Major Milestonein Patient Care and Safety at St. Michael’s Hospital, Toronto; Canada

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Success Story Soarian Clinicals

St. Michael’s is a 475-bed operation employing 5,250 staff Hospital.

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CPOE Deployment Marks Major Milestone in Patient Care and Safety at St. Michael’s HospitalToronto’s Urban Angel

St. Michael’s Hospital, now a $500+ million, 475-bed operation employing 5,250 staff and occupying nearly two million square feet of space in the heart of downtown Toronto, has been watch-ing over the City since the hospital’s founding by the Sisters of St. Joseph in 1892. St. Michael’s is a Catholic academic health sciences centre, fully affiliated with the University of Toronto and com-mitted to innovative patient care, teach-ing and research.

Trauma, neurosurgery, heart disease, kidney transplants, therapeutic endos-copy, bariatric surgery and multiple scle-rosis care are just a few of the hospital’s specialties, along with the largest hemo-philia program in Canada and the largest cystic fibrosis program in North America. The hospital has a reputation for provi-ding compassionate care for all who enter its doors, including some of the most disadvantaged people in Toronto’s inner city as well those referred and flown in from across Ontario for highly complex care.

CPOE Uptake Surpasses StandardsIn February, 2012, the Obstetrics unit at St. Michael’s went live with Computer-ized Physician Order Entry, marking the completion of the deployment of CPOE across all of the hospital’s inpatient acute care services. It also signaled a major milestone in the organization’s

Strategic Plan commitment to continu-ously improve patient care and safety.

“CPOE is recognized as the key enabler for safer medication management, and leading studies note a decrease of 55% to 81% in the rate of serious medication errors following CPOE implementation,” states Anne Trafford, CIO, St. Michael’s Hospital.

CPOE is now being used for all types of orders at St. Michael’s, including drugs, lab tests, radiology exams and the com-plete gamut of patient care orders, from vital signs and dressing changes to nutri-tion orders. With nearly 550,000 orders placed via CPOE by more than 700 dif-ferent physicians over a seven-month period, the hospital is enjoying a roughly 96% utilization rate for those orders that can in fact be placed using CPOE rather than via the telephone or as verbal orders given to nursing staff.

“We are significantly ahead of the indus-try best-practices standard for CPOE, which specifies that a minimum of 85% of orders should be placed directly by providers,” enthuses Trafford.

Siemens Soarian® Clinicals Enables Practice TransformationThe implementation of CPOE is a critical waypoint in St. Michael’s transformation journey, which started in April, 2003 with the launch of the hospital’s Gemini

initiative and continues today. The Gem-ini goal is to harness the power of work-flow technology to transform clinical practice at St. Michael’s into a patient-centered, best-practice framework for care delivery based on inter-professional practice and evidence-based care pro-cesses and decision-support systems.

Among other things, Gemini identified the need for an integrated, enterprise-wide clinical information system; and in 2004, St. Michael’s implemented Sie-mens Soarian® Clinicals to fill this role. Soarian Clinicals is an innovative work-flow technology that gives physicians and other caregivers access to real-time, online patient information.

Since then, St. Michael’s has continued to build-out its Soarian environment, integrating industry-leading third-party and Siemens clinical applications, including an electronic Health Records Management System, Laboratory Infor-mation System, Radiology Information System, Picture Archiving & Communica-tions System (PACS), Pharmacy System and more.

The organization’s five-year Corporate Plan for 2007-2011, which put a clear emphasis on quality and patient safety, highlighted Information Management as a strategic enabler for continuous improvements in patient care and made implementation of the CPOE component

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Closed-Loop Medication is resulting in a much safer environment.

The use of Order Sets improves the process of care for patients.

of Soarian Clinicals a Board-level objec-tive. As a direct result, the CPOE initia-tive at St. Michael’s began in March, 2010.

Teamwork Gets the Job Done

Following in-depth training of the St. Michael’s IT operations team by Siemens at Siemens’ Malvern, Pennsylvania head-quarters and onsite at St. Michael’s hos-pital, the joint team worked together to implement Soarian Clinicals CPOE capa-bility in the first few hospital units.

“We had a lot of support from Siemens to configure the CPOE function within Soarian Clinicals to fit our needs,” says Dr. Mike Freeman, Director of Medical Informatics at St. Michael’s and Physi-cian Lead for the Gemini program, fur-ther explaining that, “This included excellent response from senior Siemens people, who listened a lot and responded in numerous areas with sig-nificant adaptation for the way we prac-tice.”

The St. Michael’s team carried on with the CPOE rollout across the remaining hospital units largely on its own, engag-ing each unit leadership to do assess-ments and process re-design and to build Order Sets particular to each ser-vice. Obstetrics was the last unit to go live with CPOE in February, 2012. Throughout this period, Siemens staff remained available on an as-needed basis as implementation consultants.

“The Siemens people on the ground here at St. Mike’s were good coaches and worked side-by-side with my team on how to set the system up and to transfer the knowledge,” says IT’s Trafford, add-ing that, “Whenever we needed more support or more education in order to do something, they were right there with the resources we needed.”

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CPOE Spells Big Benefits for Patients & Staff

According to Dr. Freeman, the top bene-fit of the Soarian Clinicals CPOE solution for St. Michael’s patients stems from the use of pre-built admission Order Sets that have been developed by the very same clinicians who are using them. Use of these Order Sets drives the cor-rect investigations and evidence-based therapies for different diagnoses and ensures that nothing is overlooked.

“The use of Order Sets not only improves the process of care for patients and reduces the amount of needless investi-gation, but is also a great teaching tool for our Residents’” explains Freeman, who then goes on to say that the second most significant benefit they gain from CPOE is the ability of the Soarian system to warn physicians of any problems that

might arise as a result of drugs they order for their patients. These problems could include for example adverse inter-actions with drugs the patient may already be taking, allergic reactions the patient may have to certain drugs, dupli-cate medications inadvertently being ordered or improper dosing. The system flags these potential situations during the ordering process, allowing physi-cians and pharmacists to collaborate for safer prescribing.

“There has been tremendous uptake of CPOE by our physicians, who realize that even though it takes a bit more time to do their ordering, it’s resulting in a much safer environment and patients are actu-ally getting their meds faster,” claims Freeman, citing the fact that time-to-first-dose for administration of antimi-crobial drugs, for example, has been reduced by 46%. This is not only an

The staff checks if barcodes, patient wrist bands and drug packaging all match.

expression of greater efficiency brought about by CPOE but also indicates an improved experience for patients, for whom treatment starts sooner.

Closed-Loop Medication Management Ensures SafetyThe rollout of CPOE, which is part of the Siemens Soarian® Clinicals solution forming the core of the hospital’s clinical information management system, was accompanied by an upgrade to Siemens Pharmacy and implementation of the Med Administration Check™ component of Pharmacy (called MAK). The Pharmacy application is used by pharmacy staff to receive, validate and fill medication orders, while MAK manages the portable medication cart used by nurses at the bedside for drug administration, inclu-ding reading and checking that barcodes on staff badges, patient wristbands and drug packaging all match.

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“In today’s bedside environment, the patients are sicker and the care require-ments are more complex, so the system provides alerts, queues and guidance to help clinicians provide best care every time,” suggests Trafford.

CPOE Puts St. Michael’s Amongst Canada’s BestThe completion of the rollout of CPOE, in conjunction with the complete closed-loop medication management process, positioned St. Michael’s squarely in the top 0.2% of Canadian hospitals studied, according to the Healthcare Information and Management Systems Society (HIMSS) Analytics Electronic Medical Records (EMR) Adoption Model1.

The HIMSS Analytics EMR Adoption Model was introduced in 2005 to track EMR adoption progress at hospitals and health systems, and scores hospitals on their use of advanced IT capabilities and their implementation of a fully electronic health record to improve process perfor-mance, quality of care and patient safety. St. Michael’s has successfully leveraged Siemens Soarian Clinicals to reach the prestigious Stage 6 designation as only one of three hospitals in Canada.

Together with the Pharmacy upgrade and also introducing the use of the eMAR (electronic Medication Adminis-tration Record) component of Soarian Clinicals for viewing and updating patient medication history, the imple-mentation of CPOE gives St. Michael’s a closed-loop medication management system that improves patient care and safety by ensuring that the right drugs get to the right patient at the right time and by reducing time-to-first dose.

The closed-loop Soarian system at St. Michael’s is also creating greater job sat-isfaction amongst nursing staff and phy-sicians alike, according to Trafford, who likens the system to a ‘safety net’. The system adds to the confidence of nurses, for example, by helping them ensure they achieve the so-called “8 Rs” of nurs-ing best practice – right patient, right drug, right dose, right time, right route and so on. For physicians using CPOE, that safety net not only takes the form of adverse drug interaction checking, but also comes in the form of prompts from the system that help to ensure that all the required diagnostic procedures and treatment therapies take place for any given patient situation.

eMAR• Validated medication order appears in eMAR and current order screen

CPOE• Soarian is the new "green sheet" for practitioners‘ orders including medication• System alerts for medication allergies, drug-drug interactions

MAK• RN reviews/verifies medication order• Scans barcodes on staff ID badge, medication and patient ID band• Documents medication administration

Pharmacy• Receives medication orders• Reviews/validates order• Dispenses medication• Medication cart loaded and sent to unit

Siemens Pharmacy

Soarian Clinicals

A Closed Loop Medication

ManagementSystem

Medication administration information displays in eMAR for all clinicians to view

Allergies, lab results, medi-cation orders sent to MAK

Nurse and pharmacist communicate on clinical

interventions on as-need basis

Closed-Loop Medication by Siemens Healthcare IT.

St. Michael’s is one of only three hospitals in Canada, and the only academic health sciences centre, to achieve this level.“St. Michael’s Hospital is an innovative Canadian teaching and research aca-demic medical facility that has developed the ‘virtual ward’, which is a tran-sitional care solution making use of clini-cal IT to continue comprehensive and excellent inpatient care in the less finan-cially or personnel-intensive outpatient environment,” says Patrick Powers of HIMSS Analytics.

When asked about getting to the final Stage 7, Trafford responded by saying that the new Information Management (IM) Plan calls for her team to focus on building sustainability for the Soarian environment St. Michael’s has already invested in and implemented, such as CPOE, and to continue to adopt new IM systems and technologies to support ongoing quality improvement.

“We’ve done really well in getting this far, and our plan will likely see us get-ting to Stage 7 within a few years,” pre-dicts Trafford, “But where we really need to push the envelope now is on using all the patient data we now have in the sys-tem to help us understand how well we are doing with respect to health out-comes and to drive further improve-ments in clinical process.”

To that end, the Siemens-St. Michael’s team is implementing the Embedded Analytics component of Soarian Clinicals to leverage the system’s data mining and business intelligence capabilities to guide care planning and delivery.

The Journey to Improved Care ContinuesWhile the hospital’s transformation jour-ney isn’t over yet, they are now at a tran-sition point in their strategy, having completed what they set out to achieve with respect to the previous Strategic Plan. As part of the new plan driving the implementation of Embedded Analytics, Siemens will also be helping St. Michael’s look at adding a Critical Care solution to their Soarian system to collect data from

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lems integrating the other Soarian and third-party applications.” She concludes her comments by saying that, “Siemens has been a good partner and has stayed with the St. Michael’s team through the good, the bad and the ugly of it all; and from an executive engagement perspec-tive, they’ve been very responsive and brought the right people together when needed.”

bedside monitors for the purposes of nursing documentation and care plan-ning, as well as replacing their aging PACS and Emergency Department Infor-mation System.

“With respect to the pure IT side of things, I’m happy with where we are,” reports Trafford. “Soarian is very easy to integrate with, so we’ve having no prob-

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Canada EMR Adoption ModelSM

Stage Cumulative Capabilities 2011Q3

2011Final

Stage 7 Complete EMR; CCD transactions to share data; Data warehousing; Data continuity with ED, ambulatory, OP

0.0% 0.0%

Stage 6 Physician documentation (structured templates), full CDSS (variance & compliance), full R-PACS

0.5% 0.5%

Stage 5 Closed loop medication administration 0.2% 0.2%

Stage 4 CPOE, Clinical Decision Support (clinical protocols) 2.3% 2.3%

Stage 3 Nursing/clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology

34.5% 36.5%

Stage 2 CDR, Controlled Medical Vocabulary, CDS, may have Document Imaging; HIE capable

22.0% 20.4%

Stage 1 Ancillaries – Lab, Rad, Pharmacy – All Installed 14.4% 14.5%

Stage 0 All Three Ancillaries Not Installed 26.2% 25.6%

Data from HIMSS AnalyticsTM Database © 2012

Physicians can place their orders online electronically, see their results, including diagnostic imaging - and do this mobile.

Commenting on the clinical side of the Gemini program, Dr. Freeman points out that with a significant portion of the Soarian environment that they envi-sioned now deployed and operational, physicians can not only place all their orders online electronically, but can also see the results of all their investigations, including diagnostic imaging – and do this from anywhere, including bedside, their office or their home.

“Our physicians are finding this extreme-ly beneficial in improving care,” enthuses Freeman, explaining that, “We have ex-perienced a huge change from how we worked five years ago, and most physi-cians would say that although it hasn’t been easy, the Soarian Clinicals system makes caring for their patients easier and more streamlined, and results in improved outcomes and safety.”

1 According to HIMSS Analytics EMR Adoption

Model, Q4/2011 Results at http://www.himss-

analytics.org/stagesGraph.asp

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Note: Technical descriptions in this docu-ment may deviate within a defined range of tolerance. Images always lose a certain degree of attention to detail in reproduc-tion.

All patient data displayed in this docu-ment in software screenshots or other-wise is purely fictitious. Screenshots are created on Siemens own systems for de-monstration purposes.

The outcomes achieved by the Siemens customers described herein were achie-ved in the customer‘s unique setting. Since there is no „typical“ hospital and many variables exist (e.g. hospital size, case mix, level of IT adoption) there can be no guarantee that others will achieve the same results.

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