cpoe for health tech net

8/3/2019 CPOE for Health Tech Net

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CPOECPOEIssues and ControversiesIssues and Controversies

Kenneth L. Geoly, M.D.Kenneth L. Geoly, M.D.

Medical Director, Clinical InformaticsMedical Director, Clinical Informatics

Inova Health SystemInova Health System


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ComputerizedComputerized

Physician Order Entry (CPOE)Physician Order Entry (CPOE)What is it?What is it?

The definition for CPOE as it is being promulgated for patientThe definition for CPOE as it is being promulgated for patient

safety is:safety is:The use of an institutional computerized health record byThe use of an institutional computerized health record by

physicians to electronically enter their orders.physicians to electronically enter their orders.

There are THREE major reasons to support this initiativeThere are THREE major reasons to support this initiative -- theythey

all refer to the INall refer to the IN--PATIENT environmentPATIENT environment


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Reasons for CPOEReasons for CPOE

Order CommunicationOrder Communication

Clarity of OrdersClarity of Orders

Ease of Identifying the Ordering PhysicianEase of Identifying the Ordering Physician

Standardization of CareStandardization of Care

Clinically validated order sets forClinically validated order sets for

Clinical diagnosesClinical diagnoses

ProceduresProcedures

Situations (postSituations (post--op order sets)op order sets)

Alerts and Reminders (Real Time Decision Support)Alerts and Reminders (Real Time Decision Support)

Drug Safety Database (Conflict Checking)Drug Safety Database (Conflict Checking)

Clinically validated rulesClinically validated rules


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Physician Order Entry (CPOE)Physician Order Entry (CPOE)What it is NOTWhat it is NOT

There are multiple definitions for Electronic MedicalThere are multiple definitions for Electronic Medical

Records (EMRs)Records (EMRs) InIn--PatientPatient

OfficeOffice--BasedBased

These both (OP & IP) are clinical data repositoriesThese both (OP & IP) are clinical data repositories

(CDRs) BUT(CDRs) BUT Their use is frequently distinctly differentTheir use is frequently distinctly different -- especiallyespecially

in our areain our area


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Physician Order Entry (CPOE)Physician Order Entry (CPOE)What it is NOT (contd)What it is NOT (contd)

The OfficeThe Office--Based EMR isBased EMR isper forceper force an out growth of the basic physicianan out growth of the basic physician

billing system. Purchased by private physician practices.billing system. Purchased by private physician practices. Most officesMost offices

do not have them.do not have them.

Most of the orders are for meds (Rxs), labs and proceduresMost of the orders are for meds (Rxs), labs and procedures

usually not done in the physicians officesusually not done in the physicians offices

results are frequently manually (occasionally electronically) enteredresults are frequently manually (occasionally electronically) entered

into the system if they are entered at all.into the system if they are entered at all.

These EMR systems are designed to track Rxs, labs and proceduresThese EMR systems are designed to track Rxs, labs and procedures

both for clinical continuity and billing purposes and for some, to serveboth for clinical continuity and billing purposes and for some, to serveas repositories of office notesas repositories of office notes

Few have real time decision supportFew have real time decision support

There are usually no issues with order communicationThere are usually no issues with order communication


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Physician Order Entry (CPOE)Physician Order Entry (CPOE)What it Might BeWhat it Might Be

Only when the out patient environment is electronically mergedOnly when the out patient environment is electronically merged

with the inwith the in--patient environment (Universities, Mayo, fullypatient environment (Universities, Mayo, fully

integrated IDNs) does the office (clinic) based EMR becomeintegrated IDNs) does the office (clinic) based EMR become

part of a true institution based CDR and thereby a part of apart of a true institution based CDR and thereby a part of a

CPOE initiativeCPOE initiative

Otherwise office based EMRs are not what Leapfrog had inOtherwise office based EMRs are not what Leapfrog had in

mind as benefiting from CPOEmind as benefiting from CPOE

Todays discussion will focus on the inTodays discussion will focus on the in--patient CPOEpatient CPOE


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Physician Order Entry (CPOE)Physician Order Entry (CPOE)IssuesIssues

IOM Report and the Leapfrog GroupIOM Report and the Leapfrog Group

Assumptions of ValueAssumptions of Value Actual ValueActual Value

Vendor SelectionVendor Selection

Physician Acceptance and UsePhysician Acceptance and Use

ImplementationImplementation

ExpectationsExpectations -- from all sidesfrom all sides

ROIROI -- real and virtualreal and virtual


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CPOE: IssuesCPOE: Issues IOM Report (yada yada yada)IOM Report (yada yada yada)

Leapfrog GroupLeapfrog Group

Defined use of CPOE as one of the three major initiatives whichDefined use of CPOE as one of the three major initiatives which

might improve medical errorsmight improve medical errors

Based their data onBased their data on university applicationuniversity application of the processof the process

Residents, Health Care Extenders, Full time MDs, HospitalistsResidents, Health Care Extenders, Full time MDs, Hospitalists

However, since pressures will still be present, CPOE is beingHowever, since pressures will still be present, CPOE is being

fostered as necessary in all infostered as necessary in all in--patient clinical environmentspatient clinical environments

May affect payment, insurance status, etcMay affect payment, insurance status, etc

Will require that visiting attendings utilize the CPOE systemWill require that visiting attendings utilize the CPOE system Less than 10% of all hospitals currently have itLess than 10% of all hospitals currently have it

Physician acceptance will be an issuePhysician acceptance will be an issue

Best to do it proactively than reactivelyBest to do it proactively than reactively


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Note


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Actual Value of CPOEA

ctual Value of CPOE Order CommunicationOrder Communication

Clarity of OrdersClarity of Orders

Ease of Identifying the Ordering PhysicianEase of Identifying the Ordering Physician

Standardization of CareStandardization of Care

Clinically validated order sets forClinically validated order sets for

Clinical diagnosesClinical diagnoses

ProceduresProcedures

Situations (postSituations (post--op order sets)op order sets)

Alerts and Reminders (Real Time Decision Support)Alerts and Reminders (Real Time Decision Support)

Drug Safety Database (Conflict Checking)Drug Safety Database (Conflict Checking) DrugDrug--Drug, DrugDrug, Drug--Lab, DrugLab, Drug--Disease, Allergies, etcDisease, Allergies, etc

Clinically validated rules for careClinically validated rules for care


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Order CommunicationOrder Communication Clarity of OrdersClarity of Orders

A large percentage of written physician orders areA large percentage of written physician orders are

not clearnot clear 100% of electronic orders are100% of electronic orders are

Physician IdentificationPhysician Identification

Between 20 and 50% of Physician signatures areBetween 20 and 50% of Physician signatures are

illegibleillegible Electronic Identification is absolute (almost)Electronic Identification is absolute (almost)

Worse with larger medical staffsWorse with larger medical staffs


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Pharmacy Workflow FacilitationPharmacy Workflow Facilitation


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Real Time Decision

Support

Real Time Decision

Support

Pharmacy Rules (alerts) appear if there are conflictsPharmacy Rules (alerts) appear if there are conflicts

DrugDrug--Drug; DrugDrug; Drug--Lab; Allergy; Maximum DoseLab; Allergy; Maximum Dose

Must be aware that the more granular these rules are, theMust be aware that the more granular these rules are, the

more they will be ignored by the usersmore they will be ignored by the users

Rules must appear only for the most frequent and seriousRules must appear only for the most frequent and serious

situationssituations

Other rules which are disease situation specific (Digoxin and KOther rules which are disease situation specific (Digoxin and K++;;

ABX and Kidney Function)ABX and Kidney Function)


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VendorS

electionVendorS

electionFacts of Life...Facts of Life...

Many Vendors have their own CPOE modulesMany Vendors have their own CPOE modules

Most Health Care companies already have an existing HealthMost Health Care companies already have an existing Health

Care Information System (HIS)Care Information System (HIS)

Therefore, unless the time has come to change the HIS, evenTherefore, unless the time has come to change the HIS, even

though another Vendors CPOE module might be better than thethough another Vendors CPOE module might be better than the

one for the existing HIS, most health care systems will be usingone for the existing HIS, most health care systems will be using

the one from the system they now usethe one from the system they now use


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What to Look forWhat to Look forOptions on Order Communication to NursingOptions on Order Communication to Nursing

How does a nurse or pharmacist know that an order has beenHow does a nurse or pharmacist know that an order has been

writtenwritten

Nursing and PharmacyNursing and Pharmacy Must BeMust Be involved in selecting theinvolved in selecting the

method of communicationmethod of communication

Most Vendors will offer flexible ways to communicate to theMost Vendors will offer flexible ways to communicate to the

nurse / pharmacist that electronic orders have been writtennurse / pharmacist that electronic orders have been written

Unit Secretary alertsUnit Secretary alerts

Nursing AlertsNursing Alerts -- Real timeReal time

LogLog--in alertsin alerts


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What to Look forWhat to Look forEase ofInsertion of Rules and RemindersEase ofInsertion of Rules and Reminders

Most Vendors already have thisMost Vendors already have this

At various stages of developmentAt various stages of development Need to have these tailorable by institutionNeed to have these tailorable by institution

Density is an issueDensity is an issue

Adding or subtracting rules should be easyAdding or subtracting rules should be easy


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What to Look forWhat to Look forRemote AccessRemote Access

Big selling point for physiciansBig selling point for physicians

can modify orders from home and officecan modify orders from home and officeminimizes the medical record delinquenciesminimizes the medical record delinquencies

Need to be able to have MDs write and sign ordersNeed to be able to have MDs write and sign orders

remotelyremotely


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PhysicianA

cceptance and UsePhysicianA

cceptance and Use Community Based Physicians areCommunity Based Physicians areper forceper force

spending less time in the hospitalsspending less time in the hospitals

CPOE will be viewed by many as a waste ofCPOE will be viewed by many as a waste of theirtheirtime and put in place mostly for the hospitals benefittime and put in place mostly for the hospitals benefit

(now they want us to be unit secretaries)(now they want us to be unit secretaries)

There must be significant local physician (not only theThere must be significant local physician (not only the

leadership) input at multiple levels in developing andleadership) input at multiple levels in developing and

tailoring the system before it goes livetailoring the system before it goes live


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PhysicianA

cceptance and UsePhysicianA

cceptance and Use Physician Input:Physician Input:

Screen Flow (how the orders are actually put in)Screen Flow (how the orders are actually put in)

Decision Support (which rules go in and which do not)Decision Support (which rules go in and which do not)

Order Set Creation (best done by department or section andOrder Set Creation (best done by department or section and

validated by medical staff)validated by medical staff)

Find a Physician Champion to help implement itFind a Physician Champion to help implement it

Provide adequate education and support weeks before a unitProvide adequate education and support weeks before a unit

implements CPOEimplements CPOE

Provide 24/7 support on the unit for weeks after go liveProvide 24/7 support on the unit for weeks after go live

Wireless Computing will also help (usually not PDAs)Wireless Computing will also help (usually not PDAs)


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ExpectationsExpectations Expect at first:Expect at first:

physician resistancephysician resistance

slow starting and high frustration levelsslow starting and high frustration levels

communication issuescommunication issues

Expect ultimately:Expect ultimately:

clearer orders with ease of MD IDclearer orders with ease of MD ID

improved nursing and MD satisfactionimproved nursing and MD satisfaction

better patient safety and clinical carebetter patient safety and clinical care Be Patient!Be Patient!


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ExpectationsExpectations Do Not ExpectDo Not Expect -- at first:at first:

Immediate AcceptanceImmediate Acceptance

Significant measurable ROISignificant measurable ROI Smooth ImplementationSmooth Implementation

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


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ROIR

OI Many Vendors already have an order communicationMany Vendors already have an order communication

module in place (for nursing and pharmacy)module in place (for nursing and pharmacy)

These systems may therefore provide the CPOEThese systems may therefore provide the CPOE

module as part of this order communication modulemodule as part of this order communication module If it must be bought separately, prices varyIf it must be bought separately, prices vary

Implementation costs will vary but are probably closeImplementation costs will vary but are probably close

to .5 to 1M overallto .5 to 1M overall

Mostly Staffing and supportMostly Staffing and support


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Questions...Questions...

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