cpoe issues and controversies

CPOECPOEIssues and ControversiesIssues and Controversies

Kenneth L. Geoly, M.D.Kenneth L. Geoly, M.D.Medical Director, Clinical InformaticsMedical Director, Clinical InformaticsInova Health SystemInova Health System

Computerized Computerized Physician Order Entry (CPOE)Physician Order Entry (CPOE)

What is it...What is it... What it is NOT...What it is NOT... What might it be...What might it be...


What is it?What is it? The definition for CPOE as it is being promulgated for patient The definition for CPOE as it is being promulgated for patient

safety is: safety is: The use of an institutional computerized health record by The 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 initiative - they There are THREE major reasons to support this initiative - they

all refer to the IN-PATIENT environmentall refer to the IN-PATIENT environment

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 (post-op order sets)Situations (post-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


What it is NOTWhat it is NOT There are multiple definitions for Electronic Medical There are multiple definitions for Electronic Medical

Records (EMR’s)Records (EMR’s) In-PatientIn-Patient Office-Based Office-Based

These both (OP & IP) are clinical data repositories (CDR’s) These both (OP & IP) are clinical data repositories (CDR’s) BUT BUT

Their use is frequently distinctly different - especially in our Their use is frequently distinctly different - especially in our areaarea


What it is NOT (contd)What it is NOT (contd) The Office-Based EMR is The Office-Based EMR is per forceper force an out growth of the basic physician billing an out growth of the basic physician billing

system. Purchased by private physician practices. system. Purchased by private physician practices. Most offices do not have them.Most offices do not have them. Most of the orders are for meds (Rx’s), labs and procedures Most of the orders are for meds (Rx’s), labs and procedures

usually not done in the physicians’ offices usually not done in the physicians’ offices results are frequently manually (occasionally electronically) entered into the results are frequently manually (occasionally electronically) entered into the

system if they are entered at all.system if they are entered at all. These EMR systems are designed to track Rx’s, labs and procedures both for clinical These EMR systems are designed to track Rx’s, labs and procedures both for clinical

continuity and billing purposes and for some, to serve as repositories of office notescontinuity and billing purposes and for some, to serve as 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


What it Might BeWhat it Might Be Only when the out patient environment is electronically merged Only when the out patient environment is electronically merged

with the in-patient environment (Universities, Mayo, fully with the in-patient environment (Universities, Mayo, fully integrated IDN’s) does the office (clinic) based EMR become integrated IDN’s) does the office (clinic) based EMR become part of a true institution based CDR and thereby a part of a part of a true institution based CDR and thereby a part of a CPOE initiativeCPOE initiative

Otherwise office based EMR’s are not what Leapfrog had in Otherwise office based EMR’s are not what Leapfrog had in mind as benefiting from CPOEmind as benefiting from CPOE

Today’s discussion will focus on the in-patient CPOEToday’s discussion will focus on the in-patient 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 Implementation Implementation Expectations - from all sidesExpectations - from all sides ROI - real and virtualROI - real and virtual

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 which might improve medical Defined use of CPOE as one of the three major initiatives which might improve medical errorserrors

Based their data on Based their data on university applicationuniversity application of the process of the process Residents, Health Care Extenders, Full time MD’s, HospitalistsResidents, Health Care Extenders, Full time MD’s, Hospitalists

However, since pressures will still be present, CPOE is being fostered as necessary in However, since pressures will still be present, CPOE is being fostered as necessary in all in-patient clinical environmentsall in-patient 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

Actual Value of CPOEActual 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 (post-op order sets)Situations (post-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)

Drug-Drug, Drug-Lab, Drug-Disease, Allergies, etcDrug-Drug, Drug-Lab, Drug-Disease, Allergies, etc Clinically validated rules for careClinically validated rules for care

Order CommunicationOrder Communication Clarity of OrdersClarity of Orders

A large percentage of written physician orders are not A large percentage of written physician orders are not clearclear

100% of electronic orders are…100% of electronic orders are… Physician IdentificationPhysician Identification

Between 20 and 50% of Physician signatures are illegibleBetween 20 and 50% of Physician signatures are illegible Electronic Identification is absolute (almost…)Electronic Identification is absolute (almost…) Worse with larger medical staffsWorse with larger medical staffs

Pharmacy Workflow FacilitationPharmacy Workflow Facilitation

Write Order

Flag Chart

MD Unit Sec. Nurse Pharmacy

Return Chart to Rack

Periodically Review

Chart Rack

Check Order Completeness

Enters Orderin Computer

Notify Nurse

Notify NurseIf Stat

Check Order Completeness

NotifiesRx

Rx Verifies Order

Med Sent to Floor

Locate Chart

Rx Enters the Order

NotifiesRx

Standardization of CareStandardization of Care

Rules and order sets must be clinically and Rules and order sets must be clinically and locallylocally validated (medical staff must approve of them before validated (medical staff must approve of them before use)use)

Provide a Provide a clinically validatedclinically validated care path for the care path for the situations to which they refersituations to which they refer

Most Physicians are opposed at first (“cookbook Most Physicians are opposed at first (“cookbook medicine”) but rapidly become comfortable with these medicine”) but rapidly become comfortable with these order sets as they use themorder sets as they use them

Real Time Decision SupportReal Time Decision Support Pharmacy Rules (alerts) appear if there are conflictsPharmacy Rules (alerts) appear if there are conflicts

Drug-Drug; Drug-Lab; Allergy; Maximum DoseDrug-Drug; Drug-Lab; Allergy; Maximum Dose Must be aware that the more granular these rules are, the Must 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 serious Rules 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)

Vendor SelectionVendor Selection

Facts 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 Health Most 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, even Therefore, unless the time has come to change the HIS, even

though another Vendor’s CPOE module might be better than the though another Vendor’s CPOE module might be better than the one for the existing HIS, most health care systems will be using one 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

What to Look forWhat to Look for

Ease of UseEase of Use CPOE CPOE WILL WILL delay rounding time for visiting MD’s at first. Expect delay rounding time for visiting MD’s at first. Expect

months of grousingmonths of grousing The module’s must be intuitive and reflect how MD’s currently write The module’s must be intuitive and reflect how MD’s currently write

ordersorders Electronic Signature must be available by groups of ordersElectronic Signature must be available by groups of orders Order Sets must be easy to find and useOrder Sets must be easy to find and use Most vendors will have already had significant input as to the use from Most vendors will have already had significant input as to the use from

previous physician client consultation and this can be invaluable but... previous physician client consultation and this can be invaluable but... Obtaining Obtaining local physicianlocal physician input on the ease of use is essential input on the ease of use is essential


Options on Order Communication to NursingOptions on Order Communication to Nursing How does a nurse or pharmacist know that an order has been How does a nurse or pharmacist know that an order has been

writtenwritten Nursing and Pharmacy Nursing and Pharmacy Must BeMust Be involved in selecting the method of involved in selecting the method of

communicationcommunication Most Vendors will offer flexible ways to communicate to the nurse / Most Vendors will offer flexible ways to communicate to the nurse /

pharmacist that electronic orders have been writtenpharmacist that electronic orders have been written Unit Secretary alertsUnit Secretary alerts Nursing Alerts - Real timeNursing Alerts - Real time Log-in alertsLog-in alerts


Ease of Insertion of Rules and RemindersEase of Insertion 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


Remote AccessRemote Access Big selling point for physiciansBig selling point for physicians

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

Need to be able to have MD’s write and sign orders Need to be able to have MD’s write and sign orders remotelyremotely

Physician Acceptance and UsePhysician Acceptance and Use

Community Based Physicians are Community Based Physicians are per forceper force spending less time in the hospitalsspending less time in the hospitals

CPOE will be viewed by many as a waste of CPOE will be viewed by many as a waste of theirtheir time and put in place mostly for the hospital’s benefit time and put in place mostly for the hospital’s 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 the There must be significant local physician (not only the leadership) input at multiple levels in developing and leadership) input at multiple levels in developing and tailoring the system before it goes livetailoring the system before it goes live

Physician Acceptance and UsePhysician Acceptance 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 and Order 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 unit Provide 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 PDA’s)Wireless Computing will also help (usually not PDA’s)

ImplementationImplementation Vendor InvolvementVendor Involvement

Other Customers’ Experience will be helpfulOther Customers’ Experience will be helpful Necessary CommitteesNecessary Committees

Representation from IS, Nursing, Pharmacy and Medical StaffRepresentation from IS, Nursing, Pharmacy and Medical Staff Steering CommitteeSteering Committee

Screen FlowScreen Flow Order SetsOrder Sets Decision SupportDecision Support

Dedicated AnalystDedicated Analyst Project Plan with fixed (realistic) time line (six months to a year from inception to Project Plan with fixed (realistic) time line (six months to a year from inception to

completion of first unit)completion of first unit) One unit at a time One unit at a time

support team, education, process developmentsupport team, education, process development 100% conversion by unit100% conversion by unit

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!

ExpectationsExpectations

Do Not Expect - at first:Do Not Expect - 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

ROIROI Many Vendors already have an order communication Many 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 CPOE These 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 close Implementation costs will vary but are probably close

to .5 to 1M overallto .5 to 1M overall Mostly Staffing and supportMostly Staffing and support

ROIROI There will be no appreciable measurable ROI for a health care systemThere will be no appreciable measurable ROI for a health care system The virtual ROI’s are:The virtual ROI’s are:

CPOE will probably be mandatory CPOE will probably be mandatory If the health care system doesn’t have it, there will probably be financial If the health care system doesn’t have it, there will probably be financial

penalties (California)penalties (California) Improved patient safety will result in:Improved patient safety will result in:

Reduction in Medical ErrorsReduction in Medical Errors Shorter Lengths of Stay (B&W’s study)Shorter Lengths of Stay (B&W’s study) Fewer Law SuitsFewer Law Suits Better Care (Better Reputations)Better Care (Better Reputations)

Questions...Questions...

cpoe issues and controversies

Documents

private physician practices

basic physician billing

contdthe officebased

cpoe systemless

clinical continuity

inpatient environmentreasons

office clinic

time mds