Current State and Future Direction CPOE Abington by liaoqinmei

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									         CPOE @Abington


           Current State
               and Future Direction

  Henry Mishel, MD - Chief Pulmonary & Critical Care,
             Liaison Specialty Physician to H.I.S. Dept

Kathleen Mansfield – Senior Analyst / H.I.S. Department
               CPOE
• Voluntary Physician Order Entry-TDS 1992
• Mandatory Physician Order Entry: 1/2/2001
                   CPOE
• Voluntary Physician Order Entry-TDS 1992
• Mandatory Universal Physician Order Entry:
  1/2/2001
   – continues to be successful in 2005
• Enhanced Physician Order Entry: 1/22/05
   – 85 % of all orders, others verbal/telephone!
   – 99% of all medication orders
• Not one physician left the staff!
   – Many competing hospitals < 5miles away
   – 30% specialists on multiple staffs


   How did we do it?
Abington Memorial Hospital

            •   Licensed Beds: 508
            •   Admissions: 33,309
            •   Births: 4,870
            •   Emergency Room Visits: 65,972
            •   Short Procedure Visits: 18,224
            •   Other Outpatient Visits: 322,904
            •   Medical Staff: 611
            •   Residents: AMH - 120 & Drexel
                Residents
             CPOE
• Mandate from an enlightened Board of
  Trustees and Medical Executive Committee
  in an effort to provide QUALITY
• Physician involvement from end users in
  planning and design
     Balance Two Prime Concerns
      For CPOE Implementation

• Patient Safety
   – “driver” to implement CPOE
• Workflow
   – minimize impact compared to
      paper orders.
   – Hopefully add value.
               Patient Safety
        References Supporting C.P.O.E.
•                                                             emergency
    Promoting patient safety and preventing medical error in emergency departments.
    Acad Emerg Med. 2000 Nov;7(11):1204-22. Review. PMID: 11073469
                             Nov;7(11):1204   -
•                                                             intervention
    Effect of computerized physician order entry and a team intervention on prevention of serious
    medication errors. JAMA. 1998 Oct 21;280(15):1311-6.PMID: 9794308
                                           21;280(15):1311-
•                                                                    methods,
    Embedding guidelines into direct physician order entry: simple methods, powerful results.
    Proc AMIA Symp. 1999;:221-5.PMID: 10566353
                 Symp  . 1999;:221-
•                                                                       error
    The impact of computerized physician order entry on medication error prevention.
    J Am Med Inform Assoc. 1999 Jul-Aug;6(4):313-21.PMID: 10428004
                                     Jul- Aug;6(4):313-
•   Winning support for physician order entry.
    Health Data Manag. 1999 May;7(5):54-6, 60, 62-3. No abstract available.PMID: 10387705
                 Manag.        May;7(5):54-         62-
•   Multiple perspectives on physician order entry.
    Proc AMIA Symp. 2000;:27-31.PMID: 11079838
                 Symp. 2000;:27-
•                                                                  practices.
    Effects of computerized physician order entry on prescribing practices.
    Arch Intern Med. 2000 Oct 9;160(18):2741-7.PMID: 11025
                                 9;160(18):2741-
•                                                                  events:
    A computer alert system to prevent injury from adverse drug events: development and evaluation
    in a community teaching hospital.
    JAMA. 1998 Oct 21;280(15):1317-20.PMID: 9794309
                      21;280(15):1317-
•                                                             intervention
    Effect of computerized physician order entry and a team intervention on prevention of serious
    medication errors.
    JAMA. 1998 Oct 21;280(15):1311-6.PMID: 9794308
                      21;280(15):1311-
•                                                           inpatients.
    Medication errors and adverse drug events in pediatric inpatients.
    JAMA. 2001 Apr 25;285(16):2114-20.PMID: 11311101
                       25;285(16):2114-
•   * Order Entry Gets Out of Hand, Health Data Management, July 2001, 20-24. (AMH Article)
                                                                       2001, 20-
                      Patient Safety:
               Driver for change to CPOE

                                     Board of Trustees
                                        Chairman


President Medical Staff         Hospital                                  Hospital
   Elected Position           Chief of Staff                          President & CEO


        Dept of Medicine    Dept of Surgery      Dept of Pediatrics       Nursing
             Chair               Chair                 Chair              Director


  Div of IM       Div of Pulm/C.C.
   Chief                Chief


  C.P.O.E. : Does the leadership of the organization accept
  this as a method to achieve patient safety from the top
  down?
        Phase 1

A look back to the Year 1992…

   Implementation of Voluntary
      Physician Order Entry
              TDS
  Workflow: Software Design
        Flexible support of C.P.O.E.

• Project Champion in every Division
   – Physician Advisory Group-PAG
• Each Division reviewed 20 charts per Dx
   – Admission orders
   – Common orders
• Buy-in
   – Not much variance between Docs
   – Room for Improvement- 800 orders vs 0!
   – Division specific design

               Buy-in
   Workflow: Software Design
        Flexible support of C.P.O.E.

H.I.S. awareness of physician work flow
• 80% of a physician’s work use 20% or less of the
  orders
   – make common screens easily accessible
• 80% of a physician’s orders should be within 2
  clicks of the Master Guide
   – requirement for safety has modified this goal
Workflow - Work Station




•   Computer
•   Phone
•   Countertop
      C.P.O.E. Utilization: 1994 – 1999
          Attending Physicians
60%
                                         51%
                                  47%
50%                         43%
                    42%
40%
      30%     32%
30%

20%

10%

0%
      1994   1995   1996   1997   1998   1999
               Patient Safety
        References Supporting C.P.O.E.
•                                                             emergency
    Promoting patient safety and preventing medical error in emergency departments.
    Acad Emerg Med. 2000 Nov;7(11):1204-22. Review. PMID: 11073469
                             Nov;7(11):1204   -
•                                                             intervention
    Effect of computerized physician order entry and a team intervention on prevention of serious
    medication errors. JAMA. 1998 Oct 21;280(15):1311-6.PMID: 9794308
                                           21;280(15):1311-
•                                                                    methods,
    Embedding guidelines into direct physician order entry: simple methods, powerful results.
    Proc AMIA Symp. 1999;:221-5.PMID: 10566353
                 Symp  . 1999;:221-
•                                                                       error
    The impact of computerized physician order entry on medication error prevention.
    J Am Med Inform Assoc. 1999 Jul-Aug;6(4):313-21.PMID: 10428004
                                     Jul- Aug;6(4):313-
•   Winning support for physician order entry.
    Health Data Manag. 1999 May;7(5):54-6, 60, 62-3. No abstract available.PMID: 10387705
                 Manag.        May;7(5):54-         62-
•   Multiple perspectives on physician order entry.
    Proc AMIA Symp. 2000;:27-31.PMID: 11079838
                 Symp. 2000;:27-
•                                                                  practices.
    Effects of computerized physician order entry on prescribing practices.
    Arch Intern Med. 2000 Oct 9;160(18):2741-7.PMID: 11025
                                 9;160(18):2741-
•                                                                  events:
    A computer alert system to prevent injury from adverse drug events: development and evaluation
    in a community teaching hospital.
    JAMA. 1998 Oct 21;280(15):1317-20.PMID: 9794309
                      21;280(15):1317-
•                                                             intervention
    Effect of computerized physician order entry and a team intervention on prevention of serious
    medication errors.
    JAMA. 1998 Oct 21;280(15):1311-6.PMID: 9794308
                      21;280(15):1311-
•                                                           inpatients.
    Medication errors and adverse drug events in pediatric inpatients.
    JAMA. 2001 Apr 25;285(16):2114-20.PMID: 11311101
                       25;285(16):2114-
•   * Order Entry Gets Out of Hand, Health Data Management, July 2001, 20-24. (AMH Article)
                                                                       2001, 20-
            Phase 2



Universal Physician Order Entry
       Medical Executive Committee:
         Advanced notice in February, 2000


    “NO WRITTEN ORDER SHEET on 1/2/2001!”
         Universal Physician Order Entry
                    TDS 7000
• Our “green” order sheet will be pulled, and will not be
  available for any physician to use.
• A yellow TDS Order Sheet will be available for “downtime”
  emergencies only.
• Pre-printed order sets will be eliminated.
• Message: start learning now, don’t wait until 1/2/2001!
Workflow: Enhancements to get “Buy-In”:
  Completed Prior to Universal C.P.O.E.

Between 4/00 and 11/00:
      • H.I.S. completed 58 service requests (ISRs)
      • Totaling 1,130 hours of staff time
Projects include:
      •   New ETC Triage screens and report
      •   Pediatric Trauma Order Set
      •   Coumadin Order Retrieval
      •   Department Order Sets
      •   SCN-Oxygen Weaning Orders
      •   Display Last Echo
         Workflow:
New Devices Required for CPOE
     • Wireless Computers (20)
     • Desktops Computers (83)
        – Med / Surg Units (48)
        – Emergency Trauma Center (35)
     • Total New Computers (103)


  Champion Docs located sites for CPUs!
  Address peak times usage not average time
Workflow: A.M.H. Infrastructure
Hardware Improvements Required for C.P.O.E.

 Mainframe Upgrades
    5/8/00: Internal Disk Drives of Mainframe for
      Performance
    10/29/00: Central Processor for Performance
 Network Upgrades

 Desktops & Laptops
    Year 2000 2001: Increase # and Upgrade Desktop
     Deployment:
Speed of system critical for acceptance !!!
Workflow: Preparation
Support Plan Year 2000
  • Super Users
     – Nursing (TDS Super User Buttons; Nurse Managers with Cell Phones)
     – Physicians (Liaison with Departments and Divisions)
  • Sign-on Screen - Help Desk Numbers
  • Eclipsys Physician Tips (Newsletter)
  • Eclipsys Enhancement Hotline and Info Guide
  • Training Sessions available all shifts and weekends
  • Physician Advisory Group members identified to medical
    staff and accessible
Workflow: Eclipsys Training

 • Sessions
    – Divisional: Didn’t work
    – Open: 7-10 sessions per month for Doctors
    – One on One (high volume order writers = priority)
 • Reports
    – To Chair, Pt Safety Oversight Committee & PAG
    – 3 contacts for training; then escalated
    – All Physicians are listed with attendance
    – Includes Comparative Statistics 3/00 - Present
         Support Plan: January 2001
               Universal C.P.O.E. Start Week

Physicians:
    – “TDS Super User” buttons
    – P.A.G. meeting daily from 1/2 through 1/8
Information Systems:
    – 2 Clinical Systems staff stationed at hospital for training
      and support: 6 a.m. - 6 p.m., 1/2 - 1/5
    – Help Desk manned by Clinical staff
    – Tech Services support (for hardware) at hospital:
      6 a.m. - 6 p.m., 1/2 - 1/5
            Attending Physician
       C.P.O.E. All Orders Utilization
       Med. Exec. Cmtte.                  Universal
       Announcement                        CPOE
90%
80%
70%
60%
50%
40%
30%
20%
10%
 0%


                                         Nov
      Jan

             March




                                  Sept
                     May

                           July




                                               Jan-01

                                                        2002- 2005
       --------------2000 ------------------
                  A.M.H. Pharmacy
               Error Reporting with C.P.O.E.


Improvements                       Problems
• Decrease in illegible orders     • Slight increase (1.24% – 1.51%) in
• Decreased use of inappropriate     orders clarified including potential
  abbreviations                      serious reactions due to:
• Decrease in incomplete orders       – Safety Program, encourage
                                         increased reporting!
• Quicker medication delivery
                                      – Pharmacy with enhanced
• Standardization of orders              screening protocols
• Allergic “calls” decreased 50%      – No baseline prior to CPOE
• Hospital Formulary “calls” re:      – More complex med orders
  prescriptions improved by 41%          (chemo)
                                   • Selecting Wrong Patient –
                                     improved +/-
                                   • Type-in Function – needs attention
Physician Tree Hugger Non-Compliance
          ---------------
with C.P.O.E. after 1/2/01


  Protocol
  • Nursing to enter order into Eclipsys.
  • Nursing to document the written order on
    “Downtime Sheet” and forward to Nursing
    Coordinator.
  • Nursing Coordinator to forward copy of written
    order to Chairman of Patient Safety Committee.
    Personal Communication followed.
    How to handle Resistance?

•   Plenty of lead time but deadline for C.P.O.E.
•   Offer multiple training schedule opportunities
•   Provide champions on all floors
•   Offer computer trainer to “trail” physician
•   Chair of Patient Safety personally involved.
             Phase 3 CPOE




Enhanced Physician
Order Entry
    Maturity of C.P.O.E. Systems
Functionality drove need to migrate from TDS to SCM




          + +         +       +      +      +       +      +          +




   From First Consulting Group; www.leapfroggroup.org/CPOE/CPOE%20Guide.pdf
            Why AMH Moved
            from TDS to SCM?

New Toys!
            Why AMH Moved
           to SCM from TDS?
New Tools!
• Order Sets
   – Improved User Interface (Scrollable windows with
     annotations) Most but not all agree!
   – Improved turnaround time to create compared to TDS
• Alerts: Heads Up Display
   – Surveillance – Reduced time to clinical response
   – Order Entry – Interact with the physician using CPOE
• Reports – Improved turnaround time for development
• Documentation – Some physicians eager to use templates
AMH Timeline Information Systems

                            SCM 3.04
                   •SCM Surveillance Alerts
                   •TDS Order Entry


                            12/11/04
1/2/01       12/7/03                    1/22/05
TDS 7000     SXA                        SCM 3.5
           Alpha Site:                 •SCM-All Orders
           •Stability &                 And View Results
            Speed Issues               •TDS Retired
           •Restored TDS               Except in ECU
           •Maintained for             & History File
            Superior Results View
                 Order Entry Alerts
                 Workflow Issues!
    Initial Plan                   New Plan
    Use Multum Database            • Maintain Drug Allergy
    • Drug – Allergy               • Implement limited list of
    • Drug – Drug                    Drug – Drug Interactions
    • Drug Duplicate                 (50-60 to start again).
                                     Based on Pharmacy
    Lab Orders                       experience of Frequency
    • Lab duplicates disabled        and Severity of warnings
       except CXR and TSH              – Borrowed from Senterra
                                         Health Systems


Adopt Workflow Rule: 5% of orders should generate an alert and
change behavior 33% of the time.
                       CPOE: The next step
              Order Entry Alerts & Surveillance Alerts

         Physician Orders                            !   Critical Results
         Medications
         Laboratory                                           Lab
         Radiology
         Discharge / Transfer
                                   Query Checking
                                   Contraindications
                                   Dosing                  Radiology
                                   Duplicates
                                   Missing Data
                                   Assist Calculations


Tables
Medications
Allergies
Health Issues
Laboratory
Radiology
Demographic: age, weight, gender
Example of Surveillance Alert
               Surveillance Alerts
HIPPA Police




                               Alerts
                               Acknowledged?
                               Who is responsible?
         Surveillance Alerts
      Workflow & Patient Safety
• MKIC Consensus: Clear the flag of thousands of old alerts by “auto-
  acknowledge” statement (12/11/04)
   – “This Alert was auto-acknowledged due to the age of the alert and
     because the information remains viewable elsewhere in the
     electronic record”.
• Acknowledge Responsibility Defined on 12/11/04
   – Residents required by 4:00 PM
   – Attendings by 6:00 PM if not acknowledged by Resident (Remote
     Access Available)
• Volume of alerts
   – After SCM 3.04 implemented < 90 alerts not acknowledged by end
     of day
   – 500 alerts / day not acknowledged when switched to SCM 3.5 and
     used Multum Level 1 Drug-Drug, Drug Duplicate and Drug-
     Allergy functions
• Future - block “Discharge Patient” order if any active alerts on the Pt?
   Orders & Alerts
AMH Typical Day 6/15/05

  Category                #      %
  In-Patient Orders     13210
  Medication Orders      2800
  Alerts                  187 1.4%
  Acknowledged Alerts       90 48.1%
  As of 6/17/05
  Changed Behavior       ?
          CPOE Created Errors



Transition of Systems.
Managing Errors with
Education
        Transition of Systems
Change in Process of Med Error Corrections

           TDS                      SCM




           Printed orders               E-Link
             Pharmacist                Interface
         Re-enters / Modifies
                                Pharmacist
                                Reviews Orders

                    McKesson
                    Pharmacy
                     System
Medication Errors Transitioning
      Between Systems




    Dexamethasone 12 mg daily in dose field vs.
    Dexamethasone 4mg “give 3 tablets daily”
       typed into instructions field
   New Med Errors on Transition to
           New System

  Look for Patterns (Examples)
  • Not reading the units field (Dose Error due to
    using # of tablets for the field, not mgs)
  • Error trying to limit number of days or doses of
    therapy
  • Unable to appropriately schedule specific dosage
    times

Is there an effective & efficient way to correct errors?
  Effective Order Entry Medication
      Error Correction Program
1) Pharmacist Notes Error in
   McKesson Pharmacy System
2) Logged into SCM and Screen
   Print of Error as viewed on SCM
3) Printed Pages of Errors forwarded
   to SCM Champion
4) SCM Champion uses standardized
   education newsletters describing
   the corrective actions for the error
   with standard cover letter to the
   Doctor.
5) H.I.S. Trainers review the errors
   and incorporates appropriate
   focused education sessions with
   Residents and new Trainees.
Implementation reduced errors > 25 day to 1-2 Errors/Day
   Building Order Sets
to meet Quality Standards
    Quality Focused Organizations
  Leapfrog / NQF /                  JCAHO / CMS                             IHI
      AHRQ
Safe Practices (30 cat.)         Core Measures (4) /            Save 100,000 Lives
                                 Nat. Pt Safety Goals (9        Campaign (6 cat.)
                                 cat. with subgrps)
Implement a computerized         MI: routine use of ASA, Beta           ADEs:
                                                                Prevent ADEs: Medication
prescriber-order entry system.
prescriber-                      Blockers                       Reconciliation, etc.


Use only standardized            Pneumonia: routine                               Evidence-
                                                                Deliver Reliable, Evidence-
abbreviations and dose           Immunizations – Influenza      Based Care for Acute
designations.                    and Pneumovax                  Myocardial Infarction


Utilize validated protocols to   Goal: Accurately and           Prevent Ventilator-Associated
                                                                        Ventilator-
evaluate patients who are at     completely reconcile           Pneumonia
                  media-
risk for contrast media-         medications across the
induced renal failure            continuum of care.
 Quality Focused Order Sets
Immunization Screening & Rx




          Defaulted “on”
    Quality Focused Order Sets
MI: B-Blocker / Smoking Cessation



                Core Measures Identified
          Monitoring Success

• Order Sets (current)
   – Use reports to measure frequency of use or non-use of
     disease specific orders & order sets by group/provider
     (passive)
• Alerts (future goal)
   – Surveillance Alerts for errors of omission / commission
     based on health issues or lab results inferring diagnoses
     (active)
       • DVT Risk Stratification Alert with recommended prophylaxis
Summary for Abington Memorial
   Hospital Implementation

• Quality needs to be the driver.
• Support needs to be strong beginning at the top.
• End users by division need to be intrinsically
  involved in the development to obtain buy-in.
• Need fast response times and enough devices.
• Design needs to be division specific. 80:20
• Need to support imagined needs and be prepared
  for ad hoc needs.
Questions
          Future Functionality
        Medication Reconciliation

 • At each point of transition, Admission, Transfer
   and Discharge
 • Review appropriateness of resuming outpatient
   medications
 • Capture decision for each medication on transition
    –   Held
    –   Discontinued
    –   Converted to Formulary
    –   Continued

Must work with your vendor to define needs / upgrades
Structure Note – Med Reconciliation
  Enhance Communication for
 Residents in Transitions of Care

• RRC rules require limited work hours for
  Residents. Forces more transitions in care.
  – Progress notes
  – Doc to Doc notes to enhance “sign out”

								
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