CPOE… Not just a Four Letter Word!!!

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CPOE Not just a Four Letter Word!!!

• Richard MacKenzie MD FACEP
• Chair DEM, LVHHN
• richard.mackenzie_at_lvh.com

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Overview

• LVHHN Case Report
• Review the literature on CPOE

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Objectives

• Discuss the controversies in CPOE
• Understand the lessons of one institutions
  successful implementation of CPOE
• Imagine the Future of CPOE in Improving ED Care

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Abbreviations

• HIS Health Information System
• IDX/Last Word our HIS
• CAPOE Computer Assisted Physician Order Entry
• EMAR Electronic Medication Administration
  Record
• AP Administrative Partner (aka Unit Clerk)

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Problems

• Assessment and Accountability
• 1988 Relman NEJM
• Evidence Basis only 50
• 2003 McGlynn NEJM
• Large errors
• 2005 Rothschild Crit Care Med
• Regional, racial, and ethnic inconsistency or
  disparities
• 1999 Wennberg NEJM IOM 2002
• Leapfrog 3 initIal 3 safety leaps
• 2003 Eikel Joint Commission Journal Quality and
  Safety

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Solutions

• Develop Critical Care Paths
• Develop Case Managers to assure EBM
• Specialty societies clinical pathways
• Improve access to the literature via internet
• Bring EKGs prior transcriptions to provider
• CAPOE

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Its Time To Make The CAPOE!

• The LVH Experience

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CAPOE at LVHHN

• Project started in 2001
• Physician led and advisory
• Trauma first
• ED and Peds last
• Required Jan 2006
• 99 compliance today

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CAPOE in the ED

• Not now
• Not now
• OK but dont make me work in paper and computer
• Look for clipboard and computer excesssive work
• Must use HIS CAPOE
• Many Ordersets Developed.

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The LVHHN ED Experience

• Starts August 2003
• Strategic Initiative super capital budget
• New tool that redefines work
• 3 sites phased implemention
• Fully implemented July 2005
• ONGOING Operationally!

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Preparation6

• Cannot overemphasize the collaboration necessary

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Vision

• Stagger Implementations
• Use Paper CAPOE
• CAPOE, EMAR, EMR Implementation.
• Complaint Specific Order Sets.
• Diagnosis Specific Order Sets.

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Define Problems

• Research
• What EMR provides what you need?
• How are people and institutions constructing
  order sets?
• How are the orders sets going to look and
  function? Easy, Fast, Intuitive.
• How can you use these order sets to change
  physician practices to be more in line with
  hospital protocols

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Workflow Analysis

• Understand the work of all staff in ED
• Especially the shortcuts data use
• One test is rare
• AP
• Real time abstractor for PI
• Interface with community
• Census screen in HIS action location

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Support

• Identify Your Physician Super Users.
• Collect Information From Current Users of CAPOE
  and the EMR you are planning on implementing

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Work Groups

• Steering Committee
• ED administration
• IS administration
• Pharmacy
• Billing
• Medical Records
• Subcommittees
• CAPOE
• Many others

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Pharmacy

• Compendium additions
• Pyxis
• Floor stock
• VTs
• Trade and Generic
• Common dose

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Process

• How do nurses know there are orders?
• Limited verbal communication
• Doc to Nurse and Nurse to Doc
• Pop ups on assigned patients

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Hardware

• Use Lastword and T System
• SSO (Single Sign On)
• Various devices
• Speed
• Mobility
• Battery life
• Charging
• Support

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Hardware

• Different area Different needs
• Different EDs Different needs

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Ordersets Are Key

• Initial work in collaborative fashion
• Match to T-system templates
• Working with incomplete information on workflow
• Diagnosis specific developed later

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Development Order Sets

• First Nurse Order Sets
• Protocol driven

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Development Order Sets

• First Nurse Order Sets
• Protocol driven

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Development Order Sets

• Structure of the order sets
• IV, O2, Monitor.
• Different Physicians do things differently
• Editing content was the responsibility of the
  subcommittees.

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Development Order Sets

• Complaint Specific Order Sets Modeled After
  T-system Complaint Specific Templates. One Stop
  Shopping.

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Development Order Sets

• Diagnosis Specific Order Sets Modeled After LVH
  Treatment Protocols.
• Common ED Order Set

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Pre-implementation

• Resistance is inevitable!

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Staff Support

• Positive environment for change
• Upstaff!
• Residents trained and already using CAPOE on
  other floors

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Implementation!
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Go-live

• Phased
• Paper CAPOE
• Screen shots complaint specific ordersets
• CAPOE EMAR
• Management on the floor
• Support on the floor
• Up staffed
• EMR

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Tasks

• CAPOE face
• Dont drift
• To old
• Or create new
• Take the feedback
• Empathy
• This is really tough
• Yes it is complex
• Do this when you want that

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Post Implementation
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Post-Implementation

• Two-Week Tweak
• The Stat Sheet
• Feedback

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Post-Implementation
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Post-Implementation
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Post-Implementation

• Quick changes
• Set standards for communication, changes, and
  feedback.
• Always things to add
• Additional first nurse guidelines
• Communication
• On-Going !!!

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Post-Implementation What Really Helped?

• Interoperability essential - SSO
• Implementing at one site at a time.
• Identified process issues that were not
  anticipated..only one site felt the pain.
• Paper Capoe
• Physicians became familiar with the look of the
  order sets.
• CAPOE feedback, Stat Sheet , Two Week Tweak

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Post-Implementation What Really Helped?

• Nurse and physician super users present at
  go-live to provide education and relieve some of
  the clinical pressures.
• Steering Committee oversight.

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Positives

• Billing and revenue
• Hospitals contribution to margin 8.5
• ED as well but has a documentation system as
  well.
• Speed to testing
• Length of Stay
• Down _at_ LVHM up _at_ others
• Census up _at_ all
• Tracking Orders

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Implementation Lessons(UACs resonate)

• CAPOE EMAR together
• Encourage communication
• Diagnosis specific _at_ start
• Maintenance underestimated
• CAPOE paper s l o w s
• I am going to my comfort zone now
• Accept or bigger discomfort?

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Negatives

• ED specific
• Juxtaposition errors
• Wrong med errors
• Toggling errors
• Wrong patient errors
• Context management coming
• Network errors
• Down 20
• Other systems in place
• Pharmacist interventions UP

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Objectives

• Discuss the controversies in CPOE
• Understand the lessons of one institutions
  successful implementation of CPOE
• Imagine the Future of CPOE in Improving ED Care

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Literature Reveiw

• Positives Negatives

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2002 CPOE Survey

• Survey 65 response
• 60/626 or 9.6 CAPOE
• 42/626 or 6.7 CAPOE
• 25/626 or 3.9 have 90 of all orders are entered
  by a physician

Ash 2004 JAMIA
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Recommendations

• 10 recommendations
• Incorporating decision support loosely termed
  into CAPOE
• Good concepts to keep in mind as you go CAPOEing

Handler, 2004 Academic Emergency Medicine
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ED Literature in fetal stage

• Most in non-peer review
• Few lessons learned
• Reduced time to TPA by 23 min
• Nam, et al. (2007). Cerebrovascular Diseases
  23(4) 289-93.
• No change in adherance to ACS guideline
• Asaro, et al. (2006). Academic Emergency Medicine
  13(4) 452-8.
• Stay tuned

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Positives
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Immediate Benefits _at_ OSU!

• About 30 60 days immediate
• Decreased times
• Pharmacy
• Lab
• Radiology
• With EMAR removed transcription errors
• Decreased LOS significantly - one hospital
• No increase in cost

Mekhjian, 2002 JAMIA
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ICU too!

• Initial CPOE vs MICU CPOE
• Initial - 4 generic ordersets (floor based)
• Pulled, reconfigured, redeployed
• MICU specific
• 29 condition specific order sets
• 9 protocols
• Almost 50 less work/orders in selected tasks
• No change in LOS, Vent days/

Ali, 2005 Critical Care Medicine
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Implement Well, Grasshopper

• Descriptional study of successful implementation
• Written halfway through imp.
• 80 compliance on deployed units
• 3 success factors key
• Specialty Ordersets
• Physician Leadership
• Large scale implementation

Ahmad, 2002 JAMIA
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Collaborate and Win _at_ OSU!

• 3 site qualitative study
• Sought to determine 80 users
• Characteristics correlate with high usage
• Collaboration
• Trust
• Active clinicians
• engaged in the adaption

Ash, 2003 JAMIA
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Chest Pain EBM

• Vanderbilt 2002-2003
• Admission Advisor
• Pushes ACS orderset upon admit
• Orderset usage up by 10
• Aspirin with orderset 92 v 78
• Beta blocker up by 5

Ozdas, 2006 16
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Orderset Manual

• University of Washington, Seattle
• Descriptive study
• Orderset dev. and methods
• Usage up by 26 two years later
• Lessons
• Clarity for simple complex
• Dont assume, study
• Maintain with stakeholders
• Never done

Payne, 2003 78
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Return on Investment

• Brigham and Womens
• 9 years in the making
• 5 years before net benefit
• Almost 1 million per year ROI
• Although 12 mil to build
• Cost of CAPOE ADEs???

Kaushal, 2006 7
Frisse, 2006 14
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Negatives

• a.k.a. Things to avoid
• (or at least anticipate)

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CAPOE meets Swiss Cheese

• Sentinel case of pt. receiving 316 mEq of KCL
  over 42 hours
• 2 providers
• Dates not clear in CAPOE
• Continous IV order screens should look different
  from others
• Potassium alerts

Horsky, 2005 71
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Increases Mortality?

• Association increased mortality 13 months pre vs
  5 months post CAPOE
• 6 day institutional implementation
• No ordersets
• Contradicted July 2006 Pediatrics
• Dont implement this way!

Han, 2005 76
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Facilitating Errors!

• University of Pennsylvania
• DOS based CAPOE
• Largely an interview study
• Facilitated 2 med errors
• 5 recommendations

Koppel, 2005 53
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Negative Emotions Duh!

• Interview qualitative study
• Happiness to Satisfaction (very few)
• Shame to Loathing (much more)

Sittig, 2005 55
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Orderset Controversies

• Really twisted paper controversy
• Elemental decision support
• Protocol compliance through protocol ease
• Pulled v. pushed ordersets
• Evidence - vendor or local?
• Paper to computer limits
• Evidence changes maintain
• Private changes faster

Bobb, 2006 87
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Unintended Adverse Consequences

• Qualitative
• 9 UACs
• More/New Work for Clinicians
• Unfavorable Workflow Issues
• Never-Ending Demands for System Changes
• Problems Related to Paper Persistence
• Untoward Changes in Communication Patterns and
  Practices
• Negative Emotions
• Generation of New Kinds of Errors
• Unexpected and Unintended Changes in
  Institutional Power Structure
• Overdependence on Technology

Campbell, 2006 1
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Richard MacKenzie, MD Richard.MacKenzie_at_lvh.com