CPOE Implementation in the Community Setting

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CPOE Implementation in the Community Setting

• What do you need to know?
• Avoid a Towering Inferno by creating a burning
  platform
• Avoid medical staff revolution with the evolution
  of a patient safety culture

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Scope of the Challenge
Current and Projected CPOE Implementation at
U.S.A. Hospitals
100
90
80
70
60
US-2005
50
US-2010
40
30
20
10
0
lt300 beds
gt300 beds
US estimates from Kaushal R, et al. Health
Affairs 2005241281-1289.
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CPOE is a key component of any medication
safety initiative

PO Medication Delivery
CPOE Provider writes order
PO med
Smart IV Pump
IV med
Decision Support
Pharmacy Pharmacist Approves Order
Completing The Loop Web Reporting Team
Training Medication Reconciliation Improving
Transitions
Electronic Identification
Pump sends documentation To eMAR RN verifies
eMAR RN acknowledges Approved order
ADE Surveillance
Delivery to Site
Med Repackaging
omnicell, robotics, etc.
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CPOE Implementation in the Community Setting

• Factors Critical for Success
• Communicate Vision, Rationale and Goals
• Provide Data to Support Vision, Reinforce
  Benefits and Measure Performance
• Demonstrate Leadership Commitment
• Mentor Physician Champions
• Develop Incentives and Sanctions
• Respond to Physician Concerns
• Marketing and Communication

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Communicate, Communicate, Communicate Vision,
Rationale and Goals

• CPOE has been proven to enhance patient care.
• CPOE reduces medication errors and provides
  alerts for potential drug interactions and when
  dosage adjustments are required.
• Define firm targets 75 of medication orders
  entered electronically by June 2007

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Data to Support Vision and Rationale
Serious Medication Error Rates Before and After
CPOE
12
10
Phase I (Before CPOE)
8
Serious Medication Errors (Events/1,000 Patient
Days)
Phase II (After CPOE)
6
4
Delta -55 P lt .01
2
0
Bates et al. Effect of Computerized Physician
Order Entry and a Team Intervention on
Prevention of Serious Medication Errors, JAMA
1998.
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CPOE provides real advantages in providing
quality patient care

• Quality and safety benefits from decision support
  tools
• CPOE continuously delivers evidence-based
  treatment.
• Care is more reliable, more efficient, and safer
• All involved physicians know patients
  medications
• Fewer call backs from pharmacy
• Fewer call backs from nursing
• Faster delivery of inpatient medications
• Physician orders are legible

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Data to Reinforce CPOE BenefitsMedication
Errors Before and After CPOE Implementation
NSMC Adult Psychiatry CPOE live on 9-9-05
NSMC Geriatric Psychiatry CPOE live on 11-8-05
0.3
4.6
Errors Per Month Jan. 05 March 06
0.4
2.3
0.1
1.7
Actual
Potential
0.1
BEFORE
AFTER
BEFORE
AFTER
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Why we need to adopt CPOE now?

• It is widely accepted as the new standard of
  care.
• It distinguishes our quality of care from
  hospitals that are late adopters.
• It is increasingly a significant point of
  leverage in negotiations to maximize
  reimbursement from private insurers.

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Demonstrate Leadership Commitment

• Hospital Executives and Physician Leaders play
  formal roles.
• NSMC Chiefs Forum reviews CPOE progress every 2-4
  weeks.
• CEO and President participates in discussion once
  per month ad hoc meetings as needed.
• Appointment of IS medical director CMIO
• Create the necessary infrastructure to effect
  change.

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Medical Staff Leadership Reporting and
Accountability Structure
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Leadership and Governance

• Chiefs Forum (CF) assumed responsibility as the
  CPOE Physician Advisory Group.
• CF develops policy recommendations, identifies
  areas of resistance, reviews physician
  utilization and provides communication.
• Medical Executive Committee functions as the
  governing body of the medical staff.
• Education and engagement of Board of Trustees on
  a regular basis

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Expect mixed reaction and pushback during
initial rollout

• Big Bang vs Sequential Implementation
• - Initial focus on medication orders at NSMC
• MD compliance variable
• MDs will complain about the length of time it
  takes to enter orders compared to writing on
  paper.
• Large practices without hospitalists place a
  significant burden on rounding MDs

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Moving the Ball Forward

• Focus on steady progress
• 24/7 at the elbow technical support
• Usability enhancements will help with overall
  acceptance
• -Process to prioritize order set development
• -System speed and responsiveness
• Identify and mentor high volume, high compliance
  CPOE users as physician champions.

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Monitoring and Reporting

• Data for orders entered via CPOE are very
  accurate
• Accurately identifying the ordering MD on paper
  orders is required for accurate CPOE compliance
  reports
• - Encourage second identifier on written
  orders i.e. print name, beeper , etc
• - Orders with illegible signatures are
  attributed to the attending MD
• Weekly reporting to Department Chairs
• - Numerator Medication Orders Entered Into
  CPOM by prescriber
• - Denominator Total Medication Orders by
  prescriber

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Weekly Utilization Metrics
Full names provided on actual report.
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Pharmacy Study of Handwritten Orders May 22,
2006 June 2, 2006

• Accurately identifying the Ordering MD on
  paper can be a challenge due to illegible
  signatures

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Achieving a Tipping Point through Physician
Level Reporting

• Chairs need to focus on high volume/low
  compliance MDs.
• For those who continue to write on paper, a
  tougher compliance policy is needed.

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Incentives and Sanctions

• CPOE P4P incentives ideally aligned with
  physicians and hospitals.
• Consider recognition, contests and give-aways.
• Mandatory Training
• -All physicians must attend a CPOE education
  class prior to receiving system login.
• -New medical staff receive training as part of
  the orientation process.

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Sanctions required for those who continue to
write on paper

• NSMC CPOE Compliance Policy Process
• Individual CPOE compliance set at 85.
• Department Chairs own primary management
  responsibility
• MDs have multiple opportunities to remediate
  their compliance.
• Compliance policy patterned after Medical Records
  completion policy.
• Written notification of deficiency, with cc to
  chief/chair.
• Appearance before Medical Executive Committee.
• Suspension of privileges.

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CPOE Utilization Compliance Policy
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Respond to Physicians Concerns
Demands on Massachusetts Physicians Continue to
Increase
Declining Reimbursements
Increasing Practice Expenses
Malpractice Premiums
High Cost Of Living
Transparency/ Public Reporting
CPOE / EMR
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Nursing Unit Implications

• Routine Verbal Orders are not allowed per JCAHO
  standards
• Telephone Orders will only be accepted for urgent
  orders or when CPOE is not accessible.
• CPOE support staff and RN super users will offer
  to show MDs how to enter orders. If rebuked,
  Nurse Manager or Supervisor explains hospital
  policy regarding reporting of the incident to the
  Department Chair.

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Marketing and Communication

• Develop a logo
• Heighten awareness reaffirm commitment to CPOE
• Weekly on-line and paper newsletter publish
  go-live dates, FAQs, tips
• Hold regular informational meetings.
• Post signage on each unit reminding MD that this
  is a CPOE unit

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Marketing and Communication
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Measuring CPOE Performance
Non-CPOE
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Measuring CPOE Performance
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CPOE Implementation in the Community Setting

• The Final Move
• Remove all paper order sets from the floors.
• As of _________, written orders will not be
  accepted and all routine orders must be entered
  via CPOE.

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CPOE Implementation in the Community Setting

• Final Thoughts and Key Take-Aways
• Patient Care is safer
• Adopting CPOE requires commitment by busy
  physicians
• Appeal to sense of professionalism
• Time is required, but time is saved.
• Physicians respond to data
• Recognize physician champions
• Explore physician incentives and sanctions
• Increase financial incentives that reward use

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CPOE Implementation in the Community Setting

• Final Thoughts and Key Take Aways
• Respond to physician concerns
• -Continue efforts to improve the ease of use,
  speed of the applications and surrounding
  workflow
• Create a patient safety culture that embraces
  evidence based, standardized, coordinated care
• Once you reach a tipping point, growing
• intolerance of non-users
• Plan to learn along the way