- Multiple processes have been found that are frequently less than ideal prior to CPOE and become magnified when CPOE is implemented. It is imperative that the sites understand the actual current state of these processes, and the gap between how they think they function, and how they will function in a CPOE future state. These investigations must involve end users and their daily reality, and not rely on management’s perception of what the processes are (i.e. medication reconciliation).
- The facility must invest time to understand how CPOE changes some major common processes such as direct admissions, ED admissions, ED holds, consultations, compliance with co-signing verbal/phone orders within 48 hours, admission process, transfer and hand-off processes, chart reviews (abstractors, quality, HIM, etc.), chart orders review (shift review of orders by nurses), discharge process, and initial medication history.
- Proper usage of clinical tools such as the patient access list (PAL) and the multi-patient task list is key.
- Well-trained and engaged physician liaisons and super-users (the latter on each unit/department) are extremely important for process reviews, training, activation support, and ongoing support of all users, including physicians.
- Health information management (HIM) and coding processes, as well as concurrent scanning and impact of physician documentation on HIM processes, are important to review.
Methodology
Through the two pilots, AHS refined it complex deployment methodology, which allowed for a 7.5-month engagement window before go-live. AHS identified one of the critical success factors for CPOE would be the change management efforts around the deployment. Using this methodology, each hospital meets 90 days prior to kickoff for a four-hour executive workshop that includes key directors from ICU, pharmacy, quality department, IT, as well as physician champions and clinical informatics. The group is taken through several change management exercises and 10 champions, who are all responsible for a different area (i.e. training/knowledge management, workflow, stakeholder analysis, employee engagement) are selected to lead the project. Over the following 24 hours, the 10 champions are interviewed and asked questions like: how do you feel about CPOE?, what is the business case around CPOE?, what are the current obstacles and resource problems?, how would you respond to angry physicians? This interview is followed up by administration of a survey, the Denison Organizational Culture Survey, which in 64 questions gives managers a glimpse of what is needed to emphasize and improve on at an organizational level.
The team then creates a theme for the CPOE kickoff (past themes have included NASA, cattle drive, Top Gun, and Transformers). At the kickoff the CEO does a 20-minute presentation on the CPOE process and solicits questions. Then over the next three months, the hospital will present two “sneak peeks” that are day-in-a-life workflow scenarios at town hall meetings. Training begins eight weeks prior to go live, with an active support model of super users and 10 additional support personnel at go-live.
Impressive Results
Earlier this year AHS did a behavior analysis of CPOE usage for January and February and found that clinicians made 650,000 orders, with 68,000 alerts firing that resulted in a change to the order. “We thought that was pretty amazing that we were changing behavior on one out of every 10 orders, and we were actually seeing a change in behavior based on clinical decision support,” says Smith.
On the other hand, there were also about 10 percent of alerts that are not acted upon, says Smith, so AHS is working with its vendor to roll out a rules engine to filter out false-positive or “nuisance alerts” in October. “We’ll be the first in the industry to take [the rules engine] live across all of our hospitals, which we think will revolutionize alerting,” says Smith. “And we were able to get the leverage to get that engineering done since we have so much data on alerts because we have been willing to stay the course and understand what’s going on.”
Through Oct. 1 of this year, AHS physicians created a total of 13.3 million CPOE orders and 4 million medication orders, with 400,000 alerts firing that changed ordering behavior. There has been a 95 percent reduction in call backs from pharmacists calling physicians to clarify orders since CPOE activation. Overall corporate CPOE order rates are between 87 and 88 percent, with all but three hospitals being on 100-percent electronic documentation in the ED. The system just completed analysis on its top 10 diagnosis-related groups (DRGs), and among heart failure cases alone, there has been an 11-percent length of stay decrease and a 16-percent decrease in cost-per-case from those physicians using the corporate evidence based content.
Implementation Challenges
Smith admitted a challenge from the beginning was the possibility of alienating a few physicians at each hospital who criticized the method of system optimization through rapid deployment. Smith says that it was difficult to change the methodology mid-stream since there was always three hospitals in various stages of deployment at one time. “We decided to move forward and make it happen because we were seeing so many patient safety gains that we felt it was more important for our patients to benefit from CPOE rather than stopping to leverage everything we could to make the system as great as it could be,” he says. “We settled for ‘good’ and moved forward.”
