Embedding Evidence Into Physician Ordering

Well, the reason we didn’t have any major problems was that we prepared very diligently for CPOE, emphasizing that this system was being created by clinicians, for clinicians, and we involved clinicians in every step of the design process. And we emphasized the potential of evidence-based order sets and CPOE for improving patient safety and saving lives; we shared with them articles from the literature that demonstrated those benefits. We made sure they knew that although their workflow would be slower at first, the result would be better patient outcomes, since evidence is built into the new workflow. And it’s hard to argue with that, since they all want the best for their patients.

So overall, then, the physicians have embraced it?

Yes, we have 100-percent physician adoption, and 94 percent of physician orders are directly entered by physicians into the system. The remaining 6 percent are verbal or are made by telephone; you can’t completely eliminate that, since doctors are not always near a computer or have their hands free to enter orders. And in terms of the medication-specific orders, physicians directly enter 86 percent of those into the system. That’s significantly above the Leapfrog standard, which calls for 75 percent of orders to be entered directly into the system by physicians.

Now that you’ve been doing this for over a year, do you have any thoughts on lessons learned?

Well, CPOE is sometimes treated as a bit of a check-box kind of process in some hospitals, particularly in the States, where you have meaningful use driving tight implementation deadlines. But the thing is, CPOE can be built well or built poorly, and the end result can be quite different in terms of its impact on the care of patients. You need to look at how your system is going to mesh with your current clinical workflows, because if you just perpetuate existing workflow problems, the new system will be blamed for pre-existing poor outcomes.

What’s more, if you don’t look carefully at the staffing, skills, and workflows necessary to mobilize the evidence contained in CPOE and order sets, you’ll miss key opportunities to improve patient care. For example, in terms of stroke, there’s clear evidence in the literature that a patient should undergo a swallowing assessment within the first 24 hours. The evidence and the corresponding order for swallowing assessment were in our new stroke order set for CPOE; however, we couldn’t meet the standard of assessment in less than 24 hours, because we have a limited number of specialists available in speech language pathology, particularly on weekends.

So we trained some front-line nurses to do a swallowing screening test, which is not as in-depth as a swallowing assessment, but it does help to determine which patients are most at risk. And now that we’ve trained a group of nurses who can perform that test, we are able to meet the evidence-based standard of assessment in less than 24 hours. The patients determined to be high-risk by the nurses are in turn referred for specialty assessment by speech language pathology.

And that’s an example of where if we had just plunked that evidence into the order set without examining the process, we would not have improved patient care, since there was an underlying gap that had to be addressed in the staffing, skills, and workflow. So unless you look at each order set and examine the processes involved, you’re just creating a system that doesn’t create the patient benefit that it’s supposed to.

So one of the key lessons learned here is to rethink processes, and to optimize them, and not simply automate past processes? 

Absolutely. So often, the temptation is simply to automate without thinking things through. And once you’ve implemented CPOE, it’s not an end-point, it’s part of a journey. You have to constantly measure what your system is doing well and what things it’s not doing well, so that you can make continuous improvements. We have a business information system that we’ve attached to our Cerner system, which generates regular metrics that help us to look at our patient outcomes and decide where we need to focus our improvement efforts next.

Do you have any explicit advice for CMIOs and CIOs?

Really, the last couple of points I’ve made are the important ones. First to implement CPOE not for the purposes of automation, but rather to build evidence into decision-making at the point of care and construct the associated hospital workflows, in order to ensure that the best care reaches the patient. Second, realize that once CPOE is turned on, it’s not the end of the journey; rather, it’s the beginning of a process to continually look at performance metrics and create clinical care process improvements that result in better patient outcomes.