Yes, CPOE implementation is hard. It's very hard. What's more, it requires sustained commitment and cultural transformation in order to be truly successful. But the patient safety, care quality, and clinician workflow improvement gains that can be made are tremendous. Indeed, the whole initiative must be driven by patient safety and care quality goals, say the leaders of organizations that have successfully implemented CPOE and then built quality advances using its power. Call it the CPOE value proposition.
What's more, if a CPOE implementation requirement is embedded into the final draft of the ARRA-HITECH legislation's funding disbursement protocols (see “CPOE and Meaningful Use,” p. 42), the lessons learned will be all the more valuable. And what is the key to understanding CPOE success? It's about vision and process.
Excelling in Akron
At the five-hospital, 2,060-bed Summa Health System in Akron, Ohio, the team of clinicians, clinical informaticists and non-clinician executives who led the CPOE implementation knew exactly what they wanted out of the project from the start.
“My major concern was patient care quality, and risk management. And I felt that medication management was one of the biggest problems we had,” says then CIO, Charles Ross, M.D., who has since become CMIO. Ross says he had strong CEO and board support for initiating the long, complex process of CPOE implementation.
That process, of course, involved the development of order sets, one of the most multi-phasic and challenging aspects of CPOE implementation (see “The Order-Set Challenge,” p. 42). A quick glance at some of the results that the Summa folks have achieved, though, underscores the value of the pursuit. Among the gains: a leap from a 37 percent rate of physician compliance with the old paper-based order sets, to a rate of 93 percent; a reduction in readmissions within 31 days of stroke patients by 35.7 percent; and a reduction in stroke patients' hospitalization costs of 11.4 percent, after CPOE was used to help drive intensive stroke program improvements.
“An advantage we had going into CPOE was that we already had a strong, well-defined process for order set creation,” says Linda Gleespen, R.N., lead quality and clinical analyst for the system. “The problem was that when order set creation had been paper-based, there were different versions of every order set, and not everyone was working off the same versions or interpretations.” Now, Gleespen says, once an order set is updated by the multidisciplinary team she chairs, its expression is available, standardized, and system-wide.
But while CPOE is powerful technology, says Pamela Banchy, R.N., system director, clinical information systems, Summa, “It's just technology. It has to be integrated into the quality and workflow of the care delivery model that your organization has. That's where the collaboration with your users and with your vendors is important, to help mold it over time.”
Inevitably, says Banchy, who has been one of the key leaders of the CPOE initiative, “Every part of care delivery is touched, from registration through to discharge. That's why this is transformational.” Banchy adds that very close collaboration with one's vendor (Summa's CPOE solution is from Atlanta-based Eclipsys Corporation) is essential.
Greg Kall, system vice president and CIO, joined Summa shortly after the organization's initial CPOE rollout began, but had led a CPOE implementation in his previous organization. “I couldn't be more unequivocal in saying that CPOE implementation is not an IT project. You have to initiate it as a multidisciplinary, stakeholder-based project.” In fact, he says, “An IT guy like me can't put this into a hospital; it has to be the physicians and nurses. And Summa was particularly blessed with having an M.D.-CIO at the time.”
As for the CIO role in CPOE implementation and post-implementation, it is to be “an interpreter, a gatherer of knowledge, and a coordinator, helping to educate and prepare end-users for the changes to come in care delivery,” he says.
Unity in diversity
Nationwide, those hospitals and health systems having the greatest success with CPOE implementation are approaching it in a variety of ways, but always with the same general credo as the folks at Summa: CPOE is being implemented to improve care delivery, not simply to automate it. As Erica Drazen, Sc.D., managing partner in the Waltham, Mass.-based Emerging Practices division at Falls Church, Va.-based CSC, puts it, “The goal must be patient safety improvement; it must be clinician-led. This is going to touch everybody, so you really need to have extraordinary project management, and you also need a very efficient decision-making process.”
Drazen's colleague at CSC, principal researcher Jane Metzger, adds that, “One of the core challenges involved in CPOE development involves the process of order set development and order set management; and that process inevitably becomes part of the broader effort to reduce unnecessary variation in care.” Metzger was one of the lead authors in a recent CSC white paper, “CPOE: Getting Order Management Right” (see “The Order-Set Challenge”).
A small but significant number of hospital organizations have leveraged CPOE for clinical transformation. Among them:
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