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For All the Right Reasons

August 31, 2009
by Mark Hagland
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Approaching CPOE from a patient safety and care quality perspective is the first critical step toward success

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”).

Jacqueline dailey

Jacqueline Dailey

A small but significant number of hospital organizations have leveraged CPOE for clinical transformation. Among them:

  • At Children's Hospital of Pittsburgh, which has been live enterprise-wide with CPOE since October 2002, Vice President and CIO Jacqueline Dailey, and CMIO Jim Levin, M.D., Ph.D., note that adverse medication safety events have fallen from 0.09 events per 1,000 doses in 2003 to just over 0.04 last year - in other words, to less than half the pre-CPOE level. Meanwhile, overall patient mortality has dropped from about 0.99 at the time of implementation to 0.49 in the fourth quarter of 2008, again, a drop of nearly 50 percent. “The focus from the beginning was on doing CPOE to improve patient safety” says Dailey. That focus, she says, includes “monitoring our patient safety events. Part of our success derives from our use of the automated alerts that come out of the system, and part has involved our continuously working in a performance-improvement mode.”
    Michael bryant

    Michael Bryant
  • At Methodist Medical Center of Illinois in Peoria, President and CEO Michael Bryant and CIO Ellen Swoger share the same mentality as those at Children's in Pittsburgh. “When we put together the project charter for CPOE,” says Bryant, “We organized it entirely around achieving our strategic mission, which is delivering outstanding healthcare, period. In order to do that, we needed to be the safest place for our patients.” Swoger says she and her colleagues agree that CPOE implementation has been key to the hospital's achievement of exceptionally low mortality and complication rates. Methodist's overall mortality rate from July 2007 through June 2008 was 2.49 percent, compared to Medicare's nationwide 4.41 percent average; while its inpatient complication rate was 1.73 percent, compared to Medicare's 1.99 percent average. The challenge to CIOs will always be “trying to get data out of systems,” but it is a welcome challenge, Swoger says.

  • At Emory Health Care in Atlanta, the first of its facilities to go live with CPOE achieved a 99 percent physician adoption rate, which CIO Dedra Cantrell, R.N., attributes to good planning, thorough processing of clinician end-user feedback, and continuous improvements. “The most challenging part of this,” she reflects, “is sustaining change after you've gone live, and making things better every day.”

  • At Trinity Health system, which is based in Novi, Mich., “We now have 23 facilities live with an average of 74 percent of orders made on the system,” says J. Michael Kramer, M.D., vice president and CMIO. “That's extraordinary.” In fact, Kramer says he believes that adoption level is the highest of any large, community hospital-based multi-hospital system in the country (Trinity spans 45 hospitals in seven states). The key? Trinity's leaders have created and reinforced a very strong linkage between CPOE implementation and their ongoing intensive care quality improvement initiatives.

What is clear, experts say, is that getting CPOE implemented takes a lot of hard work and some cleverness, particularly in community hospital settings with voluntary medical staffs. According to James Keel, III, M.D., CMIO and medical director of quality at 800-bed Mission Hospital in Asheville, N.C., training is not overlooked. “We made education mandatory, and required every physician to go through a four-hour class; but we also were able to arrange for them to receive eight hours of CME credit for becoming certified in CPOE use,” he says.

Getting the doctors on board is doable, says Paul Browne, senior vice president and CIO at Trinity Health. “We look at CPOE as a way to make it easiest for physicians to do the right thing. And how do you make it easiest to do the right thing? You create really good order sets.” And, on a broader level, he says, continuous restatement of an organization's commitment to constant patient safety and care quality improvement must support the practical work.

In the end, says Reid Coleman, M.D., CMIO at Lifespan Health system in Providence, R.I., “There is no secret clue to getting physician buy-in, other than providing a system that works.” The good news for the four-hospital Lifespan is that its successful implementation has not only bonded physicians to its CPOE system, it has also facilitated broad clinical care improvements, including reducing drug-drug interactions.

G. Daniel Martich, M.D., CMIO at 20-hospital University of Pittsburgh Medical Center Health System, says his organization and others have laid the foundation for fundamental care quality improvement. “We're really at the tipping point in proving that what we're doing with EMR, clinician documentation, and CPOE is of value in terms of quality and pa tient safety,” he says. “Will it have the level of financial return that President Obama wants? Maybe, maybe not. But, going forward, this is just going to be a part of the cost of doing business in healthcare.”


The Order Set Challenge

There is a “rubber meets the road” aspect to any challenging IT issue, and when it comes to CPOE, that aspect involves clinical order set development and management. The industry is vastly improved from 10 years ago, with many organizations providing basic order sets. However, the challenge remains matching such development to actual care delivery processes, which inevitably requires customization.

The requirements that get worked out under ARRA-HITECH funding mean hospitals better start thinking about CPOE - and thus, order set development - now. “There are an awful lot of hospitals that are gearing up to try to do it faster, sooner,” says Jane Metzger, principal researcher in the Emerging Practices division at CSC of Falls Church, Va. “We think that part of getting CPOE implementation right the first time means really honing in on the complexities of order management.”

According to a report Metzger and her colleagues recently authored, it means that one group, which would need to include representation from the C-suite level, must oversee the project and set policy. It also calls for a designated, physician-led multidisciplinary group to review clinical practice issues; and for multidisciplinary workgroups to sort through all the design issues involved.

James Feldbaum, M.D., a consultant who specializes in CPOE implementation (following 25 years of clinical practice) urges hospital organization leaders to apply strong governance discipline across the process of CPOE implementation, and very specifically across order set development.

“When order sets are implemented without rules or governance, chaos can result,” he says. Feldbaum says an organization's board of trustees and C-suite must sign off on a clear CPOE implementation plan and establish strong day-to-day governance over that plan, and must enforce a universal mandate for physician adoption. In return, physicians have the right to demand that the CPOE system be reliable, evidence-based, and time-efficient. - M.H.


CPOE and Meaningful Use

At the June 16 meeting of the Office of the National coordinator's HIT Policy Committee, the committee's Meaningful Use Work Group presented its initial recommendations on meaningful use; and those included that 10 percent of orders would have to be made via CPOE by hospitals seeking ARRA-HITECH funds. Whatever the specific outcome of the iterative process, few doubt that CPOE will hold some place in the definition of meaningful use under HITECH. Given that no surveys have found that a majority of hospital organizations have fully implemented CPOE to date, some industry observers see a mad dash towards CPOE implementation. And that could lead to sloppy work, which could actually set CPOE usage back.

On the other hand, Celwyn Evans, a senior partner at the Malvern, Pa.-based Greencastle Associates Consulting, says, “The ARRA could be a game-changer. Right now non-academic hospitals and systems are very, very reluctant to mandate physician adoption, because physicians can simply take their book of business to the hospital down the street. But if ARRA requires CPOE adoption for its meaningful use provision, then everyone is going to be implementing CPOE, and that will lead to mandated adoption.” - M.H.


Who's Gone Live?

One of the more challenging aspects of CPOE is simply determining how widespread its implementation really is across the industry. A number of recent surveys provide rather diverse answers.

The Ann Arbor, Mich.-based College of Healthcare Information Management Executives surveyed its members in late June, and found that 59.4 percent of responding organizations were “at some level of adoption;” but only 8.5 percent of respondents said their organization would be at 100 percent adoption within the next year.

A report on CPOE optimization produced this summer by the Falls Church, Va.-based CSC quoted an American Society of Health System Pharmacists 2007 study that found that 14.8 percent of hospital organizations surveyed had implemented CPOE, with 7.7 percent of responding organizations reporting that CPOE covered all beds in their organizations, and 5.7 percent reporting 75 percent or more of medication orders were created electronically.

A Healthcare Informatics online survey, conducted in June, found 26 percent of responding organizations had implemented CPOE, and another 17 percent were in the process of implementing it (see chart below). - M.H.



  • True CPOE success is about facilitating improved patient safety, care quality, and efficiency in a multidisciplinary environment, and on an ongoing basis.

  • CPOE implementation forces clinician leaders to examine and rework long-ingrained care delivery processes, especially as they build or adapt order sets.

  • The likelihood that CPOE will be a requirement of meaningful use could compel a rapid acceleration in implementation.

Healthcare Informatics 2009 September;26(9):40-44

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