When evidence-based order sets of a computerized physician order entry system (CPOE), together with real-time clinical decision support (CDS), are used by clinicians within a fully integrated in an electronic medical record (EMR) system, miracles can happen. Specifically, the risk of dying while an inpatient in a hospital can be reduced, as was presented during a HIMSS14 virtual session the week of February 23, as the HIMSS Conference was taking place at the Orange County Convention Center in Orlando.
North York General Hospital (NYGH) discovered that its diligent, appropriate use of carefully implemented health information technology helped make it the top performing hospital in reducing inpatient mortality among all Toronto area hospitals and the second best performing hospital in Canada in 2012. While numerous factors can contribute to inpatient mortality reduction, a study presented at HIMSS 2014 directly linked the use of real-time CPOE/CDS to this positive outcome.
North York General may be perceived as a typical mid-sized healthcare enterprise. It consists of a 418-bed acute care community teaching hospital that is affiliated with the University of Toronto, an ambulatory care center, and a seniors health center. Its healthcare facilities and regional programs serve a population of about 400,000 living in the metropolitan Toronto area and south central Ontario. During the 2012-2013 calendar year, North York General Hospital had nearly 30,300 inpatient admissions and nearly 116,150 emergency department visits.
From a healthcare IT perspective, this community health system was light years ahead of the pack. In April 2011, it achieved stage 6 in the HIMSS Analytics EMR Adoption Model, one of only three hospitals in Canada to achieve this status. (No Canadian hospital had as yet attained stage 7.) In October 2010, NYGH had replaced its manual systems with CPOE and closed loop barcode medication administration systems. With these additions, the hospital’s EMR had the ability to provide intelligent, evidence-based advice to physicians as they entered electronic orders for patients. This was phase 2 of eCare.
eCare was a multi-year, hospital-wide clinical transformation project utilizing health IT to improve patient outcomes. The primary goal of the project that began in 2007 was to improve quality and safety of patient care using advanced EMR technology to improve patient outcomes.
“Our hospital leadership was concerned about the fact that adverse events in Canadian hospitals represented 7.5% of acute care admissions and the potential of causing 9,250 to 23,750 preventable deaths per year. Inpatients are exposed to risks. Our leadership wanted to address this head on, and make our hospital a safer hospital,” said Jeremy Theal, M.D. a gastroenterologist and the organization's chief medical information officer. “We wanted to transition to a culture where our clinicians and staff embraced evidence-based care. We wanted them to take ownership of a project that would be the shared vision of its clinical staff and hospital administration.” As many hospital administrators know well, it’s one thing to implement a CPOE/CDS system, but it’s something else entirely to get physicians to use it.
Grassroots planning from the start
The project team began by evaluating inpatient discharge data for a 12 month period to identify patient conditions that the hospital treats. The objective was to cover at least 80% of diagnoses with standardized order sets. After a gap analysis had been performed, 350 order sets needed to be developed. The hospital opted to develop a “bespoke” rather than an off-the-shelf system, one developed by its clinical staff to fit the way the hospital worked. A centralized interdisciplinary order set build team consisting of four physicians, two pharmacists, and 15 clinical informatics applications analysts representing the equivalent of 3.5 FTEs reviewed sources of evidence. Evidence-based order sets were developed from existing local hospital order sets, protocols, and diretives as well as Canadian and International guidelines, peer-review journal articles, and vendor-provided information.
An additional 80 physicians and 150 clinical staff were recruited to review each order set and provide interdisciplinary and inter-professional input. Dr. Theal emphasized that physician/clinical staff hands-on involvement was essential to the project’s success. Then it was necessary to see how each order set would fit into workflow. If problems were identified, new solutions were identified and tested. “The idea of putting a new solution onto an old broken process could have spelled disaster. We looked at this project as a key opportunity to integrate evidence into new workflows that would better fit the new system that was being implemented,” said Dr. Theal.
Each clinical process was scrutinized: how roles would change, what processes would continue/be terminated/start. A “loop” was defined for every orderable, a decision that resulted from visits to hospitals which had experienced orders languishing in cyberspace because all elements hadn’t been addressed. The loop processes were then tested in a laboratory-type environment. Different physicians who would be using the order sets were given a clinical scenario, such as admitting a patient with a suspected hip fracture into the hospital, and asked to walk through the process. This process identified snafus that could then be addressed and retested before go-live.