Expert Panel Discussion on The Road to CPOE

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Edward Koschka

We installed CPOE in our first hospital, The Indiana Heart Hospital, in February 2003. The Heart Hospital was a for-profit, physician-invested hospital that set the objective of being an all-digital hospital as a differentiation strategy with the other three heart hospitals in Indianapolis. Initially, we achieved a 75 percent CPOE utilization rate. That has dropped to 45 percent over the last seven years due to increased utilization of external specialists brought in to manage multiple chronic diseases associated with patients in this specialty hospital. These external specialists are not using CPOE anywhere else, so using it at one hospital periodically has been a major barrier.

Two years ago, we created a network informatics committee that has been focused on our systems upgrades, including implementation of CPOE. This group meets monthly to discuss content and workflow issues with a subcommittee that is focused on CPOE. We anticipate our first pilot in the OB area of our second hospital to commence in November 2010. Our goal is for the other three hospitals to achieve 10 percent CPOE by July 2011. We chose the OB area for the pilot because we wanted the minimum number of physicians involved to achieve the 10 percent compliance goal.

David Fiser

Akron General's CPOE project initiative is slated for 14 months--from the initial project start date to implementation. We have scheduled a phased go-live in the first quarter of 2011. The planning leading up to project kickoff began one year prior with vendor discussions and multiple reference site reviews leading up to final contract execution.

Jeff Bell

David, you spent a year selecting and contracting for your CPOE system. Did you stay with your current clinical systems vendor? Did you look at other systems? I believe this is going to be an issue for some health systems that may decide their current CIS vendor is not one they want to stay with for the more advanced clinical systems. In those instances, this will certainly lengthen project time frames.

David Fiser

Yes, Akron General decided to remain and expand its partnership with McKesson to provide our core clinical solutions, including CPOE. We are expanding McKesson Horizon product suite as the standard for the Akron General Health System that includes Akron General Medical Center, Lodi Community Hospital and the Edwin Shaw Rehabilitation Institute.

We had reviewed multiple clinical vendors and solutions on the market dating back to 2006. We believed that strengthening our relationship and expanding the advanced clinical solution suite with McKesson provided us with the best choice for the health system based upon clinical functionality.

The decision to standardize on the McKesson clinical solutions will greatly assist in the speed of the application suite into production across our health system. This standardization eliminated the need for individual entity reviews and decision processes for locating a core clinical vendor, which can be a very lengthy process.

Dave Baumgardner

Union Hospital kicked off its CPOE project this past February, with several months of planning, site visits and MEDITECH dictionary training. The targeted go-live date is February 2011. Additionally, we spent several months prior to kickoff on preliminary planning.

We have experienced some staffing issues related to the pharmacy as they have been challenged due to several medical leaves and the undertaking of after-hours support for a critical access hospital. We are exploring the possibility of adding a pharmacist to handle the IT responsibilities related to this project. Order set development is requiring more resources than planned. We are also exploring the services of an outside consulting company to assist with the implementation. With the release of the final rule on meaningful use, we are reviewing the requirements and may possibly slow down our project and still meet the meaningful use requirements.

Jeff Bell

It isn't uncommon for the development of order sets to take more resources than anticipated. It's important not to implement CPOE without a pretty complete set. Order sets can speed ordering for the physician and go a long way toward improving physician perception of value. They are also an important aspect of clinical decision support--guiding evidenced-based treatments. Order set development is something that could begin long before the official kickoff of the CPOE project.

Edward Koschka

We found that Zynx evidence-based order sets have been instrumental in the rapid development and acceptance of standard orders. For example, newborn admission order sets went from 57 to 1 over four months. We plan on using Zynx as the backbone of our CPOE order set development to ensure that we continue to incorporate evidence-based content.

Jeff Bell

On a final note, the overall management of the CPOE and EMR implementation and rollout makes for a large project, quite possibly the largest project that a hospital or health system has ever undertaken. The coordination of all the facets of the project necessitates a dedicated, skilled project manager and a well-thought-through project plan--one that goes beyond what the EMR vendor typically provides. The points that David makes about monitoring and adjusting to staffing levels and progress on key tasks in the pharmacy area all point this up.

The impact of the final rule for meaningful use of an EHR has to be considered. I've just read a summary of the changes to the Stage 1 requirements for hospitals, and they have lowered the bar in a number of areas and given some flexibility. For example, there are 14 core objectives that everyone must meet, and another 10 menu objectives from which 5 must be met. CPOE use for Stage 1 is only concerned with medication orders and requires that 30 percent of patients with medication orders have at least one medication ordered directly by the provider via CPOE.

This raises the question: Would it be a good strategy to require CPOE initially for medications only? One of the most important benefits of CPOE with respect to patient safety is to prevent medication errors. Order sets should be comprehensive--not solely focused on medications. And workflow would be complicated by ordering medications one way and other treatments via paper.