Most Wired

Seeing the Light with CPOE

By Chris Serb

Still holding off on electronic order entry? Hospitals that made the leap are ready to help.

Each month, H&HN will provide continuing coverage of the annual Most Wired Survey and Benchmarking Study and other IT issues. The 2009 survey is made possible through a partnership among H&HN, the American Hospital Association, the College of Healthcare Information Management Executives and McKesson Corp. CareTech Solutions and Intel provide additional support.

Through demonstrable efficiency and safety gains, many Most Wired hospitals have already answered the “why” part of the computerized provider order entry question. But the growing consensus among health care providers that CPOE is the right thing to do hasn’t led to widespread action yet.

According to research from IT consultant KLAS, just 17 percent of hospitals with more than 200 beds currently use CPOE. Experts believe that the “how” side of the CPOE question perplexes many providers.

“People’s hopes and dreams for CPOE don’t match the way they’re voting with their feet,” says Carolyn M. Clancy, M.D., director of the federal Agency for Healthcare Research and Quality (www.ahrq.gov). “To affect quality, safety and efficiency through the use of CPOE, you need to change the way you do things, and many organizations are hesitant.”

The most critical part of building a CPOE system involves assembling a broad-based, cross-functional forum of clinical—not technology—leaders, say executives from Most Wired hospitals. At Meridian Health, Neptune, N.J., that forum included 12 to 15 physicians plus nurses, pharmacists and other ancillary staff. And at Piedmont Hospital in Atlanta, CPOE efforts began with the creation of a physician users group involving more than 60 physicians from various specialties.

At eight-hospital Detroit Medical Center, an IT-driven CPOE rollout in 2003 failed, but that failure taught the system several lessons. For its successful relaunch in 2006, DMC assembled a Clinical Order Set Advisory Committee of physicians and ancillary staff.

“Putting that team together, which we didn’t do for the first launch, was critical to our success the second time around,” says Michael Leroy, DMC’s chief information officer.

These committees’ most important task is the hard but critical work of building standardized, evidence-based order sets. “Order sets build the best practice into the technology,” says Erica Drazen, a partner in the health care practice of CSC, an IT consulting firm. “It’s a [form of] decision support that’s passive.”

Commercial knowledge vendors like Zynx Health and Thomson Reuters sell order sets, while AHRQ offers a National Guideline Clearinghouse (www.guideline.gov). The Most Wired hospitals interviewed for this article, however, chose to build their order sets from the ground up, based on their own research into best practices. They also found helping hands from their peers. “In some areas, but especially in pediatrics, other institutions were very willing to share their order sets,” says Leland Babitch, M.D., chief medical information officer at DMC.

Systems Allow Flexibility

At most hospitals with fully functional CPOE systems, doctors have free reign to deviate from standard orders except when the most critical safety issues, such as drug-drug interactions, are involved. However, relatively few doctors choose that route because it’s more time-consuming to enter orders one by one than to use the standard sets.

In many cases, straying from standards becomes a learning opportunity for the hospital, its physicians or both. Meridian Health monitors compliance with the standards not only to reinforce best practices, but also to keep its order sets up to date.

“If we see regular, constant variation by one physician, we have the department chair talk to that physician and ask, ‘Why? Is there something wrong with the protocol? If so, we’ll fix it,’” says Margaret Quinn, M.D., Meridian Health’s chief medical information officer.

Quinn cites one case in which physicians frequently selected drugs outside the hospital’s recommendations for preoperative antibiotics. “They had some fairly well-reasoned arguments, so we went back and retooled some of the protocols,” she says. “But if the answer was ‘I had a hunch,’ then the physician leader will show them the evidence and drive home that the standard is the best practice.”

Alert Adjustments Educate Users

Another concern for health care systems is over-alerting, which can frustrate even the most patient physician. Most Wired hospitals have taken a variety of approaches to the problem. Some have turned off most alerts, keeping only the critical ones; other organizations have kept alerts intact in the pharmacy while minimizing them for physician users; and still others have differentiated alert levels, with fewer active prompts for specialists.

Additionally, hospitals sometimes encounter the need for an alert that the vendor didn’t provide. Piedmont Hospital realized that its order entry system didn’t warn against prescribing blood thinners for patients who have recently had an epidural catheter, which could lead to potentially catastrophic bleeding around the spinal cord.

Piedmont Hospital custom-built an alert to warn physicians about the problem. The hospital considered the process an opportunity to improve outcomes by building and automating similar prompts in areas like sepsis and deep-vein thrombosis.

“These are something like ‘suborder sets,’ things that are not isolated to any specific department typically,” says William McClatchey, M.D., Piedmont Hospital’s chief medical information officer when CPOE was implemented. “If your patient came in for hernia repair but also has atrial fibrillation, that would invoke an alert to the physician that the patient is at risk for DVT, so you should consider invoking a suborder set to prevent DVT.”

Newt Gingrich’s Center for Health Transformation dubbed Piedmont Hospital’s approach—which combines the quality- and information-driven order sets that form the core of CPOE with the kind of clinical alert that’s frequently seen as a limitation of the technology—as “Advanced CPOE.”

While this approach took a good deal of hard work and creative thinking, it produced important results: Since implementing CPOE, Piedmont Hospital has reduced sepsis mortality by 30 percent and hospital-acquired DVT by 90 percent.

McClatchey notes that Piedmont Hospital’s CPOE journey coincided with dramatic improvements in acuity-adjusted mortality rates, which are now in the top 10th percentile.“There are many people walking through the streets of Atlanta now who would not have ‘made it’ 10 years ago,” McClatchey says. “To me, that’s more compelling than any statistic.”—Chris Serb is a freelance writer based in Chicago.

Electronic Bed Tracking

Track ’Em and Turn ’Em
The majority of hospitals that participated in the 2008 Most Wired Survey and Benchmarking Study see the wisdom behind electronic bed tracking systems. The benefits—increased admissions due to better patient flow; greater efficiency among nursing, housekeeping and transport staffs; reduced ED crowding and diversions; and improved insight into census fluctuations for better staff planning—can lead to significant savings. Most Wired hospitals are likely leveraging their systems to measure staff performance, too. Least wired hospitals, fewer than one-third of which have tracking systems, may find this potential solution to their financial constraints out of reach.

	Emergency department	Medical-surgical units
All (Aggregate data for 556 hospitals and health systems completing the survey, representing 1,327 hospitals.)	70%	65%
Most Wired (Aggregate data for the 100 highest scoring respondents.)	93%	87%
Least Wired (Aggregate data for the 100 lowest scoring respondents.)	29%	31%

Source: H&HN’s Most Wired Survey and Benchmarking Study, 2008

This article 1st appeared in the February 2009 issue of HHN Magazine.

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