While few would deny the potential of evidence-based order sets and computerized provider order entry to improve performance, the challenges presented by these complex technological rollouts are many. Chief information officers and chief medical information officers must secure tremendous collaboration to manage the hundreds of facets characteristic of these projects — all requiring a huge draw on time and resources. Many health care organizations have learned the hard way that even if just one facet goes awry, a project can stutter or fail, leaving an entire investment in the IT graveyard.
Like many large integrated health networks, Methodist Health System faced looming meaningful use deadlines requiring it to develop a sound strategy that would convince many physicians to use CPOE. The strategy not only needed to achieve rapid results, but also promote standardization of evidenced-based clinical practices. Doing so would position the health system for the performance-based, risk-bearing approach to health care.
When Failure Is Not an Option
The four-hospital system serving the greater Dallas and North Texas region had experienced a previous unsuccessful CPOE deployment, so earning physician buy-in and support would be a challenge. Because failure was not an option, the health system turned to the Failure Modes and Effects Analysis, or FMEA, framework to support long-term success of the greater CPOE initiative.
The FMEA method is certainly not new to health care. In fact, governing bodies like the Joint Commission require proactive, process improvement strategies such as FMEA as a best practice for performance improvement.
Used to design or redesign a high-fidelity process, FMEA is a natural choice for minimizing the chance of failure in a CPOE rollout. It provides a qualitative analysis of potential failure modes based on experience — whether they come from a previous failed deployment or industry knowledge.
Methodist determined that its new efforts would require an in-depth analysis of physician workflows and a streamlined rollout that incorporated physician concerns about new point-of-care processes. Also, Methodist started with an understanding of why physicians went to medical school to begin with — they care about patients. It focused on patient safety and clinical objectives rather than the looming regulatory requirements.
The FMEA analysis helped Methodist to identify several possible obstacles to physician engagement, which the IT department needed to address up front:
- Order sets needed to be credible to front-line physicians and able to improve patient care.
- Physician time could not be wasted in the development process.
- An order set steering committee could drive antagonism rather than collaboration.
- A workflow analysis of paper-based, order set usage would be critical.
- Most order set content cannot be standardized based on evidence.
Methodist used a clinical content management solution with hundreds of predefined order set templates. The solution supported efficient development and deployment of order sets; it also provided trusted content that would be respected by physician staff. Methodist also was able to show physicians it could reduce the development time for a single order set from the 12–18 months that it took under paper-based processes to just 30 days.
Methodist avoided too much focus on steering committee involvement, as experience with previous deployments revealed that while these leadership groups are beneficial for governance, they can muddy up the development process. The role of a steering committee should be more about evaluating methodology of content generation and review, not developing the actual content. That work belongs to front-line physicians who will use the order sets daily.
Switching from Paper to Electronic
Methodist conducted workflow analyses to provide a clear understanding of the current state of paper-based order sets. The team considered such factors as the amount of work that may have gone into the development of a particular paper-based order set to conclude whether it made sense to start over. If physicians poured excessive time into building a particular order set, Methodist decided to simply transfer the current content into the new electronic format.
Methodist decided to employ a phased approach to standardization of evidence-based practices. It looked at whether a standardization would substantially improve processes, as too much change up front could cause clinicians to push back during the first phase. By focusing on the essential 30–40 percent of evidence-based standard content rather than trying to standardize 100 percent, Methodist achieved greater physician engagement.
The goal of the first phase was adoption of CPOE — allowing variations in order sets where evidence was not a critical component. Phases 2 and 3 will entail consolidating to ensure greater standardization and integrating content to support higher-level quality initiatives.
Creating a Culture of Accountability
Value-based purchasing has created an unprecedented culture shift in the industry as health care organizations must standardize care practices to improve outcomes for key conditions. While the focus of order set initiatives in the past may have been more about creating efficiencies and meeting process measures, health care organizations must now use these tools to promote uptake of the latest industry evidence to address rapidly evolving clinical outcomes needs.
Currently, Methodist has achieved a CPOE adoption rate of close to 90 percent. As the organization's point-of-care strategy continues to advance, the plan is to use order sets to create a culture of accountability. When quality metrics fall short, the health system will identify where problems are occurring and determine if order sets are being used properly to identify opportunities for improvement.
Sam Bagchi, M.D., is a vice president, chief medical informatics officer and chief quality officer with Methodist Health System based in Dallas.