CPOE is much more than computers.

IN THIS ARTICLE ...

A prominent hospital in Pennsylvania turned to CPOE to help reduce medical errors and improve patient care. Learn what steps hospital officials took to establish a successful CPOE system.

In the wake of the groundbreaking report, "To Err is Human," by the Institute of Medicine (IOM), hospitals are struggling to find ways to improve the safety of our health care delivery system.

Documenting as many as 98,000 deaths every year from avoidable medical errors, the report cites information technology as an important tool to reach the goal of cutting medical errors in half by the year 2005.

When implemented effectively, computerized physician order entry (CPOE) systems can enhance the quality and efficiency of patient care and help prevent harm. CPOE is technology that creates a non-ambiguous order, permitting integration of decision support into order generation and supporting timely order implementation. (1)

To reduce errors, CPOE must be tightly integrated into a clinical information system that provides easy access to complete patient information. The best CPOE systems also provide clinical decision support and real-time access to current medical knowledge.

IT challenges

Efforts to implement information systems in clinical settings are not always successful. (1,2,3,4)

Reed Gardner, PhD, a prominent researcher in the use of information technology (IT) in health care, says the success of a health care IT project "is perhaps 80 per cent dependent on the development of the social and political interaction skills of the developer and 20 percent or less on the implementation of the hardware and software technology." (6)

CPOE implementation is particularly challenging because it requires major change in physician workflow. Change of this magnitude is not accomplished by simply deploying the technology. (7) As a result, despite solid evidence of its benefits, CPOE is deployed in only about five percent of hospitals nationwide. (8)

CPOE is not new. Several forces that recently converged fueled intense interest in the topic. In addition to the IOM report, other CPOE drivers include:

* The Leapfrog Group

The Leapfrog Group is a consortium of industry leaders including AT&T, IBM, General Electric and General Motors that are leveraging their combined health care purchasing power to drive improvements in health care safety. Leapfrog members agreed to make health care purchasing decisions that favor organizations focused on patient safety, and placed major emphasis on CPOE. To be "Leapfrog certified" a hospital must demonstrate that its CPOE system can intercept at least 50 percent of common serious prescribing errors. (9)

* Legislative pressure

In 2000, California passed legislation requiring health care facilities to adopt a plan for reducing medication related errors by 2005, including "... computerized physician order entry or other technology that has been shown effective in eliminating or substantially reducing medication related errors." (10)

California is not alone. Since 1999, more than 100 bills addressing health care safety have been introduced in 26 states. (11)

* Cost savings

There are significant financial incentives for hospitals to deploy CPOE. Leapfrog estimated that savings from reducing preventable adverse drug events (ADEs) range from $180,000 annually for a 200-bed hospital to $900,000 for a 1,000-bed hospital--a total of $370 million for all US hospitals. (12)

CPOE implementation case study

Most studies demonstrating that CPOE can reduce errors have been performed in academic medical centers. In these settings, the house staff who enter the vast majority of orders are residents and interns dependent on the institutions to complete their training. Use of CPOE is a condition of employment.

By contrast, in a community hospital where most of the physicians are in private practices, the hospital cannot mandate compliance in the same way. Instead, community physicians who are resistant to the change can admit their patients where CPOE has not been implemented or simply refuse to use the system.

Let's take a look at a successful CPOE implementation in a community setting. Lehigh Valley Hospital and Health Network (LVHHN) is a large complex health care organization based in eastern Pennsylvania, with 720 beds across three community hospitals and an active staff of 750 non-employed physicians who enter 60 percent of all inpatient orders.

LVHHN uses information technology extensively to support clinical and administrative processes that improve the quality and efficiency of care. In planning the implementation of its CPOE program, the hospital's senior management rose to the challenge of convincing a predominantly independent medical staff to embrace CPOE.

Establishing CPOE leadership

The commitment to CPOE at LVHHN originated at the highest level of the organization. In response to the IOM report, the board of trustees instructed the CEO and administrative leadership to expand the existing patient safety program to include reducing medical errors through the use of CPOE.

Early in the planning, a "physician champion" was recruited to lead the project and act as liaison between the medical staff, IT department and administration. Crucial to success is establishing a close collaboration between the physician champion and the CIO.

A CPOE coordinating group was established to provide project oversight and support the physician champion and the CIO, with particular focus on identifying and managing areas of resistance and building physician support.

In addition to the physician champion and CIO, the committee included the chief medical officer, the vice presidents of care management and nursing, the past president of the medical staff, the president of the LVHHN Physician Hospital Organization and other key physician leaders.

A CPOE design team responsible for customization and user interface brought together physicians from most specialties along with broad representation from nursing, pharmacy and ancillary departments. Members of this team were carefully chosen to ensure a wide range of backgrounds, varying degrees of computer literacy, credibility with their peers, ability to work as a team and a willingness to act as champions of the project throughout the organization.

One of the principal roles of the team was as decision-maker regarding graphical user interface design and order set development.

6 critical success factors

The physician champion needs strong clinical skills, a good reputation among the medical staff and experience in leading physicians through difficult change processes. A strong background in computer science is less important than strong interpersonal skills and a good grasp of organizational behavior principles.

Based on the experience at LVHHN, we identified a number of issues the physician champion must address to ensure successful implementation. Getting physician involvement at every stage of the process is critical to designing a system that will meet clinicians' needs, as well as developing the depth of experience necessary to respond to future requests for refinement.

1. Assess organizational readiness

Is there organizational consensus on the objectives of the project, and are objectives congruent with the organization's strategic objectives? Is there solid, credible support for the project at the highest level, especially the medical leader ship, CEO and governing board? Does the organization have a history of successful complex organization al change projects, particularly related to clinical process improvement?

2. Document the present state and define the future state

Ensure physician involvement in understanding how orders are currently created and how the workflow will change in the CPOE environment. Ensure physician ownership of the design process. Provide a method to rapidly respond to physician requests for system adjustment after rollout.

3. Measure pre- and post-implementation levels of medication errors

Potential metrics include error reduction, workflow efficiency, turnaround time of medication ordering and reduction of errors in radiology orders. If pre-implementation measurements are not avail able, estimates of ADE reduction potential can be calculated based on published research.

4. Communicate with the organization

Present a consistent and positive message at multiple times in different venues, including departmental and medical staff committee meetings and publications such as internal newsletters and the hospital's intranet. Present live demonstrations to as many physicians as possible. The message must be clear: there is no turning back.

5. Ensure adequate training and roll-out support

Present training in multiple venues and at many different times of day to ensure that as many physicians as possible have access to one on one training. Intense onsite support, 24/7, by the information systems (IS) department and immediate response to support requests helps physicians gain confidence in their ability to use the system and builds trust in the IS team. To work effectively with physicians, IS support personnel must have strong communication skills and avoid technical jargon.

6. Understand what motivates an individual's behavior

The physician champion must help physicians understand the benefits CPOE will bring them, including:

* Remote access to review test results and place orders

* Decision support for duplicate orders, drug-allergy alerts, drag-drag interaction, drug dose, maximum total dose, duration and frequency checking

* Reduced callbacks to physicians for clarification of ambiguous, incomplete or illegible handwritten orders

* Alerts for unsigned orders and abnormal test results

* Use of online electronic signatures

* Time savings through the use of order sets for specific diagnosis--such as chest pain--or treatment--such as anticoagulation protocols

* Faster order transmission to ancillary departments, reducing turnaround time and expediting the patient care process

Rollout methodology

Recognizing that people do not change easily or all at once, LVHHN chose not to implement CPOE throughout the entire organization simultaneously.

Instead, we elected to use a phased-in approach, rolling out CPOE unit-by-unit so that only a small number of users would be learning the system at any one time and the project team could respond rapidly to questions and make adjustments as needed.

Phased implementation also ensured that there would be enough IS staff available to provide one-on-one support for physicians as they learned the system.

The first area selected was the trauma step-down unit. Although on a limited number of physicians and house staff work on the unit, there is wide variety in the orders entered.

This unit provided the learning laboratory environment that guided rollout in subsequent areas of the hospital. The project team was able to evaluate the experience in each unit and incorporate those lessons into the each successive phase of the rollout.

LVHHN had provided laboratory results and transcription review using the existing information systems for several years. In the first phase of the rollout, nursing documentation (medication administration, vital signs, intake/outputs) was entered into the computer and available for physicians to view online. Once physicians were comfortable interacting with the computer, CPOE became the next logical step.

Lessons learned

CPOE is a technology best considered in the context of an organization's overall clinical process improvement and patient safety strategy. It cannot be accomplished without unwavering leadership, especially among physicians at all stages of the project. (13)

Enlist physician support by publicly acknowledging their leadership and compensating them financially for the time spent helping design the system.

At the same time, it is important to recognize the in, pact CPOE will have on ancillary departments, particularly nursing and pharmacy. CPOE brings significant changes that require time to be accepted and should be phased in.

A project of this magnitude does not happen quickly and an organization must allow sufficient time for the change to take hold. It will take some time for physicians to get comfortable with computers and entering orders by CPOE. Small wins allow the project to gain momentum over time as successes accumulate.

Support must be visible and very responsive during implementation and rollout of each unit. Physicians do not have time to wait while a support person is paged and dispatched to the floor. The project team must also be able to respond quickly to requests for modification of the system itself.

It is important that CPOE not replace personal interaction. Physicians and nurses will always need to directly communicate with each other to understand a patient's clinical status.

All improvement requires change but not all change leads to improvement. As with any organizational change effort, for CPOE to succeed there must be a clear understanding of the reason for the change and a clear vision of the intended benefits. Physicians must be heavily involved in both design and implementation and must share ownership of the project, and not view it as "just another IT project."

Convincing physicians of the need for change requires finding and articulating the overriding goal of reducing errors, improving patient care and reducing cost of care.

References:

(1.) Sittig, DF and Stead, WW. "Computer-based Physician Order Entry: The State of the Art." Journal of the American Medical Association. 1994. 1:108-123.

(2.) Southon and others, "Information technology in complex health services." JAMIA. 1997. 4:112-124.

(3.) Massaro, TA. "Introducing Physician Order Entry at a Major Academic Medical Center: I. Impact on Organizational Culture and Behavior." Academic Medicine. January 1993. Volume 68, Number 1:20-24.

(4.) Massaro, TA. "Introducing Physician Order Entry at a Major Academic Medical Center: II. Impact on Medical Education." Academic Medicine. January 1993. Volume 68, Number 1:25-30.

(5.) Williams, LS. "Microchips versus stethoscopes: Calgary hospital, MDs face off over controversial computer system." Journal of the Canadian Medical Association. 1992. 147(10):1534-1547.

(6.) Davies, GR. Keynote lecture, Proceedings of the Computer-Based Patient Record Institute Conference. Washington, DC: CPRI, i998.

(7.) Lorenzi, NM, Riley, RT. "Managing change: an overview." JAMIA 2000. 7(2):116-124.

(8.) Pedersen CA, and others. "ASHP National Survey of Pharmacy Practice in Acute Care Settings: Monitoring, Patient Education and Wellness--2000." American Journal of Health-System Pharmacy. 2000. 57:2171-2187

(9.) Kilbridge P., Welebob E., Classen D. "Overview of the Leapfrog Group Evaluation Tool for Computerized Physician Order Entry." December 2001. www.leapfroggroup.org

(10.) California Health and Safety Code, Section i339.63. 2000.

(11.) National Academy on State Health Policy, www.nashp.org/ catdisp page.cfm?LID= 59D44F84-32B5-11D6 BCEA00A0CC558925

(12.) Birkmeyer JD, Birkmeyer CM, Skinner JS. "Leapfrog Patient Safety Standards: Economic Implications." June 2001. www.leapfroggroup.org

(13.) California Health care Foundation, First Consulting Group. "A Primer on Physician Order Entry." September 2000. http://quality.chcf.org

Donald Levick, MD, MBA is chair of the Lehigh Valley Physician Hospital Organization Information Services and physician champion for the CPOE project at Lehigh Valley Hospital and Health Network in Allentown, Pa. Since October 2000, he has devoted approximately half his time to the CPOE project. He can be reached by phone at 484-884-4593 or by e-mail to [e-mail].

David O'Brien is a physician consultant with Carecast Consulting at IDX Systems Corporation in Seattle, Wash., where he is involved in clinical information system deployment with emphasis on physician adoption of CPOE. Prior to joining IDX, O'Brien practiced family medicine for more than 15years. He holds an M.S. in Administrative Medicine and Population Health from the University of Wisconsin, Madison, and has completed graduate course work in medical informatics at the Oregon Health Sciences University.