Where Saving Money Meets Saving Lives.

Priceless ROI: medication errors reduced 55 percent using Provider Order Entry system.

Keeping track of clinicians' orders when multiple physicians and technicians are involved in the treatment of a hospitalized patient is one challenge in healthcare that can lead to very serious complications. When state-of-the art technology is used to remedy this problem, the payoff comes not only in dollars--thanks to identification and elimination of duplicate medications and procedures--but potentially, in lives saved thanks to alerts for allergies and interactions.

Partners HealthCare System's Provider Order Entry (POE) system, which had its genesis nearly a decade ago at Boston's Brigham & Women's Hospital, is raising the bar for return on investment, in patient care and systems compliance as well as dollars. The most recent implementation of this technology is now in place at Partners' Massachusetts General Hospital.

The system that Partners vice president and CIO John Glaser refers to as" possibly the most formidable tool we have to deliver high-quality care while controlling costs," cross-checks physicians' orders for drug interactions, allergies, food interactions, and duplicate procedures. While the POE's original implementation at Brigham & Women's provided unparalleled benefits, building the system was not an easy process.

In fact, this early implementation required a significant shift in the information systems (IS) environment--a new platform had to be developed to support this application--as well as in the mindset of the clinical population, skeptical about the benefits to be realized from a computerized system. After surmounting system design hurdles and an initial user learning curve, the POE system went on to deliver striking results. A recent study published in the Journal of the American Medical Association (JAMA) showed that serious medication errors went down by 55 percent after the system was installed.

Taking Advantage of New Information Technologies

The initial POE system was built on a client-server framework using a character-based user interface. Since its installation, expectations of the clinical and administrative populations throughout the Partners system have grown substantially, spurred by end-users who are increasingly aware of the capabilities of information technology.

Thus, when Massachusetts General began building a new POE application, the focus was on creating a graphical, Windows-based system with the sophisticated multitasking features today's information users need to be fully productive. Launched in late 1998, this latest version of the POE system, which is now running at Massachusetts General, takes advantage of the latest information technology.

Utilizing the Cache post-relational database from InterSystems Corporation in Cambridge, MA, on a Windows NT server-based platform, it offers the hospital's physicians all of the capabilities of the original system, along with widespread enhancements in performance and capabilities, and an easier-to-use front-end interface.

At Massachusetts General, the POE system is now running on a production basis for all adult medical inpatients, automating orders for medications, lab procedures, diagnostic procedures, food and nutrition, intravenous fluids, and a host of other clinical activities. These orders are routed through a system that automatically screens for duplicate procedures or prescriptions and allergies, with alerts including interactions among drugs and between foods and drugs quickly being added to the process. The application serves almost 2,400 active users, including registered nurses, physicians, pharmacists, case managers, and unit coordinators, processing nearly 5,500 orders per day.

A Quick Payback

The alert set currently running on the system averages 10 allergy alerts and 195 medication duplicate alerts per day. Of the allergy alerts, 21 percent result in the cancellation of the medication order, and of the duplicate alerts, 19 percent result in cancellation of the medication or procedure order.

The system clearly reduces costs, particularly in eliminating unnecessary duplications and in offering recommendations for less costly therapeutic procedures. Much more critical, the POE application is positioned to make a real impact in assisting physicians in offering the most comprehensive care possible to their patients on a 24-hour-a-day basis, with screening to eliminate potential threats to effective treatment including allergies and interactions.

The POE system has already helped Massachusetts General make significant strides in one additional and unexpected area--compliance with a stream of federal regulations. With four levels of security to ensure the integrity of the system's data, including workstation timeout mechanisms, user authentication and re-authentication processes, and roles-based access controls, the system has dramatically improved the hospital's compliance with HIPAA regulations in the areas of confidentiality and security.

The system provides not only a highly secure infrastructure with an unprecedented level of access control, but also implicitly offers audit trails that can provide immediate answers to questions relating to the chain of decision in orders for medications or procedures.

Additionally, the POE provides a better mechanism for ensuring that verbal orders are cosigned in a timely manner as mandated by JCAHO regulations. Among other things, JCAHO mandates that clinicians' verbal orders must be signed and authenticated within a 24-hour time limit. The POE system automatically queues outstanding orders for each physician's review and signoff, making it much easier for physicians to assess which of their orders are outstanding and must be attended to immediately. By automating the process to be less time-consuming, few orders slip through the cracks, meaning that overall performance against compliance standards is on an upswing.

Database Performance, Scalability Critical

Key to fulfilling all of these complex demands on the system is the database technology on which the POE is built. InterSystems' Cache post-relational database was the cornerstone of the first POE implementation at Brigham & Women's.

When design began on the new Massachusetts General application, Cache was again selected, due to its ability to respond to requests for information extremely quickly, and to scale throughout the house as the system is rolled out from the medicine service to other departments. Additionally, application availability is crucial when a system like Provider Order Entry becomes the backbone of a hospital's day-to-day practice, and the sophisticated server shadowing capabilities of Cache virtually ensured that the application would always be up and running.

Finally, the Partners information systems team is evaluating the movement to bring ordering to ambulatory physicians, with a look toward Web applications, so it was crucial that the database chosen to run the system be Web-enabled. Cache offers an entire suite of tools to enhance the ease and speed of porting this application over to the Web.

As with the earlier system at the Brigham & Women's Hospital, the dollar savings made possible by the Provider Order Entry system at Massachusetts General Hospital, through the elimination of costly, unnecessary duplicate procedures and the recommendation of alternate, less costly treatments, will undoubtedly be impressive.

Systems compliance gains in terms of meeting and exceeding the requirements of federal standards will also make a significant contribution in assessing the system's value. However, potential allergic reactions and drug-drug or drug-food interactions averted by the system will prove to be as impressive, as the POE system's technology affects the day-to-day experience--and outcome--of each patient served by Massachusetts General Hospital.

Steve Flammini is director of application development; Cindy Spurr is director of clinical systems management, and Karen Grant is director of health information services, all at Partners HealthCare Systems, Inc.