Remember Ordering From Catalogues?

Does anyone still use them? If not, why not?

Out of date Can’t find the order form

(some one else used it?) Legibility Have to fill out each form

every time Etc.

Fill out the form and see what happens

Remember Ordering From Catalogues?

Ordering today

Today, most everyone seems to prefer electronic (online) order entry. Why?

Order from anywhere Immediate feedback Faster Even a place to order from

the paper catalog

Real time information during order entry

Computerized Physician Order EntryComputerized Physician Order Entry(CPOE)(CPOE)

A Recipe for SuccessA Recipe for Success

Stuart M. Cohen, M.D.

Cerner Corporation

ProviderProvider

The Need for CPOE

Improved patient safety Improved quality Improved efficiency Reducing operating costs

Patient Safety

Top 10 Causes of Death 19981. Heart Disease 724,2692. Cancer 538,9473. Stroke 158,0604. Lung Disease 114,381

5. Medical Errors 98,000*

6. Pneumonia 94,8287. Diabetes 64,5748. Motor Vehicle 41,8269. Suicide 29,26410. Kidney Disease 26,295 * Estimated. Recent reports suggest this number may be much greater.

CPOE—What It Can Do? Provides Decision Support Warns of Drug Interactions

Drug-Drug Drug-Allergy Drug-Food

Checks Dosing Reduces Transcription Error Reduces number of lost orders Reduces duplicative diagnostic testing Recommends cost effective, therapeutic alternatives

EvaluatePatientStatus

Act OnOrders

CommunicateOrders

ConsiderEvidence

AcknowledgeOrders

DocumentOrderAction

EnterOrders

CheckOrders

Close the loop

CPOE Is Really Automated Workflow

Enhance with embedded clinical knowledge

Order sets with embedded evidence

Actionable Decision Support/Alerts

Clinical Evidence

Reports: Adherence to Standards

Dynamic Analysis

Enhance with embedded clinical knowledge

Order sets with embedded evidence

Actionable Decision Support/Alerts

Clinical Evidence

Reports: Adherence to Standards

Dynamic Analysis

Enhance with embedded clinical knowledge

Order sets with embedded evidence

Actionable Decision Support/Alerts

Clinical Evidence

Reports: Adherence to Standards

Dynamic Analysis

Enhance with embedded clinical knowledge

Order sets with embedded evidence

Actionable Decision Support/Alerts

Clinical Evidence

Reports: Adherence to Standards

Dynamic Analysis

Enhance with embedded clinical knowledge

Order sets with embedded evidence

Actionable Decision Support/Alerts

Clinical Evidence

Reports: Adherence to Standards

Dynamic Analysis

Adverse Drug Reaction (ADE’s)

Several studies have found a serious medication error in 3.4%-5.3% of inpatients

The cost of a single preventable ADE is $4,685 $1.3 million annually for an average 300 bed hospital

Bates et al. JAMA 1997;277:307-311

Bates et al. JAMA 1998;280:1311-1316

Bates et al. J Am Med Informat Assoc 1999;6:313-321

Lesar et al. Arch Intern Med 1997;157:1569-1576

56%

4%*

34%

LabRad

Vitals

•Comprehensive CPOE

• Patient Care, Lab, Rad Systems (CareNet, PathNet, RadNet)

• Pharmacy (PharmNet)

• Medication Administration

(eMAR/PowerPOC)

Closed-Loop Meds Process

• Transcription6%

Medication Errors

Physician drug ordering errors are most often due to one of two causes:

1. Lack of knowledge about the drug• Wrong dose• Wrong frequency• Drug-drug interaction

2. Incomplete patient information• Documented allergies• Recent lab results

CPOE Can Help Reduce Errors

Brigham and Women’s Hospital launched its first CPOE in 1993

Since then, they have documented a 54% reduction in serious medication errors

Resulted in 62% reduction in preventable ADE’s

Improved Quality

CPOE allows for physician reminders of best practice or evidence-based guidelines

Indiana University study Pneumococcal vaccine in eligible patients

0.8% 36.0% Heparin prophylaxis

18.9% 32%

Medication Cost Savings

Brigham and Women’s CPOE system includes several alerts targeted to specific high-cost drugs. The alerts provide a possible less expensive alternative

Example of savings—Zofran TID vs. QID TID dosing used 5.9% 93.5% Estimated savings: $250,000

Improved Efficiency Maimonides Medical Center (Bronx, NY) 700 bed teaching hospital After CPOE, found substantial reduction

in order processing time Physician order to receipt by pharmacy

3.4 hours 0.5 hours Physician order to Delivery to Patient Care Area

4.6 hours 1.4 hours

Estimate 12% in LOS following CPOE

But We Fail If This Is Only About Software

Workflow Optimization

Software

TransitionManagement

Knowledge and Measurement

Technology

Project Management

VisionVisionStrategyStrategy

Transition ManagementTransition Management

TRANSITION MANAGEMENT Vision Governance Adoption Communication Learning Organizational development Value Turnover strategies

TRANSITION MANAGEMENT Vision Governance Adoption Communication Learning Organizational development Value Turnover strategies

Workflow Optimization

Software

TransitionManagement

Knowledge andMeasurement

Technology

Project Management

Things That Can Help – Work in Progress

What Is Needed For Success?

Clinicians End-users (clinicians) must be willing to champion the

implementation of CPOE Clinicians must be involved in design and

implementation of the system Clinicians must be flexible and willing to change

workflow processes

‘Doctors don’t reject things like disease

management [or evidence based

medicine, or information technology, or

decision support] because they don’t care

about them, or because they don’t believe

in the principles. There is a fundamental

clash between the ways their neurons

have been rewired during training and

the ways management and new processes

want them to behave.’

1999 Disease Management Sourcebook, ‘Redesigning the Mental Model: How to

Win Provider BuyIn to Disease Management’

H. Leider, MD, MBA

Physician MindsetPhysician Mindset

The Problem(s)

We practice with incomplete informationWe have alarming error ratesWe spend 30-50% of resources on activities that produce little demonstrable benefitWe base less than 30% of our decisions on firm scientific evidenceWe cannot assess and be cognizant of all newly discovered informationWe practice in very complex systems with dependencies and poorly measured processes.90% of malpractice claims relate directly to problems with tracking or documentation or follow-up of care

Doctors love to learn, but they hate to be taught.

What Is Needed For Success?

Information Technology (I.T. Department) Ensure fast, reliable, and easily accessible system Provide ongoing support Train, educate users

Institution Commitment to workflow changes Leadership

Leadership: the most critical factorLeadership: the most critical factor

Leadership

Endorsement of CPOE Establish CPOE as an Institutional

Commitment and Goal Identify CPOE as a Quality and

Safety Improvement Initiative

Strategic AnalysisStrategic Analysis Readiness AssessmentReadiness Assessment Team IntegrationTeam Integration Deployment Strategy & DeliveryDeployment Strategy & Delivery

Stakeholder IdentificationStakeholder Identification Stakeholder EngagementStakeholder Engagement

Knowledge ManagementKnowledge Management

Communication Plan & DeliveryCommunication Plan & Delivery

Retention PlanRetention Plan

Transformation RoadmapTransformation Roadmap

Job Impact AnalysisJob Impact Analysis Competency ModelCompetency Model Organization DesignOrganization Design

Benchmarks, Benefits and MeasurementBenchmarks, Benefits and Measurement

Learning Plan Learning Plan Dev. SessionDev. Session

Post Implementation Post Implementation Measurement PlanMeasurement Plan

CurriculumCurriculumDevelopmentDevelopment

Learning TaskLearning TaskAnalysisAnalysis

Learning Solution Learning Solution DevelopmentDevelopment

End-User End-User LearningLearning

End-User End-User Conversion SupportConversion Support

Transition Management:

Month1

Month2

Month3

Month4

Month5

Month6

Month7

Month8

Month9

Month10

Planning1

Form balanced teams Clinical, operational and IT members Executive steering committee, clinical review board, functional workgroups

Engage clinicians early Physician leadership Multi-disciplinary advisory group

Communicate Explain benefits of the system Inform about timelines and progress Recognize super-user and committee members Highlight successes

Publicize in the community Consumers will want to go to the “safe” hospital Influences community docs

Transition Management Key Success FactorsTransition Management Key Success Factors

Teamwork andCommunication

Incentives Resources Cooperative

ActionUNIVERSAL

PANICVision

Skills Resources Cooperative

Action INSUR-

RECTIONVision

Skills Incentives Cooperative

Action BLAME-

STORMINGVision

Skills Incentives Resources Cooperative

Action AWESOME CONFUSION

Skills IncentivesPRISONER’S

DILEMMAVision Resources

Skills Incentives Resources Cooperative

Action TRANSFOR-

MATIONVision

“…“…borrowed PEARLS”borrowed PEARLS”“…“…borrowed PEARLS”borrowed PEARLS”

The key to my being a good manager is keeping the people who hate me away from those who are still undecided. Casey Stengel

An army of sheep led by a lion will defeat an army of lions led by a sheep. Robbins and Finley, Why Change Doesn’t Work

You can get more done with a kind word and a gun than with a kind word alone. Al Capone

If anything goes bad, I did it. If anything goes semi-good, then we did it. If anything goes real good, then you did it. That's all it takes to get people to win football games for you.

Bear Bryant