CPOE: Wonders in Workflow

 Computerized physician order entry (CPOE) isn’t a quick fix to improve efficiency, workflow and quality patient care. On the contrary, it requires a fairly technologically sophisticated facility and an exhaustive implementation process. But the benefits of adding CPOE are clear and compelling. Two facilities share their experiences in implementing CPOE.

Once she realized how much written orders delay patient care, Angela Nicholas, MD, chief medical information officer at Susquehanna Health System in Williamsport, Pa., was on board with CPOE. It may take less than two minutes for a physician to open a chart and write an order. However, the chart doesn’t get transcribed immediately. The physician probably has it for another 15 minutes or so and then the chart goes to the unit clerk. There’s no guarantee that the unit clerk will address charts with a first-in, first-out policy, which can add up to a significant delay in patient care. “It was very eye-opening to me,” says Nicholas.

She also found that unit clerks and nurses do a lot of interpretation of orders. Physicians order tests that aren’t even conducted anymore or the terminology is outdated. “So, the unit clerk is now trying to figure out the test the doctor really wanted to order,” says Nicholas. “With CPOE, that isn’t an option. Physicians will order exactly what they want.” Imbedded best practices and protocols pave the way.

The phase in

The University of Maryland Medical Center (UMMC) in Baltimore has been phasing in CPOE for several years. The facility has been implementing Cerner’s Millenium application suite since 1999 and went live with nonmedication CPOE in 2003. Implementation of medications order entry went live over the summer as a proactive measure, says Mark Devault, director of the project.

UMMC developed a multi-year strategic plan to “bring us up into leadership position on the use of information systems in providing clinical care,” says Linda Hines, vice president, information technology group. It’s been a staged, thoughtful process to “begin to merge technology and applications into workflow, all with an eye to introducing efficiencies.”

With a tagline of “enhancing patient safety with technology,” Anna Schoenbaum, project manager, says that CPOE fit the bill.

Back in 2003, five phases filled out the implementation, with a few units going live during each phase. The units were selected based on medical service or physical location that made sense for patient and physician flow, says Devault. The implementation went well, he reports, probably because medication ordering was not part of it. “It was more benign. Lab, radiology and nursing care aren’t quite as controversial and difficult to get built into systems.”

Fortunately, CPOE was perceived as helpful by many of the clinicians, says Hines. “For the first time, they could write orders from anywhere in the facility.” Another plus was that, as a teaching hospital, residents are the primary order writers. By 2003, most residents were quite comfortable with CPOE technology. “The timing was good,” she says.

Terms of engagement

A lesson learned from UMMC’s nonmedication CPOE implementation was that “we absolutely had to have whole-house engagement,” says Devault. “It needed to not be an IT project. Leadership came from the clinical side. This is where the right leadership at the right time makes all the difference in the world.” The addition of a chief medical officer and chief medical informatics officer tipped the scales, he says.

Tim Babineau, MD, UMMC’s CMO, made CPOE implementation a priority when he came on board two years ago. The facility was partly electronic and partly paper-based. “Medications were not online, so it became a top priority for obvious safety and quality reasons. It took two full years of planning and preparation, but I was extremely pleased with the rollout.” In fact, Babineau says everyone involved worked collaboratively in a way he’d never seen before.

To get to that point, Hines learned just how “critical it was to have overwhelming support on the units. We had a very elaborate and detailed process. One of the consistent [pieces of] feedback we’ve gotten is that people felt there was such a safety net under them during the conversion.”

“We had layers and layers of conversion support,” says Schoenbaum. “Power users” supported units for the initial 10 days. They included nurses that worked in nonclinical areas. Project nurses were dedicated to the effort and IT staff came out of their department to support the project. There was a command center team in addition to trainers. “It really was a team effort. Everybody could celebrate in success.”

Even the CMO and CMIO were active during the go-live rounding, coming in during the middle of the night to connect with colleagues.

Teams worked very aggressively hour by hour, Devault says, which resulted in clinicians not even perceiving a lag. By using wireless communication, support could be deployed within minutes.

At each shift change, support staff spread the word about the status of the project. Twice a day, there was an opportunity for nursing staff to voice their impressions and concerns. Once a day, there was a session for prescribers. Twice a day, there was an executive phone call to keep everyone updated. Paper flyers were distributed to communicate the latest updates.

Going live in July with the shock-trauma hospital, and women and children’s inpatient units—about 17 units in all— really tested the system, but it also prepared everyone for the next go around in August, says Schoenbaum.

Beyond beta testing

Susquehanna has been a Siemens Medical Solutions Soarian customer and beta testing site since 2004. Development teams spent hundreds of hours at the facility studying processes and clinical workflows in an effort to figure out how to make it work better.

The facility began its first go-live phase in June 2006, with just Nicholas placing orders. Then, a pilot group of five physicians began using the system. More physicians came on board last October. With robust functionality expected with the next Soarian upgrade, Nicholas says they’ll wait for that to bring on the majority of admitting physicians in December.

The goal for CPOE at Susquehanna was to establish a completely digital platform, says Nicholas. The team knew that CPOE would improve care, but didn’t quite know how. “This was not just a piece of machinery. We were buying a vision for healthcare, the idea of using workflows to improve clinical delivery.” One obvious benefit was the ability to better measure that delivery. Without electronic data, they could only do retrospective quality reviews. “The more we automate, the more we can prove that the care we’re giving is excellent,” she says.

Before CPOE, Susquehanna received a grant from its Blue Cross company for patient safety. They used the money to remodel a nursing unit, increasing the number of computers to gear up for CPOE. However, “the hardware is changing so quickly and the number of devices you need changes. There were no studies [from other facilities] to help us.”

Despite the lack of information, implementation has gone well, Nicholas reports. The goal was to get physicians to use it and like it. They were warned that CPOE would take more time at first, but it would lead to fewer phone calls and frustrations. “We told them that they would have tools available to take care of their patients better. That makes them more interested in using it.”

The outcome

“I see smiles” on the faces of the administrative team, says Devault. “Everybody knew the stakes in an effort like this. At the executive level, everyone is extremely pleased at how well this went off.” Given the magnitude of the project, everyone is proud of how quiet the transition was. 

The LeapFrog Group, which rates hospitals, designated CPOE deployment by hospitals as one of three patient-safety goals. With this effort, UMMC reached the prestigious milestone of being designated as a LeapFrog hospital.

Nicholas cautions that CPOE systems and implementations are very expensive. “It’s a culture change and the cost of the culture change is very high. With all of the pressures on hospitals, unless you have the manpower and resources, it’s hard to coordinate.”

On the other hand, facilities just might look at the success of organizations like UMMC and decide to take a closer look at CPOE, says Devault. “Everyone should be worrying about patient safety and this is one mechanism to take care of that.”


CPOE: Lessons learned
University of Maryland Medical Center | Baltimore
Having already implemented nonmedication computerized physician order entry (CPOE), the University of Maryland Medical Center in Baltimore, could learn from its own experience.

A whole-house wireless network and lots of mobile devices aided implementation, says Mark Devault, director of the CPOE project. Trying to get clinicians to run back and forth to wired desktops would not have worked.

You cannot spend enough time training, Devault says. Even going through periods of a nursing shortage, “we kept plugging away.” Training efforts included one-on-one sessions, classes at all times of the day, night and weekend. “We did anything to get people in front of the computer to show them how CPOE works.”

Support was “at-the-elbow—-calling a phone number that might lead to voicemail wasn’t going to cut it,” Devault says, particularly with the medications OE implementation. “There was a fear among users that they would do something wrong. If you make a mistake with meds, you could kill a patient.” Support staff and power users were right at the sides of clinicians.

Continue offering support after the go-live is over. People will still have questions and issues to address, so you need an ongoing mechanism. UMMC funded a support team that was onsite 24/7. In most organizations, IT staff can fix hardware, but can’t answer more detailed questions, says Devault. “We have taken folks that know the hardware business and trained them on applications for ‘one-stop shopping’ for clinicians,” he says. “Whatever the question, the support team can provide support, whether that is a build that has to happen, a backup mechanism or broken code.” The support team was the direct result of feedback about what was needed for continued success, says Linda Hines, vice president of the information technology group.

UMMC is working on enhanced order sets to provide an ordering menu for prescribers, says Anna Schoenbaum, CPOE project manager. “The clinicians and pharmacy designed evidence-based order sets with the latest guidelines for ease of use and quick adoption.” Prescribers already are asking for more order sets and Schoenbaum says they are key to prescriber adoption of CPOE.