CPOE: Wonders in Workflow

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 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 Physicians order tests that aren’t even conducted anymore or the terminology is outdated.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