HIMSS: No universal approach for CPOE activation

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ATLANTA--Lucile Packard Children’s Hospital (LPCH) in Palo Alto, Calif., in 2005 went from a Stage One hospital with only ancillaries online applications, to a Stage Four facility, complete with live nursing documentation and partial physician documentation based on the HIMSS analytics model for EMR adoption. Having recently undergone a computer provider order entry (CPOE) activation, Chris Longhurst MD, medical director of clinical informatics at LPCH, spoke about the considerations for CPOE and clinical documentation activation strategies at HIMSS10.

During his session, Longhurst explained that initially its CPOE activation "scope and timeline was a two-phase big bang," choosing to implement the entire hospital. Due to the 300-bed hospital being an academic, evidence-based institution, facility administrators and clinicians often turn to the literature for assistance. “However, there is very little literature on the activation strategies for CPOE and clinical documentation systems,” he said.

In December 2005, the Children’s Hospital of Pittsburg published a study suggesting that mortalities were significantly increased after an implementation of a commercially-sold CPOE system. “Having giving up part of my clinical career of  taking care of patients so that I could implement a system that I hoped was going to improve safety of the hospital, this study was very distressing,” said Longhurst.

After further review of this study, Longhurst noted that the aforementioned implementation was attempted over the course of six days. “We paused, and thought maybe we should take a step back and re-think our plans,” he said.

Using the lessons learned by the Children's Hospital of Pittsburg, Longhurst and his facility went forward with their implementation. Based on their survey data and discussions with colleagues, LPCH developed an acuity-based activation strategy, noted Longhurst.

“We had a big-bang, where we activated over 90 percent of our inpatient beds, including the NICU. We activated about 20 pediatric ICU beds about 10 months later. Our cardiac ICU is not live yet, but will be later this year,” explained Longhurst.  Because the cardiac unit contains the highest acuity patients, Longhurst noted that by leaving the unit on paper, it allowed the hospital to learn all they could before implementation.

As far as functionality activation is concerned, he said that both CPOE and nursing documentation were implemented together. “From a change management perspective, it got all our executive leadership on board,” said Longhurst, noting that the cons of this implementation strategy is that it resulted in  high stress levels due to the simultaneous implementations for both nurses and physicians undergoing change at the same time.

In terms of implementation outcomes, they did not receive any physician complaints to the CEO, and the issues that presented during the activation were minimal and the hospital was able to address them right away. “I think part of this speaks to our activation strategy,” he said.

“Meaningful use says you have to have 80-85 percent of your orders in [the system] by physicians and we have been at 97 percent since day one,” said Longhurst, noting that LCPH also has improved medication, laboratory and x-ray turnaround times.

Perhaps most noteworthy, Longhurst said that at 18 months post-go-live, LPCH has seen a statically significant decrease in mortality at the hospital since implementation, the lowest observed to expected mortality ratio in the Children's Hospital Corporation of America database.

Despite the success of activation by LPCH, Longhurst noted that workflow transfer from paper units to automated units was complex and some redesign was needed prior to activation. In addition, Longhurst stressed that there is “no universal approach” to activation and that each hospital has unique considerations they must recognize prior for implementation.