Putting CPOE in Order

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Sunrise Clinical Manager from EclipsysComputerized physician order entry (CPOE) can improve efficiency, reduce medical errors, and save hospitals money. So why have less than 2 percent of American hospitals implemented the tool? Implementation is not for the faint of heart, according to clinicians who have been through the process. The vendor selection, build, training, installation, and migration are complicated but very necessary steps of the process.

From buy-in to build

State University of New York Upstate Medical University (SUNY Upstate) in Syracuse has reduced pharmacy order verification time by up to 88 percent, reduced allergy errors by 40 percent, and reduced the time to complete a STAT portable chest x-ray by 49 percent through implementation of INVISION from Siemens Medical Solutions. Neal Seidberg, MD, served as physician leader of the project. Going with Siemens for CPOE was an easy choice for SUNY Upstate, says Seidberg, because the facility was already a Siemens house. “CPOE grafted on relatively painlessly.”

Starting the facility off on the right track was the fact that “our buy-in started from the very top,” says Seidberg. “All the divisional and department chairs agreed that this was the right thing to do.” The next step was working from the bottom up. Much of the design of the system was led by physician, nurse, and ancillary design teams, he says. Before CPOE, any orders physicians wrote were entered by nurses. “That gave us 900 experts who knew the system when the docs went live,” says Seidberg. He recommends taking a good look at your institution to determine which areas are successful and why. “The goal should be to implement CPOE in a way that’s complementary to how your hospital works, not destructive.”

After the build, the facility prepared for a phased rollout. The implementation team made training available in a variety of formats. Everybody learns differently, says Seidberg, and has different hours, so each person could learn the system through their choice of training session, a CD, or an online tutorial.

Then, SUNY Upstate made CPOE mandatory. Seidberg explains, “We said, ‘This is the way business will be done here.’ That culture change is a big piece of getting people to use it. You have to explain that this is how orders get processed and this is why — they get through the system safer, faster, and without all the possibilities for being misinterpreted.”

Veteran user upgrades

CPOE is nothing new for The Queen’s Medical Center in Honolulu, Hawaii. The facility first implemented CPOE in 1995 but in 2003 decided to upgrade its clinical systems with a single-vendor solution. The organization “was very computerized but highly interfaced with best-of-breed systems,” says Sean Thomas, MD, medical director for clinical decision support and assistant medical director for clinical informatics.

Epic Systems was chosen, and then Thomas led an 18-month build. He got physicians involved in the design and build, particularly with order sets. Department by department, his implementation group was proactive, getting medical staff members to assess their documentation tools and suggest improvements to workflow. “Communication is important and being responsive to the physicians. The more docs you can get involved early, the better the buy-in.”

The need to communicate with physicians can’t be overestimated, Thomas says. “It’s critically important, and the physicians don’t necessarily realize that until you go live. Saturate them so at least you know you’ve done all you can in that respect.” Fortunately, physician buy-in was not as big an obstacle for Queen’s as it might be for other facilities, Thomas says, “because we came from a CPOE system.”

With a less interfaced system, Thomas says there’s no need for concern about whether an order was successfully translated to the pharmacy system. “I’m placing the order in the pharmacy system myself.”

Focus on safety

Another relative veteran of CPOE is Children’s Hospital of Wisconsin in Milwaukee. When their administration order entry system was phased out by the vendor, the facility’s leadership “recognized that there was potential to help with medication safety by implementing CPOE,” says Carl Weigle, MD. The search for the right CPOE system began. “We went through a pretty exhaustive and exhausting process to test all the vendors that we could find in the marketplace, including having the four leaders in for demos.” The demonstrations took place during all shifts so that as many people as possible