For All the Right Reasons | Articles & Archives | Articles/News | Healthcare Informatics

For All the Right Reasons
Approaching CPOE from a patient safety and care quality perspective is the first critical step toward success
by Mark Hagland

Yes, CPOE implementation is hard. It's very hard. What's more, it requires sustained commitment and cultural transformation in order to be truly successful. But the patient safety, care quality, and clinician workflow improvement gains that can be made are tremendous. Indeed, the whole initiative must be driven by patient safety and care quality goals, say the leaders of organizations that have successfully implemented CPOE and then built quality advances using its power. Call it the CPOE value proposition.

What's more, if a CPOE implementation requirement is embedded into the final draft of the ARRA-HITECH legislation's funding disbursement protocols (see “CPOE and Meaningful Use,” p. 42), the lessons learned will be all the more valuable. And what is the key to understanding CPOE success? It's about vision and process.

Excelling in Akron
At the five-hospital, 2,060-bed Summa Health System in Akron, Ohio, the team of clinicians, clinical informaticists and non-clinician executives who led the CPOE implementation knew exactly what they wanted out of the project from the start.

“My major concern was patient care quality, and risk management. And I felt that medication management was one of the biggest problems we had,” says then CIO, Charles Ross, M.D., who has since become CMIO. Ross says he had strong CEO and board support for initiating the long, complex process of CPOE implementation.

That process, of course, involved the development of order sets, one of the most multi-phasic and challenging aspects of CPOE implementation (see “The Order-Set Challenge,” p. 42). A quick glance at some of the results that the Summa folks have achieved, though, underscores the value of the pursuit. Among the gains: a leap from a 37 percent rate of physician compliance with the old paper-based order sets, to a rate of 93 percent; a reduction in readmissions within 31 days of stroke patients by 35.7 percent; and a reduction in stroke patients' hospitalization costs of 11.4 percent, after CPOE was used to help drive intensive stroke program improvements.

“An advantage we had going into CPOE was that we already had a strong, well-defined process for order set creation,” says Linda Gleespen, R.N., lead quality and clinical analyst for the system. “The problem was that when order set creation had been paper-based, there were different versions of every order set, and not everyone was working off the same versions or interpretations.” Now, Gleespen says, once an order set is updated by the multidisciplinary team she chairs, its expression is available, standardized, and system-wide.

But while CPOE is powerful technology, says Pamela Banchy, R.N., system director, clinical information systems, Summa, “It's just technology. It has to be integrated into the quality and workflow of the care delivery model that your organization has. That's where the collaboration with your users and with your vendors is important, to help mold it over time.”

Inevitably, says Banchy, who has been one of the key leaders of the CPOE initiative, “Every part of care delivery is touched, from registration through to discharge. That's why this is transformational.” Banchy adds that very close collaboration with one's vendor (Summa's CPOE solution is from Atlanta-based Eclipsys Corporation) is essential.

Greg Kall, system vice president and CIO, joined Summa shortly after the organization's initial CPOE rollout began, but had led a CPOE implementation in his previous organization. “I couldn't be more unequivocal in saying that CPOE implementation is not an IT project. You have to initiate it as a multidisciplinary, stakeholder-based project.” In fact, he says, “An IT guy like me can't put this into a hospital; it has to be the physicians and nurses. And Summa was particularly blessed with having an M.D.-CIO at the time.”

As for the CIO role in CPOE implementation and post-implementation, it is to be “an interpreter, a gatherer of knowledge, and a coordinator, helping to educate and prepare end-users for the changes to come in care delivery,” he says.

Unity in diversity
Nationwide, those hospitals and health systems having the greatest success with CPOE implementation are approaching it in a variety of ways, but always with the same general credo as the folks at Summa: CPOE is being implemented to improve care delivery, not simply to automate it. As Erica Drazen, Sc.D., managing partner in the Waltham, Mass.-based Emerging Practices division at Falls Church, Va.-based CSC, puts it, “The goal must be patient safety improvement; it must be clinician-led. This is going to touch everybody, so you really need to have extraordinary project management, and you also need a very efficient decision-making process.”

Drazen's colleague at CSC, principal researcher Jane Metzger, adds that, “One of the core challenges involved in CPOE development involves the process of order set development and order set management; and that process inevitably becomes part of the broader effort to reduce unnecessary variation in care.” Metzger was one of the lead authors in a recent CSC white paper, “CPOE: Getting Order Management Right” (see “The Order-Set Challenge”).


A small but significant number of hospital organizations have leveraged CPOE for clinical transformation. Among them:

At Children's Hospital of Pittsburgh, which has been live enterprise-wide with CPOE since October 2002, Vice President and CIO Jacqueline Dailey, and CMIO Jim Levin, M.D., Ph.D., note that adverse medication safety events have fallen from 0.09 events per 1,000 doses in 2003 to just over 0.04 last year - in other words, to less than half the pre-CPOE level. Meanwhile, overall patient mortality has dropped from about 0.99 at the time of implementation to 0.49 in the fourth quarter of 2008, again, a drop of nearly 50 percent. “The focus from the beginning was on doing CPOE to improve patient safety” says Dailey. That focus, she says, includes “monitoring our patient safety events. Part of our success derives from our use of the automated alerts that come out of the system, and part has involved our continuously working in a performance-improvement mode.”


At Methodist Medical Center of Illinois in Peoria, President and CEO Michael Bryant and CIO Ellen Swoger share the same mentality as those at Children's in Pittsburgh. “When we put together the project charter for CPOE,” says Bryant, “We organized it entirely around achieving our strategic mission, which is delivering outstanding healthcare, period. In order to do that, we needed to be the safest place for our patients.” Swoger says she and her colleagues agree that CPOE implementation has been key to the hospital's achievement of exceptionally low mortality and complication rates. Methodist's overall mortality rate from July 2007 through June 2008 was 2.49 percent, compared to Medicare's nationwide 4.41 percent average; while its inpatient complication rate was 1.73 percent, compared to Medicare's 1.99 percent average. The challenge to CIOs will always be “trying to get data out of systems,” but it is a welcome challenge, Swoger says.

At Emory Health Care in Atlanta, the first of its facilities to go live with CPOE achieved a 99 percent physician adoption rate, which CIO Dedra Cantrell, R.N., attributes to good planning, thorough processing of clinician end-user feedback, and continuous improvements. “The most challenging part of this,” she reflects, “is sustaining change after you've gone live, and making things better every day.”

At Trinity Health system, which is based in Novi, Mich., “We now have 23 facilities live with an average of 74 percent of orders made on the system,” says J. Michael Kramer, M.D., vice president and CMIO. “That's extraordinary.” In fact, Kramer says he believes that adoption level is the highest of any large, community hospital-based multi-hospital system in the country (Trinity spans 45 hospitals in seven states). The key? Trinity's leaders have created and reinforced a very strong linkage between CPOE implementation and their ongoing intensive care quality improvement initiatives.

What is clear, experts say, is that getting CPOE implemented takes a lot of hard work and some cleverness, particularly in community hospital settings with voluntary medical staffs. According to James Keel, III, M.D., CMIO and medical director of quality at 800-bed Mission Hospital in Asheville, N.C., training is not overlooked. “We made education mandatory, and required every physician to go through a four-hour class; but we also were able to arrange for them to receive eight hours of CME credit for becoming certified in CPOE use,” he says.

Getting the doctors on board is doable, says Paul Browne, senior vice president and CIO at Trinity Health. “We look at CPOE as a way to make it easiest for physicians to do the right thing. And how do you make it easiest to do the right thing? You create really good order sets.” And, on a broader level, he says, continuous restatement of an organization's commitment to constant patient safety and care quality improvement must support the practical work.

In the end, says Reid Coleman, M.D., CMIO at Lifespan Health system in Providence, R.I., “There is no secret clue to getting physician buy-in, other than providing a system that works.” The good news for the four-hospital Lifespan is that its successful implementation has not only bonded physicians to its CPOE system, it has also facilitated broad clinical care improvements, including reducing drug-drug interactions.

G. Daniel Martich, M.D., CMIO at 20-hospital University of Pittsburgh Medical Center Health System, says his organization and others have laid the foundation for fundamental care quality improvement. “We're really at the tipping point in proving that what we're doing with EMR, clinician documentation, and CPOE is of value in terms of quality and pa tient safety,” he says. “Will it have the level of financial return that President Obama wants? Maybe, maybe not. But, going forward, this is just going to be a part of the cost of doing business in healthcare.”


abrir aquí para acceder al artículo completo:
For All the Right Reasons | Articles & Archives | Articles/News | Healthcare Informatics