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Computerized Physician Order Entry (CPOE) Project

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1 Computerized Physician Order Entry (CPOE) Project
HINF4519 Team Omega Members: Alan Soskel, Captain Myra Rodgers Annette Baker

2 Computerized Physician Order Entry (CPOE) Project
Summary & Analysis The Ohio State University Health System (OSUHS) began working toward the application of an electronic health record in the 1970s with the goal of improving the quality and efficiency of patient care, protecting private health information, and supporting the organization’s clinical research and teaching efforts. In the 1990s, OSUHS executives, including the Chief Medical Officer and the Chief Executive Officer, formulated a strategic vision that included a computerized patient record (CPR). Subsequently, the Hospital Board of Trustees and the Medical Staff Administrative Committee approved the proposal and provided funding. Implementation of CPOE was seen as a crucial element of the CPR. Computerized physician order entry (CPOE) allows clinicians to order diagnostic tests, medications, and other procedures using computer systems at or near patient care areas. CPOE differs from other forms of computerized order entry in that a provider with decision-making authority directly enters the test request. 1 In 1995, an OSUHS EHR multidisciplinary task force of physicians, clinical and administrative personnel, and information systems staff were selected to choose a medical records system that included paperless order transmission and results reporting, along with patient documentation, scheduling and a clinical results repository. 9

3 Ohio State University Health System
OSUHS A/P/S The OSU Hospitals OSU and Harding Behavioral Healthcare and Medicine The OSU Hospitals East The Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Quick Facts 800,000 patient visits/year 6000 employees 950 physicians 500 residents 850 medical students Up to 90,000 CPOE orders monthly The case study of Computerized Physician Order Entry (CPOE) describes how the Ohio State University Health System (OSUHS) implemented CPOE software throughout their large multi-disciplinary healthcare network. OSHUS consists of four hospitals and 18 satellite ambulatory offices that process over 800,000 visits per year. In addition, OSHUS boasts a Level III neonatal intensive care unit, a Level I trauma center, organ transplant program, a rehabilitation hospital, a freestanding cardiac hospital, and a comprehensive cancer center that employ 6000 staff members—potential end users.6 A/P/S – Ambulatory, Primary and Specialty Care Offices

4 Initiatives Towards EHR
Board began initiatives towards an EHR in the 1970s: 1970’s and 1980’s – ancillary systems and IS infrastructure put in place towards EHR implementation Early 1990’s - strategic vision for a computerized patient record (CPR) was established. Implementation of CPOE seen as key element of CPR1 Deployed Clinical Information System (CIS) Notes here: 2000’s See next slide

5 1980s Ethernet network Health Level 7 (HL7) format for clinical information Electronic document transmission enabled by interface engine 1990s Single front-end Clinical Information System (CIS) Siemens CPOE system and lifetime clinical record (LCR) 2000s Deployment for CPOE system Electronic discharge instruction (EDI) Patient scheduling system Outpatient registration and billing system and electronic signature system Information warehouse for clinical and financial data access 2010s Installation of Siemens Soarian suite Development of clinical document imaging Having worked toward an EHR since the 1970s, OSUHS was categorized as having a mature IT system in place, even at the time this article was written in The IT system was composed of the following interfaces: Clinical, ADT, Financial, Other. OSUHS had based the foundation of their IT system on one master patient index which was composed of an electronic medical record number for each patient. This decision would help OSUHS develop their very own proprietary A/D/T system, master patient index and patient billing system and help attain their EHR goal “to enhance quality and efficiency of patient care by providing a lifetime of complete patient information—across time and place…” In the next four decades, OSUHS proceeded in developing the EHR as technology advanced: • 1980s: Established Ethernet network, use of Health Level 7 (HL7) format for clinical information, electronic document transmission enabled by an interface engine. • 1990s: Deployment of single front-end Clinical Information System (CIS) allowing user query through the master patient index and selection of Siemens CPOE system and lifetime clinical record (LCR). • 2000s: Deployment of CPOE system that allowed for bedside documentation, electronic discharge instruction (EDI), a patient scheduling system, outpatient registration and billing system and electronic signature system. Creation of information warehouse for clinical and financial data access. • 2010s: Plans for installation of Siemens Soarian suite and development of clinical document imaging to integrate paper-based charts from other facilities.

6 Measures of Success Development of a portable and scalable system that could be implemented across diverse and physically distinct clinical environments Identification of the physician as the primary user, and customization of the system to meet physicians' needs Clinical acceptance. In order to gauge their success, the EHR task force developed three measures of achievement to include: (1) Development of a portable and scalable system that could be implemented across diverse and physically distinct clinical environments; (2) Identification of the physician as the primary user, and customization of the system to meet physicians' needs; (3) Clinical acceptance. 1

7 5 Phases of CPOE Implementation
Needs analysis and clinical system selection System analysis and design System modification Initial system implementation Complete system deployment Even though IT systems utilized at OSUHS were always on the cutting edge and considered to be ”mature” when compared to similar institutions, the implementation of CPOE would take five years to see fruition. The implementation was broken down into five phases: 1. Needs analysis and clinical system selection 2. System analysis and design 3. System modification 4. Initial system implementation 5. Complete system deployment1

8 Needs Analysis and Clinical System Selection Initial Assessment
Physician Order Entry System Requirements1: Easy maintenance of the system. Capable of supporting advancing technologies and migration paths. All order requirements met for the patients' medical records. Stability and intuitive use. Business, clinical and ancillary system interfaces. Implementation support of best practice and clinical practice guidelines. Easily expanded system for a variety of clinical users and environments. Physician Order Entry System Requirements The EHR task force began working on the development of a manageable system that could be easily upgraded and implemented across different but distinct clinical settings. Additional goals included improving patient safety, reworking business processes, and resolving delays due to flow of orders and results. The team conducted surveys and interviews of clinicians and performed a workflow analysis, subsequently establishing the criteria for the most important system requirements, which included: Easy maintenance of the system. Capability of supporting advancing technologies and migration paths. Must meet all order requirements for the patients' medical record. Is stable, and its use is intuitive. Interfaces with business, clinical, and ancillary systems. Supports implementation of best practice and clinical practice guidelines. Can be easily expanded for a variety of clinical users and environments.1

9 Needs Analysis and Clinical System Selection Vendor Selection
Why Siemens Chosen as CPOE Vendor: Integrated with in-house CPR components Served inpatient and ambulatory environments Graphical user interface Data dictionary NEEDS ANALYSIS AND CLINICAL SYSTEM SELECTION In keeping with the strategic goal of a computerized patient record (CPR), in 1995 the executive leadership at OSUHS selected a clinical communications committee consisting of physicians from 12 different specialties and representatives from nursing, information systems, quality and operations improvement, radiology, pharmacy, administration, purchasing and medical information management. This committee was charged with determining the IT system needs that would support computerized physician order entry (CPOE). The system chosen would need to provide: 1) Paperless order communications, (2) Results reporting, (3) Patient documentation, Scheduling, Clinical repository. After studying workflow processes in all departments and gathering input from the potential users by survey and interview, the clinical communications committee reported back to executive leadership the system’s core features, the tools required for evaluation and the final request for proposal. The funding was secured and a vendor-based software was determined to be the best choice for OSUHS due to the lower cost when compared to in-house development and the continual upgrades offered by a vendor to maintain industry standards. The Siemens CPOE system met OSUHS’s selection criteria but also: • Integrated well with the CPR components already in place • Served both inpatient and ambulatory environments • Offered a graphical user interface for analyzing clinical results • Offered data dictionary recognized similar data from different systems so the date could be used for comparison and study.9

10 System Analysis and Design
Physician Consultant Team Specialties Represented: Emergency Medicine Oncology Gynecology Pulmonary Cardiology Surgical Oncology Surgical Transplant Pathology Radiology General Medicine Clinical Staff Laboratory Pharmacy Nursing Respiratory Therapy Information Systems Department Responded to clinical recommendations by: Rapid application development principles Prototype approval Pathway design for review System Analysis and Design CPOE Development Team SYSTEM ANALYSIS AND DESIGN The next step was to form the CPOE development team. This team, much like the clinical communications committee, was composed of various clinical staff from the laboratory, pharmacy, nursing, respiratory therapy and radiology. The input of this team would then report their recommendations to the IS department. In order for the CPOE system to be successfully developed, the OSUHS executive committee knew it would need to be physician centered and thus they selected a physician consultant team composed of ten physicians. To demonstrate their commitment and their respect for physician input, the executive leadership mandated the physician members be compensated for time spent away from clinical duties. In addition to reinforce the importance of their newly assigned positions, OSUHS executive leadership had each physician sign a contract which outlined their responsibilities and expected outcomes. This executive strategy in making the CPOE design “physician centered” was a key factor in the successful implementation of the CPOE system. It is well known in any healthcare organization that a physician’s approval and support are catalysts for any project. It was decided early in the design phase that all order entries would be electronic and 100% would be physician orders. There would be no opportunity for “user revolt,” going back to paper would not be an option once CPOE was instituted.9 To this end, the physician consultant team was instrumental in reassuring clinical staff that a sound system would be carefully devised so that such a bold electronic endeavor would be delivered.

11 System Analysis and Design
Physician Centered All orders are electronic. All orders are physician orders. Order sets are designed by physician shadowing. Physician feedback and participation led to successful rollout. System Analysis and Design Physician Centered Design The next core design feature addressed was the development of order sets, and the expertise provided by the physician consultant team was invaluable here as well. Order sets are the clinical guidelines or workflow processes that are specified for each patient diagnosis or treatment plan. Over 450 order sets were designed by the physician consultant team after shadowing doctors and seeing first-hand current workflow processes. The development of the order sets also tackled issues such as patient safety, quality and standardization of patient care, cost and automated alerts. Another rule established early was that there would be no physician-specific order set so the clinical content of the order sets was the result of clinical teamwork involving the physicians, nurses, pharmacists and any other clinician involved with a particular diagnosis or treatment. The IT department was then charged with translation of the order sets into CPOE format following which the physician consultant team designed a working prototype based upon intensive study of current workflow processes across the entire enterprise at OSUHS. The prototype was developed with consistency of system design and data entry the most important aspect. Even though each clinical and ancillary department dictated different needs, standardization of processes had to be adopted to support the mandated 100% electronic order entry and in turn endorsing screen recognition and ease of use for physicians, no matter where data entry might take place in the enterprise. The final working prototype was revealed to an array of physician users, and though time and labor intensive, the physician feedback and participation garnered physician satisfaction throughout the process—proving to be another key success factor in implementation

12 System Modification Decision Support Tools SYSTEM MODIFICATION
Alerts for Patient Allergies Alerts for Drug Interaction Drug Route Restriction Weight-based Dosing Order Duplicate Checking System Modification Decision Support Tools SYSTEM MODIFICATION Access was granted for users with their name and password. Passwords would expire every three months. Data privileges would be determined by the clinician’s role. Physicians would be granted access to a patient’s current order set, view and select from order sets or write an individual order. Nurses could review outstanding orders and print worklists. Medical management would print a cumulative order set and medication administration record at the time of the patient’s discharge. CPOE was designed so that medication orders were sent directly to the pharmacy and orders re-entered into the Pharmacy Information System. The IS team had to carefully translate time and day of week for medication orders so that all ancillary departments understood clearly the instructions for administration, especially with respect to the day of the week and the time of day. For example, if a postsurgical candidate is ordered nothing by mouth for 24 hours, the order must specify the timeframe to begin and end the order. Decision support tools naturally evolved from the order sets such as default order components, limiting certain high-risk ordering, expediting compliance, and best ordering practices in pharmacy. System alerts and rules positively impact patient safety (by notifying the clinical user of the patient’s medication allergies) and continuity of care (by notifying the clinical user of drug interactions with medications already prescribed by another physician).

13 Initial Implementation Pilot Studies
February through October, 1998 February 15, 2000 Check of System Functionality 23-Bed OSU Transplant Surgery Unit Initially, a system functionality check was performed from February through October of Since the plan was to input all orders electronically, CPOE had to be integrated with all of the ancillary systems before the pilot study on one inpatient unit. After delays due to Y2K concerns, the pilot application of the CPOE on the 23-bed surgical transplant unit was performed in February, ,9 Pilot testing allowed for validation of system design and stability, identification of system enhancements and modifications, data metrics for system goals, and development of in-house expert clinical users to provide support for future implementation in Ohio State University’s health system. 9 Improvements following the pilot included the programming of 450 order sets and providing additional training and support staff.9 Each physician specialty identified the order sets they would need to care for the majority of patients admitted to their clinical area. Until the necessary order sets were created, it was determined that a POE live date could not be established. Once the order sets were approved and available for physician use, the decision was made to phase in CPOE by an entire hospital at a time. 1

14 Complete System Deployment
Initial Deployment Complete Implementation April 4, 2000 – Go Live Date The James Cancer Hospital By April, 2001, Go Live at The University Hospital Dodd Hall Rehabilitation Hospital Finally, a system go-live date was chosen for April 4, 2000, at the James Cancer Hospital. Since all orders would be entered electronically, an entire hospital would be the best way to see how well all clinical and ancillary departments were integrated to respond to all physician orders. From that day forward, all order entry has been electronic, 80% by physicians and all orders electronically countersigned by physicians. Nearly a year after the pilot deployment, CPOE was fully implemented at The University Hospital (excluding women and infant units) and the Dodd Hall Rehabilitation Hospital. After each go-live date, the information systems staff remained available 24 hours a day for one month. The IS staff realized that CPOE mandated on-site help to readily troubleshoot any problems the clinicians might experience to keep workflow delays to a minimum and to foster user confidence. Again recognizing the importance of physician support and validation of CPOE, the executive leadership released key physicians from many clinical duties so that their time could be devoted to fine tuning clinical processes for order entry across an entire hospital site.

15 Clinical Improvements after CPOE Implementation
Patient Safety Measures Reduced errors in medication orders Improved medication delivery Reduced laboratory report time Reduced radiology report time Continuity of Care Measures Improved discharge instructions Financial Measures Expedited billing processes Reduced cost in printing forms Continuous Quality Improvement Measures Before CPOE After CPOE Transcription Errors 26.2% 0% Medication Delivery 5:28 1:51 Radiology Completion 7:37 4:21 Lab Results Reporting 31.3 min. 23.4 min. Counter-signature at Discharge 56.36% 99.5% IMMEDIATE CLINICAL IMPROVEMENTS In just two years from the initial pilot testing at the James Cancer Hospital, OSUHS was able to see a substantial return on their investment of time and money for the CPOE project. •Patient Safety Measures - Transcription errors in medication orders have been eradicated. When a side by side comparison was made of two different units in the hospital, one unit that used electronic input with CPOE and one unit that still uses paper orders, the results were impressive—0% for the electronic CPOE and 26.2% transcription error rate with paper records. - Medication delivery time was greatly improved—by 64%, from 5:28 to 1:51 hours. - Reporting time of results by the laboratory was reduced by 25%. - Completion time for radiology procedures was reduced by 43% • Continuity of Care Measures - Dispensation of discharge instructions is improved by better detail and includes a list of discharge medications. - At the time of discharge, the patient is instructed in follow up care, clinical contact information, pending appointments and prescriptions. All instructions are printed and a copy is given to the patient before discharge. • Financial Measures - The physician countersignature now can take place at the time of discharge, thus expediting billing processes. Consistent with OSUHS CPOE policy, only the physician can enter the order for discharge, and all prior outstanding orders for that patient must be addressed by that physician before the discharge order can be executed. - The expense for printing order forms has been almost eliminated. - Billing processes have been streamlined by the ability to audit legible physician orders. •Continuous Quality Improvement Measures - Order sets are scrutinized. An order placed outside the predetermined protocols is reviewed and then addition or revision of an order set is decided. - The operations staff is able to assess and manage quality better with an enhanced data warehouse based on the order entry information.9

16 Key Success Factors for CPOE Implementation
Multidisciplinary Multidisciplinary Committee Development of comprehensive protocols and tools Development of widely accepted protocols and tools Software Software Integration Data from CIS easily integrated Graphical user permits graphing and trending results Data dictionary permits shared information Rollout Rapid Deployment Maximal Physician Utilization High Scalability and Portability The successful utilization of the CPOE software at OSUHS was due to a carefully planned, yet rapid implementation which consisted of: Establishment of multidisciplinary committee that included physicians, nurses and pharmacists. Each clinical group had a voice in the development of over 450 order protocols. Each group helped define the decision support to ensure best ordering practices. Selection of a software product that could integrate easily with OSUHS’s proprietary components and seamlessly maintain workflow processes among the clinical workstations and ancillary departments. Probably one of the biggest factors in choosing Siemens’ CPOE software was the fact that it could easily integrate with all of the data from the Clinical Information System (CIS) that had been stored on the previously installed Siemens’ legal clinical record (LCR). The Siemens graphical user interface would permit graphing and trending of clinical results. The Siemens data dictionary would allow similar information from different systems to be utilized for comparison. Decision to proceed with a rapid rollout plan. Being a teaching hospital, the medical staff at OSUHS changes quarterly so it was mandatory that the rollout be implemented with the current clinical staff fully trained and most “bugs” worked out before the next staff rotation.9

17 Computerized Physician Order Entry (CPOE) Project

18 Grade: A Strategic IS Planning
Advance organizational and IT strategic planning was not directly discussed in this case study. However it is evident that strategic planning was conducted. Grade: A OSUHS had an EHR philosophy and stated goal. EHR goal: “enhance quality and efficiency of patient care by providing a lifetime of complete patient information – available across time and place – with safeguards for patient privacy and support for teaching and clinical research”9 Board began initiatives towards an EHR in the 1970s: 1970’s and 1980’s – ancillary systems and IS infrastructure put in place towards EHR implementation Early 1990’s - strategic vision for a computerized patient record (CPR) was established. Implementation of CPOE seen as key element of CPR1 Deployed Clinical Information System (CIS) A similar comprehensive integrated health care delivery system, Adventist Health System, spent 4 years migrating all of its hospitals to the same core clinical system.7 Board provided funding for CPOE1 in early 1990s Strategic IS Planning Characteristics of the organization: 4 hospital comprehensive integrated health care delivery system Computing environment: Numerous business & clinical systems One MPI MRN since 1970’s Clinical apps include: see study Business systems include: see study EHR philosophy and goal – enhance quality and efficiency of patient care by providing a lifetime of complete patient information – available across time and place – with safeguards for patient privacy and support for teaching and clinical research Began work towards EHR implementation in the 1970’s by: installing core ancillary systems developed own ADT system, MPI, patient billing in the 1980’s established Ethernet network used HL7 format routed thru interface engine began electronic transcription of documents in 1990 Deployed Clinical Information System (CIS) aka EHR

19 SDLC stage 1. System Planning
Recommended that physicians be the primary users of CPOE, with all subsequent decisions driven by this premise1 Heavy physician focus. Best ROI would occur if physicians interacted directly with the system. Patient-safety focused strategies support the physician as the primary user of the CPOE system and are felt to positively influence physician acceptance Developed three measurement criteria for successful CPOE implementation Broad system deployment across diverse clinical environments Physicians as primary users Clinician acceptance of the system Correct project planning structure in place: Information Systems Steering Committee Task Force Subcommittee Multidisciplinary project team, physician consultants Excellent system planning occurred: Defined specific goals, Analyzed and identified user needs and concerns, Established selection criteria, Conducted clinician surveys and interviews, Performed workflow analysis, Assembled list of CPOE requirements1 Recommendation made to move forward with selection of vendor-based solution1 Recommendations also made for future phases of the project1 1995 multi-disciplinary team appointed by Information Systems Steering Committee to study and recommend order communications and clinical patient repository solutions Information Systems Steering Committee Chaired by Medical Director of OSU Hospitals Clinical communications task force Chaired by attending physician in Cardiology Multi-disciplinary members EHR oversight committee Goals: Improving patient safety Business process re-engineering Expedition of patient care User concerns/needs: Dissatisfaction with order transcription process Concerns about costs incurred by inefficiencies in paper-intensive environment

20 SDLC stage 1. System Planning, continued
It is interpreted from the case study that change management was acknowledged early on as a key factor and CSFs were identified. Based on the literature, the three top CSFs have been identified as: 1) the “before go-live training”; 2) adequate clinical resources during implementation; and 3) the time needed for physicians to enter orders into CPOE.4 These CSFs, and several more, were addressed during the system planning, design and implementation stages of this project. The only blemish regarding system planning had to do with flawed resource allocation and project scheduling: Project stopped for 14 months as the IT department had to divert resources to prepare systems for Year 2000 Funding: Administration and IS worked to secure funding Identification of CSFs – not discussed here but obviously determined in advance Committee decided that best ROI would occur if physicians interacted directly with the system Change Management (not specifically referred to) Patient-safety focused strategies support the physician as the primary user of the CPOE system and are felt to positively influence physician acceptance 1 Ongoing research and planning has allowed them to make continual progress toward achieving EHR goal – i.e. Siemens Soarian suite install thru 2010 and clinical document imaging solution Developed three measurement criteria for successful CPOE implementation Broad system deployment across diverse clinical environments Physicians as primary users Clinician acceptance of the system Grade: B

21 SDLC stage 2. System Analysis
Phase 1 - Preliminary investigation Case study does not discuss preliminary investigation activities. According to the literature it is generally accepted in the healthcare industry that the patient care, quality and standardization benefits of CPOE have already been well documented and accepted. Therefore preliminary investigation activity can be minimal. Phase 2 – Detailed Analysis Existing processes were studied Functional needs were assessed Committee determined core features Excellent physician resources allocated to design and analysis phase:1 Non-physician clinical personnel assigned to project full-time Formalized physician consultant team established and empowered to approve system design and policies Validation from other physicians, particularly house staff, was sought Efforts to standardize practices and policies across the enterprise became an integral part of the CPOE project1 Determined that advance creation of order sets were necessary to facilitate physician utilization and promote clinical standardization1 Stage 2: Systems Analysis Phase 1. Preliminary investigation Phase 2. Detailed analysis Functionality needed: Paperless order communications Results reporting Patient documentation Scheduling Clinical repository Committee determined the core features: Phase 3: Technical analysis Grade: A

22 SDLC stage 3. System Design
Phase 1 – System design System design was adequately done. Customer requirements were converted into system specs Decision made to purchase vendor CPOE with integration to existing ancillary systems Phase 2 – System evaluation Proper system evaluation activities were conducted. This included: Committee designed the selection process Committee developed the evaluation tools Committee discussed benefits of CPOE during development of RFP Committee approved contents of RFP Phase 3 – System selection Proper system selection activities were conducted. This included: Final RFP development Demos Site visits User interviews System comparisons to key attributes This stage was also used to identify CSFs via interviews with CPOE system users Stage 3: Systems Design Phase 3-1. System Design (Unit 3 Part 1) Key design decision was that all orders were to be input electronically The CPOE system had to be integrated with all the ancillary systems Phase 3-2. System Evaluation (Unit 3 Part 2) Exhaustive study Committee designed the selection process Committee developed the evaluation tools Committee discussed benefits of CPOE during development of RFP Committee approved contents of RFP Phase 3-3. System Selection (Unit 3 Part 2) Responses from RFP narrowed to 2 Detailed demos were conducted References were queried Site visits were held

23 SDLC stage 3. System Design, continued
Phase 4 - Design of CPOE prototype: It is important to standardize as many elements of the system and resulting work processes as possible across different environments.2 Understanding current-state workflows and redesigning inefficient processes are critical steps to ensuring successful adoption of CPOE. CPOE is a disruptive technology that fundamentally changes the processes used to place, review, authorize, and carry out orders.3 To accomplish this Task Force subcommittee embarked on customizing the vendor system based on Physician consultant team recommendations and results of extensive workflow analysis. Design of the CPOE prototype involved adapting and customizing the selected system. This was needed to integrate design specs recommended by physician consultant team.1 This included: Foundation order elements Order work flow Screen design User interface consistency across all departments Decision support tools such as order defaults, best-practice order sets and clinical rules. A critical foundation for CPOE is the rapid development of order sets prior to deployment. A solid development plan must be built based on clinician workflow.8 Talked to CPOE system users about what they would do differently during implementation Value of physician champions Need to have IS staff available for training and to help troubleshoot Systems were compared based upon key attributes Selected Siemens CPOE and LCR Recommendation forwarded to Information Systems Steering Committee Endorsed by same Purchase and installation project planning began next Also, selected Siemens Soarian suite (financial solution) for install thru 2010 Specific reasons Siemens CPOE was selected: Siemens was selected in part because it would integrate well with the other EHR system components in place Based on past experience, interface between physician order and ancillary systems was possible Impressed with system’s graphical user interface Impressed with data dictionary Impressed with technical platform – client-server architecture Impressed with flexibility

24 SDLC stage 3. System Design, continued
Phase 4 - Design of CPOE prototype, ctd.: Development of order sets was approached in a systematic fashion for all departments. In fact it became policy not to implement CPOE system on a nursing unit serving a particular specialty until the necessary order sets had been developed and coded for use. Over 450 standardized order sets were created.2 Each ancillary department had to ensure that order sets were created for all their common orders. “This reengineering was achieved by order pathway and order set development through faculty consensus and strong registered nurse informatics capability with full time RN’s working in the IS department to translate the clinical requirements into electronic format.”6 The Task Force and physician consultant team reviewed all orderable services in order to automate workflow all the way through the ancillary departments.6 Screen design and user interfaces were developed to be as consistent and standardized as possible. Notes here Grade: A

25 SDLC stage 4. Implementation
Project implementation plan was excellent. Project success was assured because CSFs were identified in advance and plans executed to implement those factors. By involving physicians at all levels throughout the process and emphasizing the correlation between CPOE and improved patient care and safety, outstanding physician buy-in and participation was achieved. Continuous, frequent training and retraining are critical to the success of inpatient CPOE initiatives3. Therefore multiple training and support programs were implemented, including the use of “red-coats” and super- users. In addition, permanent clinical support positions were created. An effective campaign of change management was implemented. Keys to project success were: the focus on the physician as the primary user; the intense concentration on physician participation on all levels; and the advance creation of order sets during system design. There was an effective pilot program initiated to validate system design stability and further system enhancements and process improvements. This was similar to Adventist Health System which used pilots to test and build methodology needed for CPOE rollout to the other hospitals and units.7 Stage 4. Implementation (Unit 4, Part 1) With installation of LCR, all data in CIS repository back-loaded into permanent storage in DB2 database CPOE deployed in Prior to CPOE deployment (between 1990 and 2000) OSUHS had enhanced its EHR with: Bedside documentation system (Clinicomp) Electronic discharge instruction (EDI) Patient scheduling system (IDX) Outpatient registration and billing (IDX) Electronic signature (SoftMed) Information warehouse Replaced ADT and billing systems with Siemens Working to install PACS in radiology Before CPOE implementation, order sets had been established Evidence based guidelines; Developed by multi-disciplinary groups which included physicians, nurses and pharmacists; Approved by the Leadership Council for Clinical Value Enhancement; Facilitated physician utilization of the system; Helped promote clinical standardization of care

26 SDLC stage 4. Implementation, continued
Implementation included a phased install in different areas of the hospitals. “100% of orderable services were available at the time of each of these installs. All medications, imaging studies, nursing activities, diets, consults, and labs were orderable electronically at the time of CPOE rollout.”6 Based on studies from the Leapfrog Group2, the implementation time period was longer than the implementation time for similar healthcare organizations (12 to 30 months). This was attributable to the upfront work in systems design to create standardized order sets - the “first two years of implementation were focused on system programming to meet comprehensive physician workflow requirements. This time was necessary to develop a product that was acceptable for physician use.”1 Similarly, Adventist Health System, prior to CPOE implementation, invested more than two years in development of evidence- and expert-based content based around order sets.7 It is believed that this extra time was well spent as it led to smoother implementation where physicians and clinicians were able to immediately realize the potential for improvements in patient care and safety Implementation project plan Need for physician consultants Funds budgeted for physician release time to participate in: Building and reviewing order sets Designing screens Reviewing flow of information within the system Designing rules and alerts Consulting on other components of the system 10 member physician consulting team was empowered to approve system design and operational policy System implementation planning staff shadowed doctors to learn more about current process Learned that house staff gave most of the orders so the house staff leaders were involved so they could understand and support CPOE Training conducted for physicians shortly before implementation “Red coat” staff members available 24/7 during initial implementation & training After, at the IS Help desk Rule: Red coat went immediately to physician rather than trying to fix over phone Key clinicians released from their clinical duties to focus on issue resolution Lessons learned: Physician leadership critical to success Administrative commitment to aggressive rollout plan Slow rollout would be difficult for house staff to support System should be fully implemented before new staff starts in next hiring season (so new hires only had to learn one system) Review of flow of information and clinical staff levels was considered so that additional PCs and printers, if needed, could be installed before go-live There was no mention of CPOE- themed kickoff events that are recommended as part of change management. This, along with the lengthy implementation period, are two items that affected their grade. Grade: A-

27 SDLC stage 5. System Support
System requests and feedback were solicited from users in a variety of ways. These included help-desk phone calls, conversations with red coats, , intranet forms, communication with IS staff, and multiple meetings. Support requests were monitored. There was a decline in user modification and enhancement requests since implementation. Types of requests were tracked. None required significant changes to the system. There was no mention of a CQI program. Operational and maintenance costs were not discussed. Cost savings from process improvements and physician time were not evaluated.6 Notes here User requests for enhancements and modifications. 1 Number of tickets (y axix) vs. Months gone by (x axis) Grade: B

28 References Ahmad, A., Teater, P., Bentley, T.D., Kuehn, L., Kumar, R.R., Thomas, A., & Mekhjian, H.S. (2002). Key attributes of a successful physician order entry system implementation in a multi-hospital environment. Journal of the American Medical Informatics Association, Jan-Feb; 9(1), pp.16–24. First Consulting Group, Leapfrog Group. (2003). Computerized physician order entry: Cost, benefits and challenges; A case study approach. Retrieved from AHA_FAH_CPOE_Report.pdf U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, National Resource Center for Health Information Technology. (2009). Inpatient computerized provider order entry (CPOE), findings from the AHRQ Health IT Portfolio (AHRQ Publication No EF). Retrieved from Altuwaijri, M.M., Bahanshal, A., & Almehaid, M. (2011). Implementation of computerized physician order entry in National Guard hospitals: Assessment of critical success factors. Journal of Family & Community Medicine, Sep-Dec; 18(3), 143–151. doi: / Notes here

29 References, continued Not used.
Ahmad, A., Rucker, D.W., & Teater, P. (2002) Implementing end-to-end computerized physician order entry. Proceedings of the 2002 Annual HIMSS Conference & Exposition, Session 109. Retrieved from Prestigiacomo, J. (2011). Automating CPOE success: How Adventist Health System systemized its CPOE rollout in 26 hospitals over 28 months. Healthcare Informatics, Nov. issue. Retrieved from Fear, F. (2011). Governance first, technology second to effective CPOE deployment. Health Management Technology, Aug. issue. Retrieved from first-technology-second-to-effective-cpoe-deployment.php Curtis, E.H., (2004). Studies in EHR implementation: Computerized physician order entry. AHIMA On Demand series. Retrieved from HINF4519 Systems Design & Implementation D2L course content. Notes here

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