Presentation on theme: "CPOE Implementation in the Community Setting"— Presentation transcript:
1 CPOE Implementation in the Community Setting What do you need to know?Avoid a Towering Inferno by creating a burning platformAvoid medical staff revolution with the evolution of a patient safety culture
2 Current and Projected CPOE Implementation at U.S.A. Hospitals Scope of the ChallengeCurrent and Projected CPOE Implementation at U.S.A. Hospitals100%90%80%70%60%US-200550%US-201040%30%20%10%0%<300 beds>300 bedsUS estimates from Kaushal R, et al. Health Affairs 2005;24:
3 CPOE is a key component of any medication safety initiative PO MedicationDeliveryCPOEProvider writesorderPO medSmart IVPumpIV medDecision SupportPharmacyPharmacist ApprovesOrderCompleting The Loop:Web ReportingTeam TrainingMedication ReconciliationImproving TransitionsElectronic IdentificationPump sends documentationTo eMAR; RN verifiesGoal of the future: To close the loop between technology and provide even less room for human error. Many of the pump vendors will have wireless capability in the future (Cardinal Health alpha testing). Major companies state they can work with any of the bar code readers available.ADE SurveillanceeMARRN acknowledgesApproved orderDelivery toSiteMed Repackagingomnicell, robotics, etc.
4 CPOE Implementation in the Community Setting Factors Critical for SuccessCommunicate Vision, Rationale and GoalsProvide Data to Support Vision, Reinforce Benefits and Measure PerformanceDemonstrate Leadership CommitmentMentor Physician ChampionsDevelop Incentives and SanctionsRespond to Physician ConcernsMarketing and Communication
5 Communicate, Communicate, Communicate Vision, Rationale and Goals CPOE has been proven to enhance patient care.CPOE reduces medication errors and provides alerts for potential drug interactions and when dosage adjustments are required.Define firm targets: “75% of medication orders entered electronically by June 2007”
6 Serious Medication Errors Data to Support Vision and RationaleSerious Medication Error Rates Before and After CPOE1210Phase I(Before CPOE)8Serious Medication Errors(Events/1,000 Patient Days)Phase II(After CPOE)64Delta = -55%P < .012Bates et al.: “Effect of Computerized Physician Order Entryand a Team Intervention on Prevention of Serious Medication Errors,” JAMA 1998.
7 CPOE provides real advantages in providing quality patient care Quality and safety benefits from decision support toolsCPOE continuously delivers evidence-based treatment.Care is more reliable, more efficient, and saferAll involved physicians know patient’s medicationsFewer call backs from pharmacyFewer call backs from nursingFaster delivery of inpatient medicationsPhysician orders are legible
9 NSMC Geriatric Psychiatry Data to Reinforce CPOE Benefits Medication Errors Before and After CPOE ImplementationNSMC Adult PsychiatryCPOE live onNSMC Geriatric PsychiatryCPOE live on1.00.50.01.52.02.53.03.54.05.04.50.34.6Errors Per MonthJan. ’05 – March ‘060.42.37 East Notes - Actual ErrorsDecreased omissions from 19 prior to CPOM, to 5Decreased wrong dose from 12 prior to CPOM, to 3New Error Wrong Drug since CPOM -2New Error Wrong Patient – 1Decreased wrong time from 7 prior to CPOM, to 2 East 3 Notes- Actual ErrorsDecreased omissions from 9 prior to CPOM, to 1Decreased wrong doses from 5 prior to CPOM, to 0Decreased wrong drug from 2 prior to CPOM, to 0Decreased wrong time from 1 prior to CPOM, to 00.11.7Actual0.1PotentialBEFOREAFTERBEFOREAFTER
10 Why we need to adopt CPOE now? It is widely accepted as the new standard of care.It distinguishes our quality of care from hospitals that are late adopters.It is increasingly a significant point of leverage in negotiations to maximize reimbursement from private insurers.
11 Demonstrate Leadership Commitment Hospital Executives and Physician Leaders play formal roles.NSMC Chiefs Forum reviews CPOE progress every 2-4 weeks.CEO and President participates in discussion once per month; ad hoc meetings as needed.Appointment of IS medical director; CMIOCreate the necessary infrastructure to effect change.
12 Medical Staff Leadership Reporting and Accountability Structure
13 Leadership and Governance Chiefs Forum (CF) assumed responsibility as the CPOE Physician Advisory Group.CF develops policy recommendations, identifies areas of resistance, reviews physician utilization and provides communication.Medical Executive Committee functions as the governing body of the medical staff.Education and engagement of Board of Trustees on a regular basis
14 Expect mixed reaction and pushback during initial rollout Big Bang vs Sequential Implementation- Initial focus on medication orders at NSMCMD compliance variableMDs will complain about the length of time it takes to enter orders compared to writing on paper.Large practices without hospitalists place a significant burden on rounding MDs
15 Moving the Ball Forward Focus on steady progress24/7 “at the elbow” technical supportUsability enhancements will help with overall acceptance-Process to prioritize order set development-System speed and responsivenessIdentify and mentor high volume, high compliance CPOE users as physician champions.
16 Monitoring and Reporting Data for orders entered via CPOE are very accurateAccurately identifying the ordering MD on paper orders is required for accurate CPOE compliance reports- Encourage second identifier on written orders i.e. print name, beeper #, etc- Orders with illegible signatures are attributed to the attending MDWeekly reporting to Department Chairs- Numerator: Medication Orders Entered Into CPOM by prescriber- Denominator: Total Medication Orders by prescriber
17 Weekly Utilization Metrics *Full names provided on actual report.
18 Pharmacy Study of Handwritten Orders May 22, 2006 – June 2, 2006 Accurately identifying the Ordering MD on paper can be a challenge due to illegible signaturesPharmacy Study of Handwritten Orders May 22, 2006 – June 2, 2006# of Physicians# of OrdersName was Printed448Signature was Legible16188Signature was Illegible58178
22 Achieving a “Tipping Point” through Physician Level Reporting Chairs need to focus on high volume/low compliance MDs.For those who continue to write on paper, a tougher compliance policy is needed.
23 Incentives and Sanctions CPOE P4P incentives ideally aligned with physicians and hospitals.Consider recognition, contests and give-aways.Mandatory Training-All physicians must attend a CPOE education class prior to receiving system login.-New medical staff receive training as part of the orientation process.
24 Sanctions required for those who continue to write on paper NSMC CPOE Compliance Policy & ProcessIndividual CPOE compliance set at 85%.Department Chairs own primary management responsibilityMDs have multiple opportunities to remediate their compliance.Compliance policy patterned after Medical Records completion policy.Written notification of deficiency, with cc: to chief/chair.Appearance before Medical Executive Committee.Suspension of privileges.
25 CPOE Utilization Compliance Policy Letter describing CPOE compliance policy sent to entire medical staff
26 Respond to Physicians’ Concerns Demands on Massachusetts Physicians Continue to IncreasePay for PerformanceQuality MeasuresDeclining ReimbursementsIncreasingPractice ExpensesMalpracticePremiumsHigh Cost Of LivingTransparency/Public ReportingFamily BalanceCPOE / EMR
27 Nursing Unit Implications Routine Verbal Orders are not allowed per JCAHO standardsTelephone Orders will only be accepted for urgent orders or when CPOE is not accessible.CPOE support staff and RN super users will offer to show MDs how to enter orders. If rebuked, Nurse Manager or Supervisor explains hospital policy regarding reporting of the incident to the Department Chair.
28 Marketing and Communication Develop a logoHeighten awareness; reaffirm commitment to CPOEWeekly on-line and paper newsletter – publish go-live dates, FAQs, tipsHold regular informational meetings.Post signage on each unit reminding MD that “this is a CPOE unit”
30 Measuring CPOE Performance Non-CPOEEntered by MD into CPOE% CPOENon-CPOE
31 Measuring CPOE Performance Non-CPOEEntered by MD into CPOE% CPOE
32 CPOE Implementation in the Community Setting The Final MoveRemove all paper order sets from the floors.“As of _________, written orders will not be accepted and all routine orders must be entered via CPOE.”
33 CPOE Implementation in the Community Setting Final Thoughts and Key Take-AwaysPatient Care is saferAdopting CPOE requires commitment by busy physiciansAppeal to sense of professionalismTime is required, but time is saved.Physicians respond to dataRecognize physician championsExplore physician incentives and sanctionsIncrease financial incentives that reward use
34 CPOE Implementation in the Community Setting Final Thoughts and Key Take AwaysRespond to physician concerns-Continue efforts to improve the ease of use, speed of the applications and surrounding workflowCreate a patient safety culture that embraces evidence based, standardized, coordinated careOnce you reach a “tipping point,” growingintolerance of non-usersPlan to learn along the way