Current and Emerging Use of Clinical Information Systems Chapter 5

Outline Clinical Information Systems Definition and Functions Electronic health record/Electronic medical record Computerized provider order entry Medication Administration Telehealth and Telemedicine Definition and Functions Current Use of Systems Factors Influencing Adoption Value of Systems Barriers to Diffusion

EMR Adoption in Hospitals

Adoption of EHR Meaningful Use of Electronic Health Records, April 2011 through May 2012.

Electronic Medical Record MRI Five Levels of Computerization Level 1: Automated Medical Record Level 2: Computerized Medical Record System Level 3: Electronic Medical Record Level 4: Electronic Patient Record Level 5: Electronic Health Record

Five Levels of Computerization (Figure 5.1)

Value of EMR Improved quality, outcomes and safety Computerized reminders and alerts Improved compliance with practice guidelines Reduction in medical errors Improved efficiency, productivity, and cost reduction

Value of EMR continued Improved service and satisfaction Patient satisfaction User satisfaction Less stress Improved job satisfaction Quality of documentation

Other major types of CIS Computerized provider order entry (CPOE) Medication administration using barcoding Telemedicine Telehealth—for our purposes, we will focus on online communication (e.g. email) between patients and providers

CPOE Computerized Provider Order Entry, at its most basic level, is a computer application that accepts physicians orders electronically, replacing handwritten or verbal orders and prescriptions. Most CPOE systems provide physicians with decision-support capabilities at the point of ordering.

What is CPOE? Electronic entry of physician orders and instructions for treatment Order entry at point-of-care or off site Communication over a network to medical staff Integration of various departments (radiology, laboratory, etc..) A trend that is being implemented and used in hospitals and facilities in increasing numbers today. It is the process of entering orders and treatment instructions by the physician for patients under their care. It can be done in the hospital or facility in which the patient is admitted but also provides the ability for MD’s to enter orders off site in places such as their home. It links the various departments of the hospital when orders are entered, such as triggering the lab about lab work that was ordered and radiology departments on tests ordered and schedule times. In a sense the department responsible for filling or carrying out the order that was entered is informed via the computer network. (Wikipedia, 2010)

What is CPOE, continued Replacer of hand-written orders Immediate alerting of allergies or contraindications at point of entry Real-time clinical decision support Supports access to patient data CPOE eliminates the need for hand-written orders. As an order is entered in to the system, allergies or possible contraindications for the patient are immediately alerted to the physician before final submission. The real-time support also provides duplicate therapy warnings, alternate dosage and/or alternate medication suggestions. Allows the physician access to patient data and assessment information potentially needed for the decision making. (Open Clinical, 2006)

CPOE Hardware Desktop Computer Laptop Computer on Wheels PDA (Personal Digital Assistant) PALM Pilot CPOE software can be placed and utilized on many different types of hardware. Typically placed on desktop computers for use. It can also be utilized mobilely on laptops and PDA’s or PALM handheld computers.

CPOE Software Provider Order System Multiple manufacturers Cerner McKesson Eclipsys Siemens Quadramed HMS Meditech May be coupled with Clinical Decision Support Systems (CDSS) Many companies manufacture types of Computer Provider Order Entry systems. Most CPOE systems are combined with Clinical Decision Support Systems that reduce errors and decrease costs. (MedicExchange, 2010)

Cerner CPOE Offers single solution to automate workflow Capabilities: Enter orders Check orders Document Communicate Evaluate patient status (Cerner Corporation, 2010)

Cerner CPOE, continued Benefits with Cerner: Improve patient safety Save time Save money Enhance communication Reduce errors Easy-to-use (Cerner Corporation, 2010)

CPOE Usability Evaluated with indicators: Ease of use Ease of learning Satisfaction Efficiency of use Error tolerance Fit of system to task (McGonigle, D. & Mastrian, K., 2009)

CPOE Usability, continued Most often implemented in large academic medical centers 25-27% of U.S. hospitals over 200 beds using CPOE 11.3% of U.S. hospitals actively using CPOE (physicians entering >50% of orders) Currently 291 hospitals that use CPOE at the 100% level Most CPOE sites also using barcode scanning (Hess, J., 2010)

CPOE System Ensures standardized and complete orders Increases patient safety by reducing errors Automates workflow Supports ready access to patient data and assessment Improves efficiency by integrating multiple departments Provides order sets for easier use (Open Clinical, 2006)

CPOE Advantages Direct entry of orders into EMR Replaces handwritten orders Cross reference for potential drug- interactions or allergies Reduces wait times for patients Improves compliance with best practices Ready access to patient data CPOE has more documented advantages than disadvantages. CPOE allows for many positive results not only for the staff that utilize it but patients as well. (Open Clinical, 2006)

Advantages, continued Improves patient safety Potential to improve efficiency Cost saving benefits by: Reducing number of duplicate tests Reducing errors (Open Clinical, 2006)

CPOE Disadvantages Cost User resistance Personalization for individual hospitals Potential for integration issues with other systems Disruption of workflow with employee training CPOE is expensive to implement and maintain. (Open Clinical, 2006)

Informatics Competencies Basic knowledge of computer usage Three levels of competencies: Technical Utility Leadership

Informatics Competencies, continued Technical: Web Expert data systems Nursing and Hospital information systems Multimedia Telecommunication devices (Kaminski, 2009)

Competencies, continued Utility: Process of using computers and other technology Leadership: Ethical issues with using computers Management issues with using computers (Kaminski, 2009)

Barriers to CPOE use Physician entry an issue Takes longer to place order; many systems are ‘cumbersome’, take too many steps Incentives may not be aligned with use Lack of confidence in system reliability Insufficient training Mandating use – should you?

Medication administration Use of barcoding becoming more widespread Aids in correctly identifying patient, drug, dose, etc. HIMSS implementation guide—good resource More widely accepted Has been used successfully by many health care organizations Again, has potential to aid in making sure the right meds, get to the right patient, at the right dose…

Fitting Pieces Together (Figure 5.9)

Barriers to Adoption Financial (acquisition and support) Organizational or Behavioral (user acceptance) Technical (need for standards, integration)

Strategies for Overcoming Barriers What strategies are being employed to help overcome— Financial barriers? Behavioral barriers? Technical barriers?

Summary Examined 5 different clinical information systems—their current use, status, and value Discussed the three major barriers to adoption of these systems—financial, behavioral and technical and strategies to overcome them