Computerized Physician Order Entry

Weighing the benefits and challenges of implementation

Rhonda JoynerHMIA 5060Final Examination

A White Paper

TABLE OF CONTENTS Explore Purpose of Health Information

Technologies Statement of Issue Background/History Benefits Negative impacts Strategies Conclusion References

EXPLORING PURPOSE OF HIT

PURPOSE OF HITS The national health care expenditure was

approximately $2.6 trillion with an anticipated growth rate of 5.8% over the next 10 years.

Health care expenditures have grown at a faster rate than the national gross domestic product rate. 1

Health Information Technologies can increase efficiency and effectiveness

WHAT IS COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE)?

A mechanism for physicians and medical professionals to order medications electronically through computers or smart phones.

This order is then recorded for patient records and dispersal of medication and may facilitate the exchange of information amongst other providers. 8

HISTORY OF CPOE

WHAT ACTS?

2009 AMERICAN RECOVERY AND REINVESTMENT ACT (ARRA)

THE HEALTH INFORMATION TECHNOLOGY FOR ECONOMIC AND

CLINICAL HEALTH (HITECH) ACT Provided $19 billion

to encourage healthcare providers to adopt and use health information technologies (HITs) and electronic health records (EHR) within their organizations.

Included a provision worth $560 million to provide states with funding to increase their Health Information Exchanges (HIEs).

$17 billion to provide increased Medicare payments to hospitals and physician in exchange for usage of certified EHR systems, known as “meaningful use”. 1

Key element is the implementation of Computerized Physician Order Entry (CPOE).

The Government Has Stepped In To Ensure That The Healthcare Industry Increase Its

Utilization Of Technology.

WHY IS CPOE IMPORTANT?

CPOE is considered to be Stage 1 of the meaningful use criteria, and provides health care providers with the qualification for the HITECH incentives.

Providers that meet the meaningful use guidelines by 2014 will qualify for incentive payments. Others will be penalized if implementation is not achieved by 2014. 8

MEANINGFUL USE DEFINED

Meaningful use (MU), as defined by SearchHealthIT, is “the use of electronic health records (EHR) and related technology within a healthcare organization.” 7

Qualifies healthcare organizations for financial incentives from Medicare and Medicaid EHR Incentive Programs. 6

ISSUES

FEW TAKERS….

Study conducted in 2009 indicated: 1.5% of hospitals in the U.S. utilized an

electronic record system within all clinical units.

7.6% of the hospitals had at least one clinical unit utilizing a system.1, 4

4% of physicians indicated having extensive systems

13% only reporting a basic electronic system. 1,5

CHALLENGES

High Operating Costs Interruption of work flow May increase errors Lack of technical capabilities Physician Buy In and Trust

BENEFITS

BENEFITS

CPOE is an effort to reduce medication, and paper errors and increase proficiency within healthcare organizations and results in overall cost savings if implemented correctly.

It is estimated that medication errors results in a national cost of $2 billion annually. 9

2009 STUDY RESULTS RELEASED BY THE MASSACHUSETTS TECHNOLOGY COLLABORATIVE AND THE NEW ENGLAND HEALTHCARE INSTITUTE

Stated that cost of CPOE implementation could provide annual savings of $2.7 million for a hospital. 9 , Relative to the cost

of approximately $2.1 million and $435,000 for yearly maintenance

Indicated that CPOE could reduce the 770,000 hospital deaths and injurers that are caused by adverse drug events (ADEs). Preventable ADEs incidents

cost each hospital $5.6 million annually

Considered the leading cause of death (excluding death by motor vehicle, Aids, and breast cancer). 9

98,000 deaths occur annually due to medical errors.10

ADDITIONAL BENEFITS

“Free of handwriting identification problems Faster to reach the pharmacy Less subject to error associated with similar drug names More easily integrated into medical records and decision-support systems Less subject to errors caused by use of apothecary measures Easily linked to drug-drug interaction warnings More likely to identify the prescribing physician Able to link to ADE reporting systems Able to avoid specification errors, such as trailing zeros Available and appropriate for training and education Available for immediate data analysis, including post marketing reporting Claimed to generate significant economic savings With online prompts, CPOE systems can

Link to algorithms to emphasize cost-effective medications Reduce under prescribing and overprescribing Reduce incorrect drug choices” 12

NEGATIVE IMPACT

A CLOSER LOOK AT TWO STUDIES

ERRORS CAUSED BY CPOE

“Role of computerized physician order entry systems in facilitating medication errors” article by Koppel et al., discusses a study conducted at “a major urban tertiary-care teaching hospital with 750 beds, 39, 000 annual discharges, and a widely used CPOE system (TDS) operational there from 1997 to 2004.”

This study uncovered 22 types of medication errors that occurred as a result of the CPOE system.

CPOE ERRORS AS IDENTIFIED BY STUDY

Information Errors

Assumed Dose Information Medication Discontinuation

Failures Procedure-Linked Medication

Discontinuation Faults Immediate Orders and Give-

as-Needed Medication Discontinuation Faults

Antibiotic Renewal Failure Diluent Options and Errors Allergy Information Delay Conflicting or Duplicative

Medications

Human-Machine Interface Flaws

Patient Selection Wrong Medication Selection Unclear Log On/Log Off Failure to Provide Medications After

Surgery Postsurgery “Suspended”

Medications Loss of Data, Time, and Focus When

CPOE Is Nonfunctional Sending Medications to Wrong

Rooms When the Computer System Has Shut Down

Late-in-Day Orders Lost for 24 Hours Role of Charting Difficulties in

Inaccurate and Delayed Medication Administration

Inflexible Ordering Screens, Incorrect Medications

DOES COPE INCREASE MORTALITY?

CHILDREN’S HOSPITAL OF PITTSBURG (CHP)

CHILDREN’S HOSPITAL AND REGIONAL MEDICAL CENTER (CHRMC) IN SEATTLE, WASHINGTON

Involved 1942 children Conducted over a

period of 18 months (13 pre-implementation and 5 post-Implementation).  

Indicated an increased morality of 6.6% from 2.8%.

Involved 2533 pediatric patients

Conducted for a total of 26 months, 13 pre/ 13 post- implementation.  

No significant increase in the mortality rate after CPOE implementation.

Study that compares two CPOE system implementation to determine the pediatric mortality rate after implementation of this system in pediatric intensive care units. 

VARIANCE IN STUDY RESULTS

CHP study had a smaller population size due to the difference in the period of study, 18 months (CHP) and 26 months (CHRMC). 

Demographics of population were also younger, and study included transferred patients.

Use and application of data mining and statistical analysis varied.

Different approaches to implementation in terms of time frame, training, and availability and use of subject matter experts.

Procedural and logistical changes were implemented at the same time as CPOE implementation at CHP which had a negative impact on effectiveness and efficiency of care.

CHRMC personnel had an opportunity to review the results of CHP and visit with the staff to improve implementation errors which provided a second mover advantage.

CRITICAL FLAWS IN CHP STUDY

Short implementation period of only six days. Order entry could not occur until a patient was

physically in the hospital. As a result, critical patients in transit could not have their medications processed and ordered until arrival to the hospital.

ICU pharmacy moved to a centralized pharmacy not near ICU unit.

This pharmacy could not dispense medication until physician ordered through the CPOE system.

Predetermined order sets were not established in the CPOE system prior to implementation.

REASONS FOR CPOE ERRORS

The qualitative data was an important element that impacted the CHP implementation.2

Workflow changes Lack of Order Sets Lack of Sufficient Training Technical Capabilities

STRATEGIES

RESEARCHERS INPUT

JOAN S. ASH FROM THE OREGON HEALTH & SCIENCE UNIVERSITY AT PORTLAND

Presents the following recommendations for implementation:

“now the CPOE implementation success depends primarily on

1) Time considerations (response time and user time), 2) Meeting information needs (using order sets), 3) Multidimensional integration (especially with work flow), 4) The existence of essential people (leaders and support

staff, plus involved clinicians),5) certain foundational underpinnings (e.g. trust between

administrators and clinicians), and 6) Improvement through evaluation and learning (paying

attentions to user feedback)” 2

FRANK FEAR WRITES IN “GOVERNANCE FIRST, TECHNOLOGY SECOND, TO EFFECTIVE CPOE DEPLOYMENT”

Planning a CPOE around the actual workflow of organization is the key to long-term success.

Identifying and developing order sets in advance to implementation may lead to long term success.

Order steps should be broad and general, instead of specific to allow for adjustment as physicians learn more about their system needs and requirements. 14

“A RASCH MODEL ANALYSIS OF TECHNOLOGY USAGE IN MINNESOTA HOSPITALS” BY JOHN OLSON ET AL. Indicates that prior

technological and organizational knowledge is a function of technical capabilities.

Recommendation is to implement EHR prior to CPOE implementation.1 CPOE was identified as a

challenging system that should be implemented as capabilities of hospitals increase. 1,15

Identifies the “human factor” as being a critical component of this process.

Gradually integrate HIT, allowing physicians the opportunities to develop capabilities at a slower pace.

Identifying physician or nurse “champions” of a system can also gain overall “credibility” of a project.

Providing continuous training may increase effectiveness and reduce errors.1,15

CONCLUSION

HITS ARE EFFECTIVE TOOLS

HITs can provide efficiency and effectiveness in healthcare.1,2

CPOE meets the Stage 1 meaningful use requirements and provides a financial incentive for implementation.1

TO ENCOURAGE SUCCESSFUL INTEGRATION

Healthcare organization must understand the difficulty of HIT systems and consider EHR implementation prior to CPOE

Organizations must also analyze the workflow and establish broad order sets that will enable change and input from physicians.14

The “human factor” is a critical component of this process.1,15

Slow implementation Training and developing subject matter experts who can

serve as “champions” will increase the success rate of integration. 1,15

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6. Computerized Physician Order Entry (CPOE) resource page. SearchHealthIT Website http://searchhealthit.techtarget.com/definition/computerized-physician-order-entry-CPOE . Accessed December 1, 2012.

7.  Meaningful Use resource page. Search HealthIT Web site http://searchhealthit.techtarget.com/definition/meaningful-use . Accessed December 1, 2012.

8.  Eligible Professional Meaningful Use Core Measures Measure 1 of 15. CMS.Gov Web site http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/1_CPOE_for_Medication_Orders.pdf . Accessed December 1, 2012.

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