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September 28, 2009

Learn From a Master
By Alice Shepherd
For The Record
Vol. 21 No. 18 P. 18

An old-timer when it comes to CPOE, a North Carolina medical center offers pointers on how to realize the technology’s power.

To qualify for the financial incentives under the HITECH Act, some hospitals are speeding up their plans to implement computerized physician order entry (CPOE) systems. According to industry experts, less than 15% of hospitals currently use CPOE, leaving a large number to learn lessons from the few that have made the leap.

Alamance Regional Medical Center in North Carolina was among the earliest CPOE pioneers, having implemented the technology more than a decade ago as the first step in a phased approach to deploying clinical information systems. From the vantage point of 10 years’ experience, the course charted by Alamance can guide other organizations that want to use CPOE as a starting point for an EHR installation.

“What motivated us to begin our clinical information systems implementation was the realization that other organizations had more information about how we provided patient care than we did,” says Terri Andrews, RN, MBA, Alamance’s clinical systems manager. “We were determined to create a useful tool for our physicians and clinicians, so we relied on them to define what would be of value to them and involved them heavily in the technology selection process.” After researching several systems, Alamance selected Eclipsys’ CPOE technology for two reasons: It was the one physicians and clinicians found to be the most intuitive, and it had superior clinical decision-support capabilities, which still provide value today.

At the time Alamance implemented CPOE, it was building a new hospital. “Our administration, the board, and the key physicians saw that the future was going to be heavy on information technology, so we deployed the necessary infrastructure during construction,” says systems engineer James Waite. “It was designed to support the future use of computers throughout the hospital to handle electronic health records. Even before getting specific about CPOE, we had a vision that we were going electronic.”

Pros and Cons of a Phased Approach
Why did Alamance choose to start with CPOE? “Because everything begins with a physician order, we knew that we could get the most bang for our buck by implementing CPOE first,” says Andrews. “Having the order available electronically facilitated the checks and balances necessary to eliminate transcription errors and take advantage of clinical decision support.”

Even today, Andrews recommends beginning the EHR journey with CPOE. “Some hospitals begin with nursing documentation because they prefer to tackle the group over which they have the most control,” she says. “Dealing with physicians can be daunting, but since everything is driven by the physician order, we recommend CPOE as a starting point.”

After CPOE, Alamance went live with electronic medication administration to safeguard dispensing medications. Nursing documentation was next, followed by physician documentation, pharmacy and radiology systems, and several other technologies. “All those systems are feeding our clinical data repository, which provides the physicians with a one-stop shop for all the information they need,” says Andrews. “They can access it from multiple locations, including remotely from office or home.”

Over the 10-year period, Alamance used the phased approach for both the consecutive deployment of technologies and the rollout to various areas of the hospital. This model allowed physicians and clinicians to adjust to electronic records gradually—from orders to documentation—to a point of being almost completely paperless.

“Know how much change your organization can handle,” recommends Andrews. “Few hospitals have the people and resources to support ‘big bang’ deployment across the organization.” Waite notes that there are pluses and minuses to each approach. Alamance proceeded one unit at a time based on the number of support staff and trainers it had available. “Even with thorough testing, there will be things you failed to consider, so there will always be fires to put out,” says Waite. “Therefore, the question is, do you have the bodies to support your staff, as well as respond to problems? For us, the floor-by-floor approach worked well. At other hospitals, doctors who rotate and work in many different units might be frustrated if they get used to an automated unit and then have to work with paper on another floor.”

Despite the benefits of gradual implementation, Alamance’s phased approach also brought some stress. “We rolled it out in one nursing unit at a time and got nurses trained in the month leading up to their go-live,” explains Waite. “We tried to work with as many physicians as possible who were frequent rounders on the affected floor but couldn’t always get 100% compliance. Some did 100% of the work in the computer while others stuck to paper charts and handwritten orders because they were uncomfortable with the computer or had not yet been trained. So for a while, nurses were living in two worlds—a paper world and an electronic world—and that was a stressor for them.”

 “Today, it’s going to be easier to convince physicians of the value of CPOE,” says Andrews. “Ten years ago, it was just our gut telling us that it was the right thing to do for patients, but today there is a whole body of evidence to back it up. Physicians prefer to see quantifiable data.”

Guiding Forces
To guide the deployment of CPOE and the remainder of the clinical information systems, Alamance created two steering groups that are still active today. The Physician Review Board, consisting of physicians representing the different specialty areas on the medical staff, served as an advisory council and clearinghouse. Its members tested new features and functionality and developed standards and best practices.

Within the framework of the hospital’s shared governance model of nursing, the multidisciplinary Clinical Informatics Council included representation from all nursing units and ancillary departments. This group developed the policies and procedures that determined how clinical information systems would affect patient care and workflow. “We found great value in training physicians and clinicians not only on the features of the software but also on policy and procedure workflow changes right from the start,” says Andrews. “The two groups spent significant time analyzing pre- and post-workflow. They identified exactly what would be changing for each staff member on a day-to-day basis and developed training programs accordingly for a smooth go-live.”

The hospital originally targeted 120 physicians for training and sent out surveys asking them when they wanted to attend class. But when 20 classes were scheduled at the requested times, only three physicians showed up. “The other 117 were trained one on one, and that’s exactly what we would recommend,” says Andrews. “Physicians are not people who typically do well in group settings, and they really like the individualized attention. The work effort is greater, but the benefit was that our clinical analyst trained the physicians, which meant that we could incorporate their preferences into the system in the process. That led to greater acceptance of the technology because they could see it was flexible. For an attending staff, I recommend one-on-one training. For interns and residents, a group setting might work.”

The heavy involvement of Alamance’s Physician Review Board and Clinical Informatics Council was critical to the success of its journey from CPOE to clinical information systems. “Clinical analysts with nursing or pharmacy backgrounds have representation on the two groups, so that information can flow from team to team and there is no redundancy because each group knows what the other is doing,” says Andrews. “A popular alternative today is to start by creating a clinical informatics department with a dotted line to the CIO [chief information officer]. However, our model has proven successful and we see no need to change it.” Even today, the two groups are the most powerful entities in the organization and are instrumental in guiding project teams to deliver what clinicians want.

The deployment of CPOE necessitated changes to many departments, including IT. For example, Alamance’s help desk could no longer be an 8-to-5 operation. “We had to quickly revamp our help desk structure to provide support 24/7,” says Andrews. “If you’re asking physicians and nurses to incorporate CPOE into their workflow, it’s not acceptable for them to run into trouble at 2 am and have no one to call.”

Initially, with some documents electronic and others still on paper, the medical records department had to redefine what constituted a legal medical record. “For a while, we had a hybrid policy that defined which components would be found in the clinical manager and which in the paper world,” says Waite. “As we added more technology, the policy changed over time.”

Decision Support
The order entry process presents many opportunities to introduce clinical decision support—for example, alerts.

Alamance’s technology incorporates Medical Logic Modules (MLMs), programs that run in the background to determine whether an alert should be issued in the order entry process. The alerts are customized so they can be sent to the appropriate person, whether physician or nursing staff. “Over 10 years, we have learned that alerts need to be of value to the physician, or they’re going to ignore them,” says Waite. “Don’t get alert happy. As a community hospital, we have an all-attending staff, and some of the alerts issued in a teaching facility for interns or residents may be inappropriate for physicians who have been practicing for a decade or more.”

Every time a new alert is installed, Alamance’s IT department monitors it to see how often it is viewed and whether it influenced the physician’s practice. The Physician Review Board then determines whether the alert is worth retaining.

MLMs are also handy to fill gaps not yet addressed by software. “No software can do everything you want it to do in every situation,” says Waite. “We’ll write an MLM to fill a gap in the functionality and later, when that function becomes part of the standard product, we delete the MLM. Every time we receive a new software version, we evaluate its new features against our operation, get feedback from the staff, and start prioritizing the implementation.”

Physicians and clinicians who notice an order-entry error can report it online to Alamance’s risk management department. IT receives a copy of the report so it can determine whether there is a design flaw in the software or whether the error calls for reeducation. “People sometimes assume that electronic systems make critical thinking unnecessary,” says Andrews. “They become very comfortable using the computer and think it can interpret anything.”

Alamance’s current CPOE system interfaces to another system for in-patient pharmacy orders. However, the hospital plans to purchase an integrated pharmacy module with the next release of its CPOE software. “When a physician places an order, it will be flagged on a work queue for a pharmacist,” says Waite. “There will be no need to interface to a third-party system.”

“Without CPOE’s clinical decision support, physicians would have to remember everything, and there would be no checks and balances in the order process,” says Andrews. “This would present a lot of opportunity for medication errors. As new guidelines emerge, we’re constantly looking at our order sets to make sure they’re reflective of best practice. You can’t just build orders for physicians and never touch them again. Medications change, best practices change. You have to be current and thinking through those processes.”

The introduction of CPOE, or any new technology, means changes to workflow, and that entails risk if people don’t understand the new process. One of Alamance’s strategies was to create flowcharts of pre-CPOE processes and the new processes. “It helped show the value and raised the understanding of what happens how and when,” says Waite. “As long as everyone is on board and understands how their workflow changes, it reduces the risk. If you implement a significant workflow change and don’t communicate it to everyone, you can get frustration, confusion, and mistakes.”

A final success factor at Alamance was commitment. Everyone at the hospital agreed that implementing CPOE and clinical information systems was the right thing to do, and they had top-down commitment. “Administration, the board, the physicians, and the clinicians all have to be on board 100% and be clear on the reason for the change,” says CIO Jesse Long. “Implementing clinical information systems is not a two- to three-year project; it’s a long journey. We’re still on it, and we’ll be working on it for years to come.”

— Alice Shepherd is a southern California-based business-to-business journalist specializing in healthcare topics.