July 23, 2007

CPOE — Beyond the Pharmacy
By Annie Macios
For The Record
Vol. 19 No. 15 P. 30

An estimated one quarter of all CPOE orders are relevant to radiology, which presents great potential to improve imaging aspects of patient care—from improved patient safety to quicker turnaround time.

Implementing computerized physician order entry (CPOE) enables healthcare professionals to share critical information that can improve patient safety, streamline workflow efficiency, and improve overall patient care. It also promises a significant return on investment for saving time and money.

In essence, CPOE enables information about a physician’s course of care for a patient to be shared across the continuum of care. For example, a physician may prescribe a medication for a patient and enter it into the CPOE interface. If a previous medical history for that patient—or even simple information such as age or gender—shows a contraindication for the prescription, it can alert the doctor to make alternate choices for the patient. In addition, practitioners from various specialties who may encounter that patient will have a more solid understanding of the patient’s case and can make better decisions on his or her behalf.

The technology most profoundly affects the day-to-day relationship between medical staff and the pharmacy. However, other departments feel its power, too. In radiology, for example, CPOE can be beneficial in many ways, including decreasing variance and turnaround time (TAT), improving patient safety, and increasing workflow efficiency.

“Healthcare is full of variance. CPOE is a great tool to reduce this variance,” says Donald W. Rucker, MD, MS, MBA, of the University of Pennsylvania Presbyterian Medical Center and vice president and chief medical officer at Siemens Medical Solutions.

Advantages of CPOE
According to Rucker, an estimated one quarter of all CPOE orders are relevant to radiology. Therefore, he sees great potential for CPOE to improve all aspects of patient care. “One reason people are excited about this technology is for patient safety,” says Rucker.

In a traditional paper system, physicians write the order and then a clerk transcribes the order and sends in the radiology requisition. Once it gets to radiology, a technologist or clerk enters the order into the radiology information system (RIS), presenting a second chance for variance and interpretation.

For example, a physician may order a chest x-ray with the simple written instructions of “CXR.” This still leaves a lot of unknown information that technologists and radiologists must yet uncover: what (if any) contrast agent is to be used, whether the patient uses a ventilator, or even if the patient is ambulatory. For radiologists, critical information could be lacking that would help them know more clearly what the referring doctor hopes to learn from the exam.

With CPOE, however, a physician sends the specific order electronically from a desktop computer or mobile device, and it immediately appears on the RIS worklist. “With CPOE, there is less chance for variance and less interpretation,” Rucker says.

Part of what makes CPOE a win for radiology is that radiologists have a better quality indication of the reason for the ordered study, as well as information on any other patient issues that may impact the case. “It offers a lot of potential for decision support,” Rucker says.

Mark Halstead, MD, chief of research, radiology informatics, at Cincinnati Children’s Hospital Medical Center (CCHMC), where CPOE went live in 2002, has seen tremendous success with CPOE at his facility. “From a radiology perspective, we deliver better care,” he says.

Radstream, CPOE software developed in conjunction with the University of Cincinnati College of Business for CCHMC, eliminates paper from the workflow and helps give radiologists a clearer picture of the patient’s case. “Radstream provides a tool that if a critical or unexpected finding is uncovered by radiology, a mouse click relays it to an operator’s workscreen who contacts the clinician, and the finding is documented permanently,” he says.

In addition, if there is a complex finding and radiology needs to talk directly to the clinician, a simple click of a button will contact the operator, who will automatically pull the patient’s chart and contact the clinician for immediate consultation. “It affects patient care, the delivery of care, and clinicians can make decisions very quickly,” Halstead adds.

Time Is Money
“People talk about patient safety, but another real win with CPOE is reduction of cycle time and the efficiency created by physicians placing orders directly,” says Rucker. “You just make a place work faster.” Among hospitals that use a CPOE interface in radiology, TAT has been found to decrease by 90 minutes on average.

At CCHMC, there has been a measurable decrease in TAT for radiology orders. “Since CPOE went live, it has changed the workflow,” Halstead says. “When doing rounds now, the team travels with a wireless laptop and involves the patient’s family in discussions as to the patient’s situation, enabling more complete care. The computerized order entry is so efficient that when the ward rounds team leaves a room, you may see an ultrasound tech enter immediately after to complete the order. What used to be a 24-hour turnaround changes to just a few hours.

“Studies are read more rapidly, and it buys patients and teams a day in implementing the decisions made by a physician,” Halstead adds. He says that the decrease in TAT was measured by comparing 26,000 data points before and after implementing Radstream; results indicated a 40% reduction in TAT.

Improved Workflow
Another advantage is that CPOE systems can become workflow engines. Initially, implementing CPOE can be difficult because it requires a significant change in workflow processes and involves learning new ways of processing, storing, and retrieving information. But once these processes were in place, the results showed their value at CCHMC.

The Radstream system filters, prioritizes, and distributes cases from throughout the facility, putting the sickest patients first in the work queue. “The sickest patients are the ones most likely to interrupt the workflow in the radiology department, so if you can read those cases first and call the clinician with results, it closes the loop,” says Halstead. “We’ve found that this reduces interruptions by 23%.”

Voice recognition is also a critical component in the efficiency of the hospital’s CPOE program. For example, a radiologist can open the next case queued to the system and dictate a report using voice recognition. The report is immediately placed, the clinician is contacted, and the staff is provided with the results, all of which are permanently documented.

“I think the trend in the next five to 10 years will be toward using CPOE in focusing on the increasing workflow,” Halstead says. He adds that with the shortage of radiologists, the growing number of images and cases, and the number of images per case, it will be critical to improve workflow. CCHMC has saved the equivalent of hiring two additional radiologists by streamlining its workflow with Radstream.

Order Sets and Quality Enhancement
Rucker also mentions pay for performance as a driving factor in CPOE. One half of all orders are placed in order sets. “By using an order set that makes sense, it can drive a lot of behaviors regarding that patient’s care,” he says. Order sets are comparable to a point-of-sale transaction. Using CPOE, a physician can log onto the system using the patient case number or identification and indicate the order by choosing a predetermined set of menus. With order sets, imaging orders are combined with other types of orders necessary for the comprehensive care of a particular patient—like one-stop shopping—including elements such as pharmacy, nursing, or lab orders.

“Order sets help influence doctors’ performance,” says Rucker. They remove labor steps with automation, which has already proved successful in billing the lab, and they provide quality and cost-effectiveness by ensuring all the steps necessary to treat the patient are taken.

Ramin Khorasani, MD, MPH, vice chair of the department of radiology and director of medical imaging IT at Brigham and Women’s Hospital in Boston, is also a strong proponent of CPOE. “For radiology, CPOE makes sense. We started using CPOE with the primary goal of improving quality by focusing on evidence-based medicine,” he says. In the beginning phases, the value was in having an application capable of delivering knowledge at the time of decision making.

“We realized, however, that CPOE also increased the opportunities for quality and safety in the process of performing radiological tasks,” Khorasani adds. Among the added benefits Khorasani and his colleagues found at Brigham and Women’s Hospital were improvements in contrast agent safety; enabling better screening of the patient population for diseases that would hamper imaging, such as a patient with diabetes; and improved efficiency in the practice, including the use of online scheduling for MRI orders.

Barriers to CPOE
According to the 2007 American Hospital Association report “Continued Progress: Hospital Use of Information Technology,” the use of CPOE is gaining traction. Specifically, physicians in 16% of hospitals routinely ordered laboratory and other tests at least one half of the time in 2006 with CPOE, which is more than triple the number in 2005. Universal implementation of CPOE, however, is hindered by several barriers, including a basic vocabulary gap in the software, as well as the complexity of integrating such a system.

“CPOE has a fundamental vocabulary gap,” says Rucker. “Commissions, PACS, billing—they all use different terminology.” The difficulty of successful implementation is how to expose the names of orders to enable some degree of standardization among searches when entering and ordering.

“Roughly, enterprises may have 3,000 imaging studies that can be ordered,” Rucker says. “Study names are related to what the billing service master uses, which must also match CPT codes.” But fortunately, the more cases that are entered into the database, the more efficient the system becomes, as there is more information to draw from.

The CPOE vocabulary needs to present comprehensive choices to the doctors who will be using the order entry—a critical fact that IT must keep in mind upon implementation. “They have to ask, ‘How do I create a usable interface where we can share terms and build a usable network?’” Rucker says.

Initial technology integration can also be a major issue. “To integrate CPOE within a hospital, IT must reengineer the entire enterprise. It’s more than just adding software; it’s changing behaviors and requires a deep insight into how things are ordered and a strong understanding of the sequences,” says Rucker.

“It’s clear in my mind that CPOE as part of the hospital information system, without detailed integration of the radiology workflow, becomes less productive,” Khorasani says. He adds it is important to have integration of the system rather than simply relying on interfaces.

But despite difficulties, Rucker and Khorasani agree that the benefits of CPOE far outweigh the growing pains of implementation. “Like most technology implementations, if you have an organizational focus on quality, each technology insertion provides massive opportunity to reduce waste and improve care,” says Khorasani.

“With CPOE, you take out the intermediaries,” Rucker adds. “It actively ensures each work step succeeds on time, it reduces handoffs and tracks each step, and it manages delays and failures.”

— Annie Macios is a freelance medical writer based in Doylestown, Pa.