CPOE: Why You Want It, Why You Need It Jeff Helfand, DO, MS May 21, 2010
EHR: Some HistoryIn 2004, President George W. Bush mandated in his State of the UnionAddress that there should be “…an Electronic Health Record for everyAmerican by the year 2014.”The Office of the National Coordinator Health Information Technology(ONCHIT) was established on April 27, 2004 by Executive Order #13335issued by President George W. BushOn January 12, 2009, in a speech at George Mason UniversityPresident Barack Obama announces that the US will need to “…computerize all health records within five years.”The American Reinvestment and Recovery Act (ARRA) was signed intolaw on February 17, 2009, and includes $19 Billion as incentives toadopt use of HIT, especially EHRs (HITECH).
HITECH Incentive Payment Programs There is a four year CMS Health IT Medicare Incentive Payment program for hospitals beginning in 2011 that will gradually be phased out by 2016, at which time penalties will be assessed for non-compliance.* For physicians, there is a five year CMS Health IT Medicare Incentive Payment program for those who adopt the program in 2011, however penalties will be begin in 2015 for those physicians who have not adopted the program by 2014.** ANIA-CARING 2010
Potential Incentive Payments A total of $9.2 million in incentives estimated for a 200 bed community hospital with an estimated $3.5 million for approximately 90 employed “eligible” professionals, and another $5.7 million for the hospital itself.* “Eligible” providers and hospitals must meet two requirements for reimbursement under ARRA 1) must acquire a certified EHR product or service 2) must demonstrate “meaningful” use * “Meaningful” use implies a host of new care processes for many providers such as “monitoring medication adherence, use of evidence- based order sets, clinical decision support tools at the point of care, patient outreach and reminders” with clinical data capture and sharing, enhanced clinical processes and “ultimately linked to achieving measurable outcomes “ in patient engagement, care coordination, and population health.” Meaningful use of EHR includes processes such as CPOE, ePrescribing and Barcode medication administration. ** ANIA- CARING 2010** “Meaningful Use: A Definition” Recommendations from the Meaningful Use Workgroup to the Health IT Policy Committee June 16, 2009
CPOE: BasicsComputerized Physician (Practitioner) Order Entry Electronic prescribing systems designed to improve patient outcomes by detecting and blocking medication errors at the time they most commonly occur, when the medications are ordered. Rather than being written on a paper order sheet that then needs to be transferred into a computer, medications are ordered directly into the computer by the practitioner, reducing the risk of medication errors. Computerized orders are more easily confirmed, compiled and integrated with other patient data and information such as medication allergies, interactions and lab results.
CPOE: BenefitsWarns practitioner about possible drug allergies, interactions orpossible dosing errorsMay provide automatic updates regarding newly released andapproved medicationsHelps eliminate confusion errors resulting from “sound-alike” drugsImproves communication between practitioner and pharmacy staffResults in cost reduction secondary to improved efficiency
Impact of the computerized provider order entry (CPOE) system on medication errors, by severity OR Total Total Difference N (%); (99.5% prescriptions prescriptions 95% CI for difference CI) Error severity pre-CPOE post-CPOE (unadjusted) (adjusted) N=5016 N=5153 ‡ Error severity, by categories 6 (<0.1%) (<0.1% to 0.13 (0.02 A (potential error; no ADE) 7 (0.1%) 1 (<0.1%) 0.2%)* to 1.07) 0.43 (0.38 B–D (error, no harm; 479 (9.8%) (8.5% to 896 (17.8%) 417 (8.1%) to potential ADE) 11.1%)*** 0.49)*** E and F (error, reached 3 (<0.1%) (<−0.1% to 0.58 (0.19 patient-contributed to 8 (0.2%) 5 (0.1%) 0.2%) to 1.77) harm; preventable ADE)•↵* p<0.05•↵*** p<0.001.•↵‡ Generalized linear, latent and mixed effects model with adaptive quadrature; multinomial logit model; clustering at prescriber level; no weightsapplied; no additional variables.•ADE, adverse drug event.
CPOE: EffectivenessMedication error rates decreased initially by 55%, and subsequently by 88%at Brigham and Women’s Hospital in Boston, and were attributed toimplementation of CPOE. *After implementation of decision support for antibiotics, similar decreases inerror rates (70%) were also demonstrated in antibiotic related ADRs at theLatter Day Saints Hospital in Salt Lake City.Main Line Health, a five facility health care system with more than 1200beds, almost 2000 physicians and 70,000 annual admissions nearPhiladelphia noted dramatic reductions in possible patient ID errors andmedication errors within the first two years after implementation in 2004.Further reductions in 2006 and 2007 indicate that staff continue to utilize thedata in a meaningful way.* Koppel et al. JAMA 2005; 293: 1197-1203
“We are now able to track wrong-drug, wrong-patient types of occurrences. MAKbrings transparency to the whole medication management system that was never there before.”Rich CentafontSystem Vice President for Pharmacy and Radiology ServicesMain Line Health
CPOE: Why You Want ItHospitals must be able to demonstrate CPOE use for at 10% of orders tocomply with Stage 1 “meaningful use” criteria for 2011One single medication ADR adds more than $2000 to the average cost of ahospitalization (1)The total direct cost to hospitals nationwide of medication errors exceeds$7.5 billion annually (2), not to mention the associated indirect costs inincreases in malpractice insurance premiums, lost productivity and notnecessarily least, hospital reputation and public image1) J Am Med Inform Assoc. 2004 Jul-Aug: 11(4):270-2772) Pediatrics. 2003 Sep; 112(3Pt 1): 506-509
“At many levels, CPOE is enhancing patient care at Holy Redeemer. We are finding that communication among the care team is better coordinated and doctors’ orders are acted upon more quickly. CPOE is an important component of Holy Redemeer’s strategy to reduce errors, enhance patient safety, and improve the quality of care.”Jonathan Sternlieb, MD, FACGChief Medical Information OfficerHoly Redeemer Health SystemAn INVISION Customer for 16 yearscurrently migrating to Soarian Clinicals
Soarian Clinicals®: Your CPOE SolutionHealthcare Process Management (HPM), the healthcare adaptation of businessprocess management is the principle behind the design of Soarian Clinicals® andplays a vital role in its CPOE capabilities, helping users reinvent operations, improveworkflow, refine patient safety and outcomes and revitalize staff satisfaction andmoraleFeatures of Soarian Clinicals® CPOE: Provides clinical staff with suggested actions to help streamline the medication ordering process Allows clinicians to enter orders while letting the pharmacy staff deal with the details of dispensing Gives access to order entry at different stages of the healthcare delivery cycle Uses embedded analytics for easy production of reports on all clinical and operational order processing data Provides advanced medication order functions such as weight based dosing and IV dripsThe end result is a more coordinated approach across many clinical disciplinesresulting in better communication and improved patient outcomes
Soarian Clinicals®: Your CPOE SolutionSoarian Clinicals® Helps redirect and simplify your workflow by reducing manual processes, so you van focus on what’s really important – patient care and revenue production Helps promote standardization to better measure and predict improvement in clinical outcomes Provides your practitioners with the information they need to make better informed clinical decisions in today’s fast-paced healthcare environment Allows your C-level management to more accurately measure performance and implement necessary changes quickly
My Two Cents CPOE made my life easierReduced my paperwork burdenAllowed me to spend more time dealing with clinical issues, ratherthan worrying if the pharmacy got it rightGave me an easy way to track medication changes prevent potential drug interactions and ADRs help my documentation “paper trail” feel more confident about the safety of my patients and ultimately in the quality of care I delivered