Redesigning Health Care System:
CPOE what it does?
Abdellatif Marini, BSN, MS
Health Care Informatics
University of Colora...
IOM Reports




To Err is Human:
Building a Safer Health
System
Placed quality on the
national agenda
Need well designed and
managed...
IOM report: the problem
A fragmented system characterized by
unnecessary duplication, long waits, and
delays.
 Poor infor...
IOM report: the problem


A system designed for episodic care when
most disease is chronic



Health care providers oper...
IOM report: 10 rules for redesigning
health care
1.

2.
3.
4.
5.
6.
7.

8.

9.
10.

Care based on continuous healing relat...
In Canada,




There are 9,200 to 23,750 preventable deaths each year.
Almost equivalent to 1 jumbo jet crashing each w...
To appreciate the significance of this
transformative change,

one needs to understand how care is
typically delivered in ...
―Every system is perfectly designed to
get the results it consistently achieves‖
—Dr. Donald Berwick
Workflow Design Concepts
Think healthcare delivery
as a ―system‖ with a large
number of components
 Focus efforts on redu...
Workflow Redesign


Focus on total value stream improvements,
not on localized improvements
Lean Six Sigma Process


Current Lean Six Sigma Project
Methodology

Focus on ―People‖ and ―Process‖
 * Lean – eliminate...
Why Workflow Redesign?
Improve quality

Reduce costs & Eliminate waste
Reduce variation
Ease any IT implementation
Key Steps to Optimize Workflow
Redesign
Document


Your Processes

Survey and assess your practice system: Staff? Patien...
Documenting Workflow
START/END: Indicates where the workflow starts and where it terminates, for the
purpose of the map
OP...
Patient

Pa ti ent Check-in Paper Process
Patient
Arrives

Signs in at
Front Desk

Marks Patient
Arrival

Patient Complete...
Examining Areas for
Improvement


After mapping existing workflows, the staff should ask themselves the
following questio...
Patient

Patient Check-in Process – EHR is Fully Integrated/Interfaced with Practice
Management System (PMS)
Patient
Arriv...
Improve Workflow:

Find and
Remove
Bottlenecks

Move Steps in
the Process
Close Together

Use
Synchronization

Use Automat...
Automation
Surprises!
adding automation is like adding another team
member, but one who may not speak the same
language or...
Testing
Test the new workflow using different clinical
and patient encounter scenarios with the
staff. This will increase ...
Problems Ordering Treatments for
Patients
For each patient, the practitioner has to remember:
 All of the appropriate tes...
This haphazard process understandably
results in:
Wasting of a practitioner‘s time by having to
handwrite from scratch eac...
None of this knowledge is delivered to
the clinician when needed at the
patient
bedside!
The five ‗rights‘
1.
2.
3.

4.
5.

The right information
The right person
The right intervention format
Through the right ...
Problem of Health Records
Current health records are:
 Paper based
 Disorganised
 Often illegible
 Lost
 Scattered
 ...
How do you think future Health
Records will be?
Electronic, lifelong, perhaps recording all
food and drink consumption, ex...
Traditional CPOE
Automates Physician Order Writing
 Focuses on Reduction of Medication
Errors as Primary Benefit
 Mostly...
How can we improve
implementation of
EBM through CPOE?
Building a CPOE
implementation
One effective first step in the planning
process is for the team to segment tasks
into thre...
Contemporary CPOE


Electronic transmission of physician orders directly to
targeted pharmacy, lab, radiology, dietary an...
Corollary orders are trigger and response pairs that cause DSSs to suggest
consequent orders in response to an antecedent ...
“Corollary Orders”


Randomized Trial of “Corollary Orders”
demonstrated that physician workstations,
linked to a compreh...
Prescribing errors classification
Prescribing errors occur in 1.5-9.2% of
medication orders written for hospital
inpatient...
Trigger Orders

Response Orders
Trigger Orders
Heparin infusion

IV fluids
Insulin (all kinds)
Oral hypoglycemic agents
Narcotics (class II)
Nonsteroidals...
Working with ―New‖ People
Written orders - talked to nurses and unit
clerks who talked to the ordered service
 CPOE - ―ta...
Investigating Side Effects of Change
―Adopt a proactive approach: examine new
technologies …for threats to safety and rede...
The first rule of any technology
used in a business is that
automation applied to an efficient
operation will magnify the
...
Redesign Health Care Delivery
Redesign Health Care Delivery
Redesign Health Care Delivery
Redesign Health Care Delivery
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Redesign Health Care Delivery

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Introduction to Redesigning of health care delivery.
How CPOE changed the delivery of care ?

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  • What ? Workflow processes must be re-engineered, including clinic policies and procedures, job descriptions, and scheduling and billing workflows.Who?Involve stakeholders from the beginning. Physician involvement is key to successFind and Remove BottlenecksIdentify constraints, exploited if possible, and removed if necessaryMove Steps in the Process Close TogetherPhysical location of people and facilities can affect processing time and cause communication problems.Use SynchronizationBy focusing on the flow of the patient through the process, each of the step can maximize efficiency.Use AutomationProcesses can be improved by the intelligent use of automation (EHR).
  • Health records might beElectronic, lifelong, perhaps recording all food and drink consumption, exercise, etcAccessible from anywhereLinked to other records, like social careMultimediaCollect information from sensors in the body or homeData mined
  • ADE1 e.g. rash when penicillin is administered to a known allergic patient
  • Redesign Health Care Delivery

    1. 1. Redesigning Health Care System: CPOE what it does? Abdellatif Marini, BSN, MS Health Care Informatics University of Colorado, Denver
    2. 2. IOM Reports
    3. 3.   To Err is Human: Building a Safer Health System Placed quality on the national agenda Need well designed and managed “systems of care”
    4. 4. IOM report: the problem A fragmented system characterized by unnecessary duplication, long waits, and delays.  Poor information systems: Healthcare is a ―knowledge based business‖ but information is poorly delivered  Doctors now suffer from the ―information paradox‖--drowning in information but cannot find the information they need  Patient information is often neither evidence based nor easily accessible 
    5. 5. IOM report: the problem  A system designed for episodic care when most disease is chronic  Health care providers operate in silos
    6. 6. IOM report: 10 rules for redesigning health care 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Care based on continuous healing relationships--care whenever its needed, not just through face to face visits Customization based on patient needs and values Patient as the source of control Shared knowledge and free flow of information Evidence based decision making Safety as a system property The need for transparency--all information available, including the system‘s performance on safety, evidence based practice, and patient satisfaction Anticipation of needs Continuous decrease in waste Cooperation among clinicians
    7. 7. In Canada,    There are 9,200 to 23,750 preventable deaths each year. Almost equivalent to 1 jumbo jet crashing each week with 300 lives lost. Medical errors are now the 4th leading cause of death in Canada.  Numerous multi-million $ projects have been launched in an attempt to identify solutions with varying degrees of success and failure.  One transformative initiative has been neglected. That is, providing practitioners with robust, evidence-based order sets with the essential up-to-date knowledge and tools to properly treat patients at the actual point-of-care.
    8. 8. To appreciate the significance of this transformative change, one needs to understand how care is typically delivered in hospitals today?
    9. 9. ―Every system is perfectly designed to get the results it consistently achieves‖ —Dr. Donald Berwick
    10. 10. Workflow Design Concepts Think healthcare delivery as a ―system‖ with a large number of components  Focus efforts on reducing non-value added activities  Reduce backlogs or wait times & consider parallel execution. 
    11. 11. Workflow Redesign  Focus on total value stream improvements, not on localized improvements
    12. 12. Lean Six Sigma Process  Current Lean Six Sigma Project Methodology Focus on ―People‖ and ―Process‖  * Lean – eliminate waste (speed)  * Six Sigma – standardize (variation) 
    13. 13. Why Workflow Redesign? Improve quality Reduce costs & Eliminate waste Reduce variation Ease any IT implementation
    14. 14. Key Steps to Optimize Workflow Redesign Document  Your Processes Survey and assess your practice system: Staff? Patients? External Services? Suppliers? Others? ASK : How do we do it better?  Involve representatives of your practice system: MDs, Nurses, ancillary services, etc. Prioritize (Strategic goals)  Select a process  Workflow design tools (Flowchart the process: Microsoft Visio; modeling software)  Select a Solution: PDCA, Lean, 6 sigma. 
    15. 15. Documenting Workflow START/END: Indicates where the workflow starts and where it terminates, for the purpose of the map OPERATION: A specific task or activity that takes place from an expenditure of labor, a processing activity, or a combination of both. DECISION POINT: A point within the flow of work in which a question must be answered to determine the next path or direction for the work. DELAY: Indicates the work or product goes into a wait line or delay. DIRECTION: Arrows indicate the direction of the flow of information DOCUMENT: Data that can be read by people, such as printed output CONNECTOR: Use this to create a cross-reference and hyperlink from a process on one page to a process on another page ON-PAGE REFERENCE: Use this to create a cross-reference to another point on the same page
    16. 16. Patient Pa ti ent Check-in Paper Process Patient Arrives Signs in at Front Desk Marks Patient Arrival Patient Completes Forms Yes New Patient? Give Pt. Forms to fill out, collect & copy insurance card No Collect and file forms in newly created chart Front Desk Receptionist Pull Paper Chart (from staging area) Does Pt Info need to be updated? Yes Yes Record updates in paper chart, collect & copy insurance card if needed No Collect Payment & generate record of payment for billing department Yes Does copay need to be collected? No Generate Flowsheet Put chart & flowsheet in bin indicating patient is ready for rooming
    17. 17. Examining Areas for Improvement  After mapping existing workflows, the staff should ask themselves the following questions:         What are the best steps in the process? What makes those the best steps? What are we doing right? (Best can be defined by practice goals and vision, such as efficiency, client satisfying, etc.) What steps could use improvement? What are the least effective? What makes those steps the least effective? How could we improve those steps? Use the answers to these questions to aid in planning a future workflow with the new process. Health Information Technology Research Center (HITRC)
    18. 18. Patient Patient Check-in Process – EHR is Fully Integrated/Interfaced with Practice Management System (PMS) Patient Arrives Signs in at Front Desk Marks Patient Arrival on EHR Patient Completes Forms Yes New Patient? Give Pt. Forms to fill out, collect & scan insurance card No Collect and enter information in EHR Front Desk Receptionist Select Patient from EHR Does Pt Info need to be updated? No Collect Payment & record into EHR Yes Yes Yes Record EHR, scan card updates in collect & insurance if needed MU Objective: Record Pt Demographics as Structured Data Does copay need to be collected? No Mark ―pt is ready‖ for rooming into EHR
    19. 19. Improve Workflow: Find and Remove Bottlenecks Move Steps in the Process Close Together Use Synchronization Use Automation
    20. 20. Automation Surprises! adding automation is like adding another team member, but one who may not speak the same language or share the same cultural assumptions. When automation is implemented that does not speak the same language as the user or share the same mental models, it results in what is called ―automation surprises.‖ Clinical Practice Improvement and Redesign: How Change in Workflow Can Be Supported by Clinical Decision Support, AHRQ Publication No. 09-0054-EF, June 2009
    21. 21. Testing Test the new workflow using different clinical and patient encounter scenarios with the staff. This will increase the likelihood that you‘ve accounted for all possible required steps.  Once implemented, conduct time-motion studies to determine if the new workflow is optimal or if there could be improvements made to the number of included steps.  Use of CPOE system may not necessarily save time, however, improve outcomes and safety. 
    22. 22. Problems Ordering Treatments for Patients For each patient, the practitioner has to remember:  All of the appropriate tests, medications and treatment options  The right sequence of steps  The right drug among many similarly named options  To write legibly (if on paper)  This process of practitioners writing by hand all the treatments required from memory poses a real challenge to the practitioner as:  Each patient typically has many conditions that need to be addressed  There are thousands of medical conditions the doctor must remember  Patients can often need 60 or more orders to receive all the care required  Modern medical knowledge is constantly evolving
    23. 23. This haphazard process understandably results in: Wasting of a practitioner‘s time by having to handwrite from scratch each order (if using paper)  Medical errors  Reduced patient safety and quality of care  Ordering of unnecessary treatments  Forgetting to order necessary treatments  Longer hospital stays  Higher rate of patients returning to hospital  Lawsuits 
    24. 24. None of this knowledge is delivered to the clinician when needed at the patient bedside!
    25. 25. The five ‗rights‘ 1. 2. 3. 4. 5. The right information The right person The right intervention format Through the right channel At the right time in the workflow
    26. 26. Problem of Health Records Current health records are:  Paper based  Disorganised  Often illegible  Lost  Scattered  Poorly linked
    27. 27. How do you think future Health Records will be? Electronic, lifelong, perhaps recording all food and drink consumption, exercise, etc Accessible from anywhere Linked to other records, like social care Able to show Multimedia Results Collect information from sensors in the body or home
    28. 28. Traditional CPOE Automates Physician Order Writing  Focuses on Reduction of Medication Errors as Primary Benefit  Mostly Manual Handoffs Downstream from Electronic Order  In-house Development Resulting in a Proprietary System 
    29. 29. How can we improve implementation of EBM through CPOE?
    30. 30. Building a CPOE implementation One effective first step in the planning process is for the team to segment tasks into three categories:  What new work tasks/process are we going to start doing?  What work tasks/process are we going to stop doing?  What work tasks/process are we going to sustain?
    31. 31. Contemporary CPOE  Electronic transmission of physician orders directly to targeted pharmacy, lab, radiology, dietary and nursing subsystems.  Re-engineering of complete service delivery workflow Decision Support tools including:  Allergy Checking  Drug Interaction  Order Duplicate Checking  Corollary Order Checking  Weight-Based Dosing  Drug Route Restriction  Evidence-Based Order Sets
    32. 32. Corollary orders are trigger and response pairs that cause DSSs to suggest consequent orders in response to an antecedent order. (An example is Warfarin, prothrombin time each morning, or, ―Since you ordered warfarin, you might also be interested in ordering prothrombin time each morning.‖) A Recommendation Algorithm for Automating Corollary Order Generation- AMIA 2009 Symposium Proceedings Page - 333
    33. 33. “Corollary Orders”  Randomized Trial of “Corollary Orders” demonstrated that physician workstations, linked to a comprehensive CPOE, can be an efficient means for decreasing errors of omissions and improving adherence to practice guidelines.
    34. 34. Prescribing errors classification Prescribing errors occur in 1.5-9.2% of medication orders written for hospital inpatient. Adverse drug events (Level 1)  Potential ADE‘s (Level 2)  Deviations from best practice (Level 3)  – Failure to deliver optimal dosing schedule – Failure to monitor drug levels or electrolytes according to established protocols – Failure to adhere to local formulary Vincent C, Barber N, Franklin BD, Burnett S.The contribution of pharmacy to making Britain a safer place to take medicines. Royal Pharmaceutical Society of Great Britain: London; 2009.
    35. 35. Trigger Orders Response Orders
    36. 36. Trigger Orders Heparin infusion IV fluids Insulin (all kinds) Oral hypoglycemic agents Narcotics (class II) Nonsteroidals Aminoglycosides Vancomycin intravenously Warfarin Amphotericin B Angiotensin converting enzyme inhibitions Chloramphenicol Air contrast barium enema, IVP, UGI Isoniazid Potassium supplements Pulmonary artery catheter Ventilator orders Vasopressin drip Response Orders (1) Platelet count once before heparin started, then once in 24 hours (2) APTT at start, again after 6 hours of a dosage change (3) Protime once before heparin started (4) Hemoglobin at start of therapy, then QAM (5) Test stools for occult blood while on heparin (1) Place a saline lock when IV fluids are discontinued (1) Capillary glucoses (four times a day) (2) Glycosylated HGB (once if not done in preceding 180 days) (1) Capillary glucose (twice per day) (2) Glycosylated HGB (once if not done in preceding 180 days) (1) Docusate (stool softener) if not on any other form of stool softener or laxative (1) Creatinine (if not done in previous 10 days: SMA12, BUN counted as equivalent) (1) Peak and troughs levels after dosage changes, and q week if no change (2) Creatinine twice per week (q Monday and Thursday) (1) Measures of serum levels pre and post 4th dose (2) Audiometry (3) Baseline creatinine for dose adjustment (1) Prothrombin time each morning (1) Creatinine twice per week (q Monday and Thursday) (2) Magnesium level (twice per week while on therapy) (3) Electrolytes (twice per week while on therapy) (4) Acetaminophen (650 mg po 30 min before each amphotericin dose) (5) Benadryl (50 mg 30 min before each amphotericin dose) (1) Creatinine at baseline then 2 weeks after dosage changes (2) Potassium (q Monday and Thursday) (1) CBC (twice per week) (2) Retic count (twice per week) (1) Pregnancy test (if patient is female, in childbearing years, had no hysterectomy, and no pregnancy tests within 3 days) (1) SGOT, SGPT (as baseline when drug started) (1) Electrolytes once each morning (1) Portable AP chest x-ray (when first placed to check for placement) (1) Arterial blood gas after changes (1) Nitroglycerin drip or nitroglycerin paste (if patient having chest pain or known CAD) J Am Med Inform Assoc. 1997 Sep-Oct; 4(5): 364–375.
    37. 37. Working with ―New‖ People Written orders - talked to nurses and unit clerks who talked to the ordered service  CPOE - ―talk‖ to a computer which relays questions back from Pharmacy  Lab  Every other ordered service 
    38. 38. Investigating Side Effects of Change ―Adopt a proactive approach: examine new technologies …for threats to safety and redesign them before accidents occur.‖ IOM report “To err is human” p. 150
    39. 39. The first rule of any technology used in a business is that automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency. ~Bill Gates

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