A White Paper Computerized Physician Order Entry Weighing the benefits and challenges of implementation Rhonda Joyner HMIA 5060 Final Examination
TABLE OF CONTENTS Explore Purpose of Health Information Technologies Statement of Issue Background/History Benefits Negative impacts Strategies Conclusion References
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 ORDERENTRY (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
The Government Has Stepped In To Ensure That The Healthcare Industry Increase Its Utilization Of Technology. THE HEALTH INFORMATION TECHNOLOGY 2009 AMERICAN RECOVERY AND REINVESTMENT ACT (ARRA) FOR ECONOMIC AND CLINICAL HEALTH (HITECH) ACT Provided $19 billion to encourage healthcare Included a provision worth $560 million to provide states with funding to increase providers to adopt and their Health Information Exchanges use health information (HIEs). technologies (HITs) and $17 billion to provide increased Medicare electronic health payments to hospitals and physician in records (EHR) within exchange for usage of certified EHR their organizations. systems, known as “meaningful use”. 1 Key element is the implementation of Computerized Physician Order Entry (CPOE).WHAT ACTS?
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
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 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 TECHNOLOGYCOLLABORATIVE AND THE NEW ENGLAND HEALTHCARE INSTITUTE Stated that cost of Indicated that CPOE CPOE implementation could reduce the 770,000 could provide annual hospital deaths and savings of $2.7 million injurers that are caused for a hospital. 9 , by adverse drug events Relative to the cost (ADEs). Preventable ADEs incidents of approximately cost each hospital $5.6 million $2.1 million and annually $435,000 for yearly Considered the leading cause of death (excluding death by maintenance 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
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 Human-Machine Interface Flaws Assumed Dose Information Patient Selection Medication Discontinuation Wrong Medication Selection Failures Unclear Log On/Log Off Procedure-Linked Medication Failure to Provide Medications Discontinuation Faults After Surgery Immediate Orders and Give-as- Postsurgery “Suspended” Needed Medication Medications Discontinuation Faults Loss of Data, Time, and Focus Antibiotic Renewal Failure When CPOE Is Nonfunctional Diluent Options and Errors Sending Medications to Wrong Allergy Information Delay Rooms When the Computer Conflicting or Duplicative System Has Shut Down Medications Late-in-Day Orders Lost for 24 Hours Role of Charting Difficulties in Inaccurate and Delayed Medication Administration Inflexible Ordering
Study that compares two CPOE system implementation to determine the pediatric mortality rate after implementation of this system in pediatric intensive care units.CHILDREN’S HOSPITAL OF PITTSBURG CHILDREN’S HOSPITAL AND REGIONAL MEDICAL(CHP) CENTER (CHRMC) IN SEATTLE, WASHINGTON Involved 1942 children Involved 2533 pediatric Conducted over a period of patients 18 months (13 pre- Conducted for a total of 26 implementation and 5 post- months, 13 pre/ 13 post- Implementation). implementation. Indicated an increased No significant increase in morality of 6.6% from 2.8%. the mortality rate after CPOE implementation.DOES COPE INCREASE MORTALITY?
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
JOAN S. ASH FROM THE OREGON HEALTH & SCIENCE UNIVERSITY ATPORTLAND 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, TECHNOLOGYSECOND, 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 INMINNESOTA HOSPITALS” BY JOHN OLSON ET AL. Indicates that prior Identifies the “human factor” technological and as being a critical organizational component of this process. knowledge is a function Gradually integrate of technical capabilities. HIT, allowing physicians the opportunities to develop Recommendation is to capabilities at a slower pace. implement EHR prior to Identifying physician or nurse CPOE implementation.1 “champions” of a system can CPOE was identified as a also gain overall “credibility” challenging system that of a project. should be implemented Providing continuous training as capabilities of hospitals may increase effectiveness increase. 1,15 and reduce errors.1,15
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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