November 12, 2007

Creative CPOE Thinking
By Elizabeth S. Roop
For The Record
Vol. 19 No. 23 P. 12

Community hospitals need to be inventive and foster teamwork when facing the difficult chore of implementing a computerized physician order entry system.

Physician involvement—from planning to implementation and beyond—is crucial to the success of any computerized physician order entry (CPOE) system. It is enough of a challenge for facilities with staff physicians, but it is even more difficult for community hospitals, which are finding that a creative touch is required to engage physicians in the CPOE process.

The reason for sluggish participation and adoption by community physicians is largely economic: More time spent at the hospital means less time seeing patients at their private practice.

“When they go to the hospital, they are taking time away from their major source of income, which is their private practice,” says Erica Drazen, ScD, vice president of emerging practices at First Consulting Group. “To get them onto planning committees and to train them to use something that they aren’t going to use every day is very difficult. This is true for things directly related to the system but also for other issues such as developing standards of practice and developing standard order sets.”

According to “Saving Lives, Reducing Costs: Computerized Physician Order Entry Lessons Learned in Community Hospitals,” a report compiled by First Consulting Group for the Massachusetts Technology Collaborative and the New England Healthcare Institute, physician adoption is one of the highest priority issues facing community hospitals implementing or planning to implement CPOE.

Among the primary challenges are defining expectations regarding community physician adoption of the CPOE system, as well as encouraging them to be actively involved in the planning process and to invest the time needed for adequate training.

“Politically, you need to involve them or they will say that you never asked them. But practically, they rarely show up,” says Drazen. “They are independent economic entities who are not operating on huge margins, so it doesn’t make business sense for them to spend a whole lot of time [on CPOE] despite the fact that they want the hospital to be there and be successful. They just can’t afford to invest a lot of time into making that happen.”

While physician adoption is critical, it is not the only significant challenge facing community hospital systems when it comes to CPOE. Designing workflow processes to ensure a smooth rollout, taking advantage of process improvements made possible by CPOE, and creating the order sets necessary for effective and efficient system use also must be addressed if community hospitals are to realize the technology’s full benefits.

“It is a huge opportunity because now you actually can optimize practice. You never could do that before in a paper system. But to ensure that it gets done and gets done optimally, it takes effort,” says Drazen. “In some ways, the system, by providing tools and data, is actually creating opportunities for more work—more good work, but still more work. And it’s not as if these things are static. The system evolves; the practice evolves.”

For two community hospital systems deploying CPOE as part of larger electronic health record (EHR) projects, the creative approaches they’ve taken to physician engagement is already paying off in both adoption and measurable outcomes.

Texas Health Resources
Community physician adoption is a conundrum with which Ferdinand Velasco, MD, chief medical information officer (CMIO) at Texas Health Resources (THR), is quite familiar.

Velasco, who had previously managed CPOE implementation at a university-based hospital, is currently overseeing the deployment of Epic’s CPOE across THR’s 13 hospitals. The project, which got underway in 2004, is now fully deployed at Presbyterian Hospital of Plano. Implementation is nearly complete at a second THR facility, and rollout has started at a third. Full deployment at all 13 facilities is expected to be finalized by 2010.

“Working with independent private practice doctors in the community hospital setting is more difficult,” Velasco says. “The way we approached that was to partner with them rather than to treat them as a target or focus group that needs to somehow be managed.”

Ultimately, Velasco knows CPOE’s success will largely depend on his ability to encourage the 3,600 community physicians with active staff privileges to use the system once it is in place at each facility. (THR is not mandating CPOE usage, although physicians with medical record deficiencies who have not completed CPOE training six months after go-live will lose staff privileges.)

That is why his first step was to determine the cultural readiness for CPOE among the medical staff at each facility by engaging First Consulting Group to conduct a detailed assessment examining things such as leadership, business drivers, organizational structure and process, care standardization, order management, and clinician IT experience.

“When I first joined THR, there was a little bit of a sense of complacency that we were ready as an organization, and it took that external analysis and assessment to invalidate that self-assuredness,” says Velasco.

Armed with the assessment results identifying Plano as the first facility for implementation, THR deployed an aggressive physician education program. Part of that strategy was also to identify champions among community physicians who understood HIT’s value and the impact CPOE can have on quality and patient safety, including a well-respected clinical thought leader willing to take on the unofficial role of the project’s lead champion.

“I knew he would be a little bit of a skeptic,” Velasco says of THR’s physician champion. “He was not by any means a high-tech physician. He was your average physician who uses some computer technology, but fairly minimal, and who would need to be patient with the changes and disruption that using electronic health records and CPOE would entail. The point was, if he could do it, then anyone could do it because he really was representative of the cross section of the medical staff.”

For training, THR offered two hours of Web-based training and four hours of instructor-led courses. A financial incentive was offered to encourage physicians to complete the training programs; those who did were eligible for $2,000 in continuing medical education (CME) seminar expenses, and four hours of CME was also offered.

Physician liaisons and superusers are in place at each facility to work with individual physicians postimplementation. Plano also offers peer-to-peer training and mentoring, and physician champions hold small group sessions to reinforce what was learned in the formal training sessions.

While physician education and training was underway, the project team began mapping and redefining the workflow changes CPOE would necessitate, identifying protocols, and creating the data sets that would populate the system.

They soon discovered a challenge nearly as significant as physician adoption: What was spelled out in policies and procedures was not always what was taking place. For the CPOE to work, those informal processes had to be taken into consideration.

“CPOE and electronic health records in general are like a big flashlight. They illuminate all the things that people have subconsciously concealed to make things work better for them,” says Velasco. “It is not like they do these things to be malicious; they do them because that is how they get things done. If you don’t design the system around how things are done, it is going to be very disruptive.”

Velasco’s team worked closely with the clinical staff to design the system and clinical decision support tools in a way that would ensure minimal workflow disruptions while still providing the maximum benefits as soon as possible after rollout.

For example, the decision was made to take a minimalistic approach to the use of alerts in the early days so that only the most dangerous—drug allergies—were turned on at go-live, giving physicians time to adjust to the system. A group of physician superusers has also been placed in charge of determining when the time is right for additional alerts and tools to be turned on.

“When you are struggling with changes to the system and you are also getting alerts that are distracting you from your workflow, it adds a lot of frustration,” says Velasco, adding that it was emphasized to physicians that the system was “not going to replace their clinical decision making. You shouldn’t subjugate your own clinical judgment [and] all the years of training and medical school and rely on the system to provide that capability.”

It is too soon for quantitative measures, although Velasco says he has seen positive indications that CPOE is on its way toward achieving THR’s goals of improving quality and reducing errors.

For example, since adding an alert to the admission orders reminding physicians about protocols for the prevention of deep vein thrombosis, the number of orders for preventive treatment has doubled.

“It is way too early to see if that will make an impact on the outcomes, whether we are preventing blood clots, but the number of prescriptions is a good indicator,” he says.

Mercy Health Partners
Mercy Health Partners (MHP), a seven-hospital system in northwest Ohio that is part of the Northern Division of Catholic Healthcare Partners (CHP), is halfway through the implementation of its Siemens CPOE application. The system is fully deployed in four hospitals, and implementation will take place in the remaining three—plus two additional facilities from a nearby region—within the next two years.

In addition to hiring an experienced CPOE project manager, one of the first steps taken was to establish a physician design committee comprised of physicians representing all involved hospitals and a balance among specialties.

“We expected a lot from that group,” says Kenneth Bertka, MD, CHP’s Northern Division CMIO. “We wanted people who were enthusiastic about the project, but we also wanted a few people who were reasonable skeptics—not necessarily negative but who had appropriate concerns and questions. We really held them out to a high level of participation in the design process.”

The design committee serves as consultants to the CPOE project and has been integral to its success. For the first two years, it met weekly and frequently had “homework” between meetings to determine implementation priorities, as well as test the system, resolve specialty- and department-specific issues, and serve as champions for their peers throughout the hospital system.

Knowing the huge demands it was placing on the community physicians that comprised the committee, MHP took a somewhat radical step by paying members for their service.

“That was something that had never been done here,” says Bertka. “There were concerns that if we paid these physicians, we’d need to pay doctors to be on every staff committee we have. But our argument was that this is not your average medical staff committee. … When you look at a project this large, we were spending millions of dollars, so to spend a little extra to bring together this team was money well spent.”

The physician design committee is one of four committees, along with clinical informatics, clinical imaging, and multidisciplinary IT, established to oversee different aspects of the EHR/CPOE implementation project. All report to the EHR oversight committee, composed of medical executive committee members, physician leaders from each facility, and the vice president of nursing.

The structure, says Bertka, was designed to send “a very clear message that this is under the control of physicians.” That physician-led approach was particularly useful when it came time to develop the computerized order sets because, while each individual facility had its own protocols and processes, there was no regional order set to work with.

“Prior to CPOE, there really was not a compelling reason to get the docs to sit down across the various hospitals and say, ‘Let’s come up with one standard.’ But once we went forward with CPOE, there was every reason to do so because we didn’t want to build four different systems,” says Bertka. “We literally had our team going out across all the hospital units and pulling order sets out of drawers.”

MHP found both official and unofficial order sets, which they compiled, evaluated, and winnowed down to 814 for use systemwide. They also went through every departmental process to identify areas where CPOE standardization could have a significant impact.

For example, postimplementation turnaround time for administration of stat furosemide is more than 50% faster than preimplementation. Elsewhere, the turnaround time for the components of a metabolic profile has shown similar improvements. “An hour of time saved with a patient in heart failure could make the difference between going on a ventilator or not, so this improvement has some important patient outcomes associated with it,” says Bertka.

To continue advancing those kinds of outcomes, the physician design committee has expanded its scope to include development and approval of new clinical guidelines for regionwide deployment.

Physician champions also play a significant role in training, particularly after it was determined that the classroom approach originally taken was less effective than one-on-one and small group sessions, some of which take place in physicians’ offices during their lunch breaks to accommodate their tight schedules.

CPOE usage among Mercy Health’s community physicians is voluntary but strongly encouraged by the hospital systems’ leadership, who went so far as to provide reimbursement to community physicians who took the time to learn and use the system in the first six months. “It’s not a lot of money, but at least it is something. It is an acknowledgement that we know this is going to take them longer,” says Bertka.

To address needs for ongoing support, Mercy Health has the equivalent of 19 technicians providing 24/7 support across all institutions with CPOE, as well as for remote connections. It also has four full-time educators and a network of superusers available to help individual physicians when needed.

Engaging community physicians from the start, tailoring education and training to their specific needs, and acknowledging the time commitment required to become proficient with the system has allowed MHP to realize some fairly immediate benefits from its CPOE investment.

More than 1,000 community physicians and more than 350 residents used the system to enter orders in during the last 12 months. Across the implemented hospitals, approximately 175,000 orders per month, or 60% of all orders, are entered by physicians.

“We have the full spectrum of utilization. We have docs who refuse to use the system, and we have others who are absolutely champions and want to do more,” says Bertka. “It is not mandated. Instead, we want to keep showing the benefits, improving the system, and getting it to where it is the easiest thing to do and the right thing to do.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.