cpoe implementation in the community setting what do you need to know? avoid a towering inferno by...
TRANSCRIPT
CPOE Implementation in the Community Setting
What do you need to know?What do you need to know?
• Avoid a Towering Inferno by creating a burning platform
• Avoid medical staff revolution with the evolution of a patient safety culture
Scope of the Challenge
US estimates from Kaushal R, et al. Health Affairs 2005;24:1281-1289.
0%
10%
20%
30%
40%
50%
60%
70%
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90%
100%
<300 beds >300 beds
US-2005
US-2010
Current and Projected CPOE Current and Projected CPOE Implementation at U.S.A. HospitalsImplementation at U.S.A. Hospitals
CPOE is a key component of any medication safety initiative
eMARRN acknowledges
Approved order
Pharmacy Pharmacist Approves
Order
Smart IV Pump
CPOEProvider writes
order
Pump sends documentation To eMAR; RN verifies
Decision Support
ADE Surveillance
Electronic Identification
Med Repackaging
Delivery toSite
omnicell, robotics, etc.
Completing The Loop:Web ReportingTeam TrainingMedication ReconciliationImproving Transitions
IV med
PO medPO Medication Delivery
CPOE Implementation in the Community Setting
Factors Critical for SuccessFactors Critical for Success• Communicate Vision, Rationale and Goals
• Provide Data to Support Vision, Reinforce Benefits and Measure Performance
• Demonstrate Leadership Commitment
• Mentor Physician Champions
• Develop Incentives and Sanctions
• Respond to Physician Concerns
• Marketing and Communication
Communicate, Communicate, Communicate
Vision, Rationale and Goals
• CPOE has been proven to enhance patient care.
• CPOE reduces medication errors and provides alerts for potential drug interactions and when dosage adjustments are required.
• Define firm targets: “75% of medication orders entered electronically by June 2007”
Data to Support Vision and Rationale
Bates et al.: “Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors,” JAMA 1998.
Serious Medication Error Rates Serious Medication Error Rates Before and After CPOEBefore and After CPOE
Se
rio
us
Me
dic
ati
on
Err
ors
(Eve
nts
/1,0
00 P
ati
en
t D
ays)
12
10
8
4
2
6
0
Phase I (Before CPOE)
Phase II(After CPOE)
Delta = -55%P < .01
Quality and safety benefits from decision support tools CPOE continuously delivers evidence-based
treatment. Care is more reliable, more efficient, and safer All involved physicians know patient’s medications Fewer call backs from pharmacy Fewer call backs from nursing Faster delivery of inpatient medications Physician orders are legible
CPOE provides real advantages in providing quality patient care
Data to Reinforce CPOE BenefitsMedication Errors Before and After CPOE Implementation
NSMC Adult Psychiatry
CPOE live on 9-9-05
1.0
0.5
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1.5
2.0
2.5
3.0
3.5
4.0
5.0
4.5
Actual
Potential
BEFORE AFTER
4.6
0.3
2.3
0.4
Err
ors
Per
Mon
th
Jan.
’05
– M
arch
‘06
NSMC Geriatric Psychiatry
CPOE live on 11-8-05
1.7
0.1
0.1BEFORE AFTER
Why we need to adopt CPOE now?
• It is widely accepted as the new standard of care.
• It distinguishes our quality of care from hospitals that are late adopters.
• It is increasingly a significant point of leverage in negotiations to maximize reimbursement from private insurers.
Demonstrate Leadership Commitment
• Hospital Executives and Physician Leaders play formal roles.
• NSMC Chiefs Forum reviews CPOE progress every 2-4 weeks.
• CEO and President participates in discussion once per month; ad hoc meetings as needed.
• Appointment of IS medical director; CMIO • Create the necessary infrastructure to effect
change.
Medical Staff Leadership Reporting and Accountability Structure
CEO CMO
Emergency MedicineMona Sigal, Interim – SalemJames Wasco, M.D. - Union
MedicineJoseph Jacobson, M.D.
Family PracticeAlain Chaoui, M.D.
Radiation OncologyJames McIntyre, M.D.
RadiologyM. Christian Semine, M.D.
Obstetrics and GynecologyAllyson Preston, M.D. Pediatrics
Edward Bailey, M.D.
AnesthesiaGlynne Stanley, M.D. (Formal Appt.Pending)
PsychiatryMark Schechter, M.D.
SurgeryMarc Rubin, M.D.
PathologyAnthony Guidi, M.D.
Medical Staff President Riad Riskalla, MD
Board of Trustees
Leadership and Governance
• Chiefs Forum (CF) assumed responsibility as the CPOE Physician Advisory Group.
• CF develops policy recommendations, identifies areas of resistance, reviews physician utilization and provides communication.
• Medical Executive Committee functions as the governing body of the medical staff.
• Education and engagement of Board of Trustees on a regular basis
Expect mixed reaction and pushback during initial rollout
• Big Bang vs Sequential Implementation - Initial focus on medication orders at NSMC
• MD compliance variable
• MDs will complain about the length of time it takes to enter orders compared to writing on paper.
• Large practices without hospitalists place a significant burden on rounding MDs
Moving the Ball Forward
Focus on steady progressFocus on steady progress• 24/7 “at the elbow” technical support• Usability enhancements will help with overall
acceptance -Process to prioritize order set development
-System speed and responsiveness
• Identify and mentor high volume, high compliance CPOE users as physician champions.
Monitoring and Reporting
• Data for orders entered via CPOE are very accurate
• Accurately identifying the ordering MD on paper orders is required for accurate CPOE compliance reports
- Encourage second identifier on written orders i.e. print name, beeper #, etc
- Orders with illegible signatures are attributed to the attending MD
• Weekly reporting to Department Chairs - Numerator: Medication Orders Entered Into CPOM by prescriber
- Denominator: Total Medication Orders by prescriber
Weekly Utilization MetricsPrescriber Level CPOE DataMedicine8/7/2006 through 8/11/2006
Prescriber* Total Med Orders
Attributed
Actual CPOE
Entered
% Entered
into CPOE
% of Total Med
Orders
Cumulative %
1 236 138 58% 20% 20%2 178 3 2% 15% 35%3 108 26 24% 9% 44%4 79 43 54% 7% 50%5 62 5% 56%6 61 56 92% 5% 61%7 51 9 18% 4% 65%8 51 17 33% 4% 69%9 41 5 12% 3% 73%10 41 3% 76%11 38 23 61% 3% 79%12 28 2 7% 2% 82%
*Full names provided on actual report.
Pharmacy Study of Handwritten OrdersPharmacy Study of Handwritten Orders May 22, 2006 – June 2, 2006
Accurately identifying the Ordering MD on paper can be a challenge due to illegible signatures
# of Physicians
# of Orders
Name was Printed 4 48
Signature was Legible 16 188
Signature was Illegible 58 178
Achieving a “Tipping Point” through Physician Level Reporting
• Chairs need to focus on high volume/low compliance MDs.
• For those who continue to write on paper, a tougher compliance policy is needed.
Incentives and Sanctions
• CPOE P4P incentives ideally aligned with physicians and hospitals.
• Consider recognition, contests and give-aways.• Mandatory Training -All physicians must attend a CPOE education
class prior to receiving system login. -New medical staff receive training as part of the
orientation process.
Sanctions required for those who continue to write on paper
NSMC CPOE Compliance Policy & Process NSMC CPOE Compliance Policy & Process
• Individual CPOE compliance set at 85%.• Department Chairs own primary management
responsibility • MDs have multiple opportunities to remediate their
compliance. • Compliance policy patterned after Medical Records
completion policy.–Written notification of deficiency, with cc: to chief/chair.–Appearance before Medical Executive Committee.–Suspension of privileges.
MD CPOE utilization < 85%
for 2 weeks
Reminder notice sent by Chair. MSO calls MD to
verify receipt.
Utilization remains < 85%
for an additional 2 weeks
Department Chair calls MD and informs of intent to
appear before MEC.
Utilization remains < 85% for
an additional 2 weeks
President of the Medical Staff calls MD and requests appearance before MEC.
MD placed on MEC agenda.
Appearance before MEC
Potential MEC Outcomes Include:
Suspension of medical staff privileges
Opportunities for remediation
CPOE Utilization Compliance Policy
Letter describing CPOE compliance policy sent to entire medical staff
Respond to Physicians’ Concerns
Declining Reimbursements
High Cost Of Living
Increasing Practice Expenses
CPOE / EMR
Pay for Performance Quality Measures
Family Balance
Malpractice Premiums
Transparency/Public Reporting
Demands on Massachusetts Physicians Continue to IncreaseDemands on Massachusetts Physicians Continue to Increase
Nursing Unit Implications
• Routine Verbal Orders are not allowed per JCAHO standards
• Telephone Orders will only be accepted for urgent orders or when CPOE is not accessible.
• CPOE support staff and RN super users will offer to show MDs how to enter orders. If rebuked, Nurse Manager or Supervisor explains hospital policy regarding reporting of the incident to the Department Chair.
Marketing and Communication
• Develop a logo • Heighten awareness; reaffirm commitment to
CPOE• Weekly on-line and paper newsletter –
publish go-live dates, FAQs, tips• Hold regular informational meetings.• Post signage on each unit reminding MD that
“this is a CPOE unit”
Marketing and Communication
Measuring CPOE Performance
Non-CPOE
Salem Campus
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Non-CPOM Entered by MD into CPOM % CPOM
Non-CPOE Entered by MD into CPOE % CPOE
Measuring CPOE Performance
Union Campus
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Non-CPOM Entered by MD into CPOM % CPOMNon-CPOE Entered by MD into CPOE % CPOE
CPOE Implementation in the Community Setting
The Final MoveThe Final Move• Remove all paper order sets from the floors.
• “As of _________, written orders will not be
accepted and all routine orders must be entered via CPOE.”
CPOE Implementation in the Community Setting
Final Thoughts and Key Take-AwaysFinal Thoughts and Key Take-Aways
• Patient Care is safer • Adopting CPOE requires commitment by busy
physicians• Appeal to sense of professionalism • Time is required, but time is saved.• Physicians respond to data• Recognize physician champions• Explore physician incentives and sanctions• Increase financial incentives that reward use
CPOE Implementation in the Community Setting
Final Thoughts and Key Take AwaysFinal Thoughts and Key Take Aways• Respond to physician concerns
-Continue efforts to improve the ease of use, speed of the applications and surrounding workflow
• Create a patient safety culture that embraces evidence based, standardized, coordinated care
• Once you reach a “tipping point,” growing
intolerance of non-users• Plan to learn along the way