Redesigning Health Care System:CPOE what it does?

Abdellatif Marini, BSN, MSHealth Care Informatics

University of Colorado, Denver

IOM Reports

To Err is Human: Building a Safer Health System

Placed quality on the national agenda

Need well designed and managed “systems of care”

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

IOM report: the problem

A system designed for episodic care when most disease is chronic

Health care providers operate in silos

IOM report: the problem

1. Care based on continuous healing relationships--care whenever its needed, not just through face to face visits

2. Customization based on patient needs and values3. Patient as the source of control4. Shared knowledge and free flow of information5. Evidence based decision making6. Safety as a system property7. The need for transparency--all information available,

including the system’s performance on safety, evidence based practice, and patient satisfaction

8. Anticipation of needs9. Continuous decrease in waste10. Cooperation among clinicians

IOM report: 10 rules for redesigning health care

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.

In Canada,

To appreciate the significance of this transformative change,

one needs to understand how care is typically delivered in

hospitals today?

“Every system is perfectly designed to get the results it consistently achieves”

—Dr. Donald Berwick

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.

Workflow Design Concepts

Focus on total value stream improvements, not on localized improvements

Workflow Redesign

Current Lean Six Sigma Project Methodology

Focus on “People” and “Process” * Lean – eliminate waste (speed) * Six Sigma – standardize (variation)

Lean Six Sigma Process

Why Workflow Redesign?

Improve qualityReduce costs & Eliminate waste

Reduce variation

Ease any IT implementation

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.

Key Steps to Optimize Workflow Redesign

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

Pa

tie

nt

Fro

nt

De

sk

Re

ce

pti

on

ist

Signs in at Front Desk

Marks Patient Arrival

Patient Check-in Paper Process

Patient Arrives

New Patient?

Give Pt. Forms to fill out, collect & copy insurance

card

Pull Paper Chart (from staging

area)

Patient Completes Forms

Does PtInfo need

to be updated?

Does co-pay need

to be collected?

Collect Payment & generate record of payment for billing

department

Record updates in paper chart,

collect & copy insurance card if

needed

Collect and file forms in newly created chart

Put chart & flowsheet in bin indicating patient is

ready for rooming

Yes

Generate Flowsheet

Yes

Yes

Yes

No

No

No

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)

Examining Areas for Improvement

Pat

ient

Fro

nt D

esk

Rec

eptio

nist

Signs in at Front Desk

Marks Patient

Arrival on EHR

Patient Check-in Process – EHR is Fully Integrated/Interfaced with Practice Management System (PMS)

Patient Arrives

MU Objective:Record Pt

Demographics as Structured Data

New Patient?

Give Pt. Forms to fill out, collect & scan insurance

card

Select Patient from EHR

Patient Completes Forms

Does PtInfo need

to be updated?

Does co-pay need

to be collected?

Collect Payment & record into

EHR

Record updates in EHR, collect & scan insurance card if needed

Collect and enter information in

EHR

Mark “pt is ready” for rooming into EHR

Yes

Yes

Yes

Yes

No

No

No

Improve Workflow:

Find and Remove

Bottlenecks

Move Steps in the Process

Close Together

Use Synchronizati

on

Use Automation

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

Automation Surprises!

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.

Testing

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

Problems Ordering Treatments for Patients

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

This haphazard process understandably results in:

None of this knowledge is delivered to

the clinician when needed at the patient bedside!

1. The right information 2. The right person 3. The right intervention format 4. Through the right channel 5. At the right time in the workflow

The five ‘rights’

Current health records are: Paper based Disorganised Often illegible Lost Scattered Poorly linked

Problem of Health Records

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

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

Traditional CPOE

How can we improve implementation of EBM through CPOE?

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?

Building a CPOE implementation

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

Contemporary CPOE

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

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.

“Corollary Orders”

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

Prescribing errors classification

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.

Trigger Orders Response Orders

Trigger Orders Response OrdersHeparin infusion (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

IV fluids (1) Place a saline lock when IV fluids are discontinuedInsulin (all kinds) (1) Capillary glucoses (four times a day)

(2) Glycosylated HGB (once if not done in preceding 180 days)Oral hypoglycemic agents (1) Capillary glucose (twice per day)

(2) Glycosylated HGB (once if not done in preceding 180 days)Narcotics (class II) (1) Docusate (stool softener) if not on any other form of stool softener or laxativeNonsteroidals (1) Creatinine (if not done in previous 10 days: SMA12, BUN counted as equivalent)Aminoglycosides (1) Peak and troughs levels after dosage changes, and q week if no change

(2) Creatinine twice per week (q Monday and Thursday)Vancomycin intravenously (1) Measures of serum levels pre and post 4th dose

(2) Audiometry(3) Baseline creatinine for dose adjustment

Warfarin (1) Prothrombin time each morningAmphotericin B (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)

Angiotensin converting enzyme inhibitions

(1) Creatinine at baseline then 2 weeks after dosage changes

(2) Potassium (q Monday and Thursday)Chloramphenicol (1) CBC (twice per week)

(2) Retic count (twice per week)Air contrast barium enema, IVP, UGI

(1) Pregnancy test (if patient is female, in childbearing years, had no hysterectomy, and no pregnancy tests within 3 days)

Isoniazid (1) SGOT, SGPT (as baseline when drug started)Potassium supplements (1) Electrolytes once each morningPulmonary artery catheter (1) Portable AP chest x-ray (when first placed to check for placement)Ventilator orders (1) Arterial blood gas after changesVasopressin drip (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.

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

Working with “New” People

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

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

To Keep in mind