What a difference a decade can make. In the early stages of converting to an electronic health record (EHR), Holy Redeemer Health System stopped printing lab results. "Initially everyone was concerned and asked us to go back to paper," remembers Karen Renson, RN, director, best practices, clinical decision support, and nursing quality.
These days, Renson receives very different requests from community physicians-the great majority of whom are independent. "Now physicians call to say, 'Why is this a piece of paper? We need you to make this electronic.' The pendulum has completely swung."
Renson points to how rapidly physicians adopted computerized physician order entry (CPOE). Within one week of converting to a new CPOE system last November, physicians were placing 75 percent of pharmacy, lab, and other orders electronically. The rate is now around 80 percent.
"We are up to an average of 1,853 electronic orders being placed each day directly by physicians," says Renson. "In comparison, we had only about 5,000 orders placed during all of 2003."
The rapid CPOE adoption rate at Holy Redeemer is partly attributable to the fact that this was the health system's second time around. The original CPOE system-launched in 2002-did not enable the health system to harbor the technology's full potential, says Anne Searle, senior vice president and CIO. Switching to a more sophisticated platform from the same vendor was determined to be less work intensive and less expensive than updating the old CPOE software, she says.
"It would have been impossible to achieve such a high adoption rate in the first week if we had not had a prior CPOE system in place," says Jonathan M. Sternlieb, MD, chief medical information officer. "Those eight years with the other CPOE system changed the culture and expectations here."
Hospitals that are launching CPOE for the first time can expect to take months or even years to achieve Holy Redeemer's 80 percent adoption rate, says Sternlieb. "CPOE is probably one of the most complex IT implementations, and it would be unreasonable to expect a quick adoption rate if you are converting from paper to electronic."
There's another advantage to a second marriage: Holy Redeemer leaders were able to draw on their past successes-and mistakes-to create the best possible launch CPOE scenario. Here are 11 keys to CPOE success from Holy Redeemer leaders.
Top-down leadership support is a necessity. "Our leaders very much understand the importance of acquiring and leveraging technology," says Searle. The ultimate goal: a patient-centric EHR that crosses the health system and allows for all providers to access and share information.
So this is much bigger than CPOE-and Holy Redeemer leaders have committed at least 20 million dollars in recent years to IT infrastructure and services. Other key EHR investments include:
"The new CPOE system alone cost $7.5 million, including equipment, licensing fees, implementation fees, and professional service dollars," says Russ Wagner, senior vice president and CFO. "That does not include the planning and implementation time spent by Holy Redeemer staff, which quite frankly, is tremendous."
Holy Redeemer leaders also made CPOE adoption "mandatory" for physicians. "I think that message made everyone stand up and take notice," says Wagner.
However, he thinks the most important strategy leaders used was "constant messaging" followed by concrete action. "We're constantly giving updates to staff about where we are going with our EHR and what our strategy is. They see us putting in multiple components across our health system-not just in the hospital. For instance, in home care, our nurses now operate in the field with handheld devices. Our staff see first hand that this is not a flash-in-the-pan course of action for us. They see we are committed to going electronic in all aspects of our business."
A physician needs to lead. "You need a physician leader who can handshake between administration as well as IT and the medical staff," says Sternlieb. "Without a physician leader, I don't think a CPOE project is possible because there's a credibility gap among physicians."
A gastroenterologist, Sternlieb manages to maintain a fairly heavy patient load-despite devoting 1½ days most weeks to his CMIO duties at Holy Redeemer. The fact that he continues to practice helps his credibility with other physicians, he believes.
Put in a CPOE system that works. "Even if your physicians believe in CPOE, you will undermine the whole project with a lousy system," says Sternlieb. Key requirements for Holy Redeemer staff on switching to a new CPOE system: more advanced clinical decision support, documentation, and workflow functions.
Decide between big bang or pilot projects. Holy Redeemer did not have a choice. Because they were converting from one CPOE system to another, they had to go "big bang," or switch from the old system to the new system at 7 a.m. on November 3, 2009.
Hospitals that are implementing CPOE for the first time can choose to go with a more phased-in approach, says Sternlieb. For instance, when Holy Redeemer launched CPOE the first time around, they piloted it with a small group of physicians before implementing it across the hospital.
You have to look at the pros and cons of both approaches, says Sternlieb. "With big bang, you sacrifice some ability to test the system before it goes live. On the other hand, pilot projects can stagnate if you don't stick to a timeline. If you are doing a pilot, realize that you cannot fix every single problem before you go on to the next step."
Provide flexible-but required-training. "When physicians walked into our building on November 3, they were going to be suddenly faced with a completely different CPOE system," says Renson. "So we had to educate 700 physicians before we did the cut over-which was quite an undertaking."
Cognizant of physicians' busy schedules, Holy Redeemer leaders decided against only providing classroom training. Instead, they went with an electronic tutorial that physicians could access from any computer. They also divided the tutorial up into chapters so physicians could review individual sections as they had time.
However, there was one catch: "Because CPOE is so critically linked to patient safety, we wanted to assure ourselves and the accrediting and regulatory bodies that our physicians were adequately prepared to use the new system," says Renson. "So physicians are not permitted to use our CPOE system until they complete the tutorial and take a test validating that they are competent to use the system."
Lighten elective surgery schedules around the go live date. Looking back, Sternlieb wishes he had taken this advice. "During our go live week, the surgeons scheduled as many procedures as they would have in a normal week. It might be easier on everyone if you lighten your surgery schedule on the day or week of go live."
Develop a password management process. "We had physicians who were locked out of our CPOE system because their passwords weren't communicated well to them or they received misspelled passwords," says Sternlieb. "Obviously, this a big detractor. It really takes away from your credibility when you have a great house to show everyone-but no key to the house."
Provide rapid updates and just-in-time support. For two weeks after Holy Redeemer went live with CPOE, the hospital maintained a central command center manned by IT professionals who rapidly responded to problems and issues. If a user identified a function that didn't work right or wanted a function to work differently, these IT experts would make the change and push the change out at all hours of the day.
"The feedback from physicians was quite positive," said Searle. "They would say, 'The next time I logged on, you had fixed the problem.' Addressing physician concerns in a rapid fashion really made them know that we were committed to this."
Also key: Superusers-or staff who had received extra training on the CPOE system-are available on every unit to help physicians and other practitioners access and use the new system.
Sternlieb offers this advice: "I always say 'travel in packs' when helping CPOE users. It is helpful to have multiple people-for instance, a clinician and an IT person-traveling together. When I rounded the week of go live, I went with the physician IT lead from our vendor, who had helped develop the product. With his programming knowledge, he was invaluable. He provided insight into issues that our physicians raised that I couldn't even have begun to answer."
Actively engage clinicians in content development. A clinical advisory committee at Holy Redeemer oversees the development of content-including order sets and evidence-based clinical workflows-that feed the CPOE and related systems. Physicians, nurses, pharmacists, and other clinicians have logged hundreds of hours on this advisory committee in the last few years-and on the subcommittees charged with the "nuts and bolts" content development work.
About five physicians currently sit on EHR-related committees, and they are not compensated financially for their time.
One example: Before Holy Redeemer went live with CPOE, a subcommittee of physicians, nurses, and pharmacists worked for months to develop more than 200 order sets, said Maira Jardak, RPh, director of pharmacy. While the hospital had purchased order sets from a vendor, the subcommittee had to rebuild many of them.
"For each order set, we looked at all the details that pharmacy, nurses, and physicians need when making decisions about how to order, dose, and administer a drug," says Jardak. "For example, critical care drips come in vials. So these drugs have to be diluted and then appropriately dosed and administered. Creating predefined orders required a three-way conversation about dosage recommendations and exceptions. By creating transparency between systems, predefined orders can be interfaced and seamlessly transmitted to the appropriate department systems (such as pharmacy and the eMAR system), which enhances medication safety. "
"Our old CPOE system did not integrate with medication administration," says Searle. "Now, the new integrated system is forcing conversations between physicians, nurses, and pharmacists-who all speak a totally different language-about how a drug needs to be ordered."
The creation of medication order sets is just the beginning. Holy Redeemer will be enhancing a critical component of CPOE later this year: clinical decision support-which prompts physicians and other practitioners on evidenced-based practices and alerts them to potentially dangerous scenarios. Sternlieb gives this example: "If I order digoxin and the patient's potassium is low at 2, the decision support may send me an alert that says, 'When ordering this medication be careful because the patient's potassium is 2. You might want to order supplements of potassium as well.'"
Clinical decision support tools are not automatically part of CPOE and require additional set up and configuration. (See related news item.) "Just getting CPOE live took all of our resources," says Sternlieb. "Now we are working on taking our CPOE system to a greater level of sophistication with decision support."
A subcommittee-which includes physicians as well as other practitioners-is overseeing the development of workflows, or complex pathways that use rules and events to drive clinical decision support. The first workflow being developed is deep vein thrombosis prophylaxis, or prevention. Eventually, the workgroup hopes to develop workflows that touch many clinical scenarios. "This is an ongoing, huge project," says Sternlieb.
Be ready to change content in light of context. After orders sets or clinical workflows go live-be ready to make adjustments, says Sternlieb. "When physicians provide input into content, they may not be able to see how that content will affect the workflow, or the context of how patient care is actually delivered, he says. "Once the physicians get a chance to see how workflow is affected, they can come back and give suggestions for modifications."
For example, on medication order sets, some physicians wanted to list every possible dose of every medication. But other physicians only wanted a few possible doses listed. "Once we went live, it became apparent that it would be better to limit the number of choices so the user would not be flooded with too many selections."
Debriefing sessions were held with each hospital department a few weeks after go live. "By going to them, you will increase your chances of learning about workflow issues that may not otherwise be reported," said Sternlieb. "We asked, 'What's good? What's not good?'" This helped us identify and reduce workarounds that people had developed because of inefficiencies in the system-but that they did not have time, energy, or skill to report.
How long does it take to resolve workflow issues? "This project is like bridge painting," says Sternlieb. "It never ends. Even when you think you solved the problem, you may have to revisit the problem again."
Set up a governance structure. Changes cannot be made in a vacuum, says Holy Redeemer leaders. "Someone might come to us and ask, 'Can we change this screen to say XX,'" says Renson. But if we make that change, it will affect all end users-physicians, nurses, medical records, physical therapists, and every person in the building."
In recent months, Holy Redeemer formed a multidisciplinary clinical operations subcommittee that is charged with reviewing all requested content changes in light of how the change will affect all end users. The subcommittee meets monthly, and confers via email when necessary, to determine which changes are made-and which are not. "We realize that we are not going to please everyone all the time," says Sternlieb.
Holy Redeemer is starting to see a payoff from its CPOE and other EHR initiatives. Core measure scores have demonstrated sustained improvement, says Renson. "We have put workflows into our CPOE system to address various quality and regulatory issues," says Renson. For example, one workflow now reminds nurses to comply with Joint Commission advance directive requirements.
Other positive results to date: Patients are getting needed medications much more rapidly, thanks to the new eMAR system. The time it takes for the pharmacy to review medication orders, send the orders to the bedside barcoding system, and obtain the drugs from unit-based dispensing machines has dropped to less than five minutes-from three to four hours.
Research also shows that eMAR technology can reduce medication errors, such as giving medicine at the wrong time and giving a patient the wrong dose. (See related news item).
Health system leaders look forward to the not-too-distant future when they will have more data mining and business intelligence capabilities, which will allow them to track performance on quality and cost measures.
In the meantime, one of the most visible results is in the culture at Holy Redeemer, says Searle: "CPOE is forcing a collaboration that has never really needed to occur before. It is forcing physicians to talk to nurses, pharmacists, and others to make sure the entire patient care process is seamless and credible," she says.
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