MISSION: IMPOSSIBLE The Use of Technology in Promoting Physician Adoption of CPOE

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MISSION IMPOSSIBLEThe Use of Technology in
Promoting Physician Adoption of CPOE

• Massachusetts Hospital CPOE Initiative Physician
  Involvement and Governance

Mark Hulse, RN Chief Information Officer North
Shore Medical Center
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The Good News The Bad News
First
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Implementing CPOE is not as difficult as you
think
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Its Worse.
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The Good News

• You have plenty of company CPOE adoption is
  growing nationally
• As more community hospitals implement, a growing
  base of on-the-ground experience is available
  to draw from
• With planning, persistence and agility the CPOE
  implementation mission is Possible.

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Critical Elements of Success

• Securing physician acceptance requires strong
  hospital and medical staff leadership
• Recognition that CPOE is Not an IT Project
• CPOE implementation throws a spotlight on many
  imperfect clinical practices
• Keeping the implementation moving involves
  deciding which battles to take on

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Establishing a Vision for CPOE
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The Migration from Paper to Electronic

• Dont use CPOE as a first clinical application
• Have results and other clinical data needed for
  decision making readily available on-line

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RESULTS
MED ADMIN RCD
CURRENT ORDERS
EXTERNAL REFERENCES
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Rapid vs. Gradual Deployment

• Deploying too quickly may not allow for changes
  in workflow adaptation, and result in implosion
• Allowing voluntary adoption will result in
  stagnation beyond early adopters
• The right balance is critical to achieve the
  tipping point

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Choosing a Pilot Unit

• Consistent patient and physician population (e.g.
  minimal boarders)
• Willing physicians and nurses
• Frequent team feedback sessions

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Dealing with Integration Issues

• Bidirectional pharmacy system integration is
  critical
• Back-end integration also highly desirable for
  Lab and Radiology
• Other ancillary areas e.g. Dietary, Blood Bank

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Workflow Analysis

• The devil really is in the details
• Over-analysis of workflow is impossible
• Ask staff what their processes are, but then
  watch them to learn what they really do
• Workflow analysis must be done for every nursing
  unit
• No matter how uniform your care unit practices
  are, minor variations will exist and can cause
  major unanticipated issues with CPOE

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Workflow Analysis

• Map the current state out, then validate it
• Use the future state map as an educational tool
• Include ancillary departments in the workflow
  analysis as well

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Order Notification

• Going from paper to electronic is unsettling for
  nursing staff too
• Orders may be received and acknowledged in
  Pharmacy before the nurse even knows about them
• Paper printouts provide security, but can become
  a crutch you cant take away later
• Heads-up computer display of new orders is
  preferable

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Order Notification Examples

• Lab order add-ons
• Consults and other orders without an electronic
  back-end system

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Training

• Be flexible when offering options for physician
  training
• Clinical Support Team available by page or phone
  for training
• Reach out to physicians who dont sign up
• Emails, memos from Chief, schedule time through
  practice manager
• Access to CPOE provided after training is
  completed

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At The Elbow Implementation Support
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Clinical Support Team

• Visible Clinical Support Team (CST) staff on unit
  24x7 during initial 3 weeks
• Offer help and assistance to MDs without being
  confrontational
• Log issues and discuss with technical team during
  daily status meetings
• Support is gradually weaned over 4-6 weeks

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Ongoing Education

• Adoption and skill level will vary widely across
  individual physicians
• Multi-mode approach to ongoing training
• Department meetings to share information
• Ready availability of ongoing support
• Feedback button in CPOE
• Tip of the Week

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Tip of the Week

• CPOM "Tip of the Week"
• ISSUE Chem-6 does not contain a creatinine it
  will be replaced with Chem-7
• TIP Our nephrologists have pointed out that
  there have been some clinical problems due to use
  of the Chem 6 (Na, K, Cl, bicarb, BUN, glu)
  because it does not contain a creatinine.
  Therefore, on 11/7, Chem 6 will be replaced in
  CPOM with Chem-7 (which is a Chem-6 plus
  creatinine).
• ISSUE Ordering heparin and warfarin
• TIP When heparin and warfarin are ordered, it is
  usually necessary to order lab tests (PT/INR or
  PTT) and instructions to nursing (e.g., "Notify
  doctor for INR above x") at the same time. In
  CPOM, heparin and warfarin have their own order
  sets, which make this easy. These order sets,
  currently called "Warfarin Anticoag Protocol",
  "Heparin Initiation" and "Heparin Maintenance"
  should be used when ordering these drugs. At
  present, these order sets are found on the Order
  Set tab in the "General" list -- see the
  attachment for a picture. Very soon, it will
  also be possible to find these order sets on the
  Med/IV tab main "common list". Please use the
  heparin and warfarin order sets when ordering
  these drugs -- it takes just a little bit of
  'getting used to' but works much better than
  ordering the drugs "alone".
• If you have questions about using CPOM, page the
  CPOM Clinical Support Team. To reach them, use
  pager 72900 or search on "CPOM" in the Partners
  Paging Directory and select "Clinical Support
  Team".

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Hardware No Waiting for CPOE
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Hardware How Much is Enough?

• Monitor of physicians on each unit during peak
  ordering times (dont guess!)
• Account for other users (nursing, case
  management)
• Space may be the biggest constraint
• Enlist nurse managers to help prioritize use of
  workstations for CPOE during peak ordering times
• Laptops, tablets, PDAs

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Example Hardware Map

• Summary of Changes
• Completed renovations
• Added 4 Desktops
• Upgraded to CISCO wireless network replaced 11
  wireless network cards
• Outstanding Work
• Adding monitor arms, keyboard trays and CPU
  Holders (Rich Kanter)
• Moving 4 RN Laptops from Bays to carts
• Adding 6 Desktops to Bays
• Adding 1 laptop cart for MD Rounds
• Note Unit will have a total of 6 laptops (4 RN,
  1 MED ROOM, 1 MD)

RN STATION
RESIDENTS ROOM
Non- HIS
US
BAY 1
BAY 2
Existing Desktop Existing Laptop Existing Laser
Printer Add Desktop Add Laptop Add Laser
Printer Deployed new Desktop Deployed new Laptop
Deployed Laser Printer Reserved for Unit
Secretary Reserved for Case Manager
FILM AREA
Non- HIS
MD ROUNDS
NEW MD WORKSTATIONS
US CM
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Addressing Usability Issues with Agility
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Order Set Design Development

• Use pre-existing order sets (OS) where available
  as a template
• Think usability and efficiency
• Consistent organization across OS (e.g.
  ADCVANDISL)
• Minimize clicks (e.g. pre-checked default values)
• Monitor use of OS vs Ad Hoc orders
• Does the volume of non-OS orders warrant adding
  these to existing OSs?
• Maximize use of Quick Pick or Common Lists

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Drugs by Classification Example
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Quick Orders Example
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Clinical Decision Support

• Achieving the right balance takes trial-and-error
• Begin with a minimalist approach, and add DS
  incrementally
• Avoid Alert Fatigue
• Physicians will click-through frequent alerts
  without reading them

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Degrees of Decision Support
Basic Alerting Advanced Alerting
Checking for duplicates, drug/allergy, drug/drug interaction Age-specific weight-based, renal function alerts, drug/lab checks

Basic Decision Support Advanced Decision Support
Predefined orders, structured orders, simple logic edits Rules engine with conditional logic, checking across multiple clinical databases
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Change Control and Enhancements

• Establish a multi-disciplinary group to manage
  CPOE content changes and enhancements
• Stick to a defined process

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Remote Ordering

• Placing orders from the office or from home
• Placing orders on patients who havent been
  admitted yet suspended orders
• Requires careful workflow analysis with nursing.
  They activate the orders.

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Mobility

• Wireless Computers On Wheels (COWs) useful for
  team rounding
• Pen-based tablets
• Utility will vary with CPOE vendor software
• Most users find them still too heavy to carry
  around
• PDAs Screen real estate too small for most CPOE
  applications

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Other Technology Enhancements

• Rapid Sign-On and Access to CPOE
• Single Sign-On
• User logs in once, all applications are
  accessible without additional log-ins
• Balancing HIPAA Privacy/Security and Clinician
  Workflow

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Good Luck on Your CPOE Mission!
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