Stellaris Health Network CPOE Adoption

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Stellaris Health NetworkCPOE Adoption

• June 2009

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Stellaris Health Network

• Based in Armonk, NY, Stellaris Health Network is
  the corporate parent of
• Lawrence Hospital Center (Bronxville, NY)
• Northern Westchester Hospital (Mount Kisco, NY)
• Phelps Memorial Hospital Center (Sleepy Hollow,
  NY)
• White Plains Hospital Center (White Plains, NY)
• Nearly 750 million dollars in combined revenue
• 1,000 in-patient beds
• 1/3 of acute care bed capacity in Westchester
  County
• Approx. 5000 employees
• Approx. 2000 voluntary physicians

The Stellaris Hospitals provide multidisciplinary
acute care services as well as a range of
community based services such as hospice, home
health, behavioral health and physical
rehabilitation, dedicated to preserving high
quality, community-based care for residents of
Westchester, Putnam, Rockland, Dutchess, Northern
Bronx, and Fairfield Counties.
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Vision and Implement

• Vision of Advanced Clinical software to care
  for the patients safely, by leveraging technology
  and software to
• Migrate from paper- based care processes
• Address patient safety initiatives and increase
  compliance
• Increase accessibility
• Translate data into information
• For Stellaris
• 2005 Lay the foundation for an integrated
  system (Core Apps EMR)
• 2006 Integrate and incorporate new Clinical
  Systems to grow clincian use and data (PCS, ORM,
  EDM, some POM)
• 2007 Implement and automate solution for
  medication safety (BMV/EMAR)

• 2008/2009 Round out the med safety cycle with
  POM

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Stellaris Implement
Steadily emerging solutions to grow adoption,
increase functionality and realize benefits.
Future State

• Clinical Decision Support.Community/ambulatory
  Integration.Paperless Medical Records?

Phase IV 2007- 2008
CPOE, DR, SCA, BMV

• Patient Safety 5 Rights of medication
  management has been thoroughly adopted, CPOE
  mandated, PDCO and DR alerting pilots grow.

Phase III 2006 - 2007
5.5 Upgrade, SCA, BMV, DR

• The Basis For Patient Safety All clinicians
  have adopted use of system.

Adoption and Functionality
Phase II 2005 - 2006
PCS, PCM, POM, AOM/RXM, EDM, ORM, CWS, CA/ESS/BF

• Integrated Clinical Systems Patient care
  focused systems with the implementation of
  nursing documentation, care plans and
  interventions., EDM, ORM and POM.

ADM, MR/ABS, BAR, GL, AP, MM, PP, ESS, ITS, LAB
Suite, OE, EMR, CWS, ORM, SS, EDM1, POM
Phase I 2004-2005

• The Foundation replaced all existing disparate
  systems with integrated MEDITECH core
  applications PLUS EMR.

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If you build it, they will come

• CPOE is not a I.T. project
• CPOE is an application that enables providers to
  enter medical orders into a computer, replacing
  traditional methods including written, verbal or
  faxed orders.
• Immediate safety benefits are gained with legible
  orders and greatly enhanced by increasing order
  accuracy and completeness, enabling access from
  multiple locations, and providing clinical
  decision support at the point of care that can
  include capabilities such as drug interactions,
  patient allergies, medication contraindications,
  and weight-based dosing checking.
• CPOE is a re-engineering project aimed at
  improving the processes and effectiveness of
  provider order entry, via technology

• While the advantages are clear, use of CPOE will
  impact clinical workflow in the hospital
• Perceptions of this technology and concerns can
  become barriers to adoption
• Cost
• Negative impact on workflow
• Training and support
• Complexity of environment

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Overcoming Barriers for Adoption

• Strong Leadership
• Shared vision of quality and patient safety from
  Administration, Medical Staff, and Nursing
  leadership
• Vendor Partnership
• Clearly communicated message of long-term vendor
  partnership among clinicians
• Overcome urge to delay for the next upgrade or
  latest and greatest emerging technology
• Leverage physician volunteers
• Early adopters, external experience,
  quality-driven volunteers to steer and lead
• Presence of house staff and hospitalists
• May have a higher level of comfort with
  technology and hospital-directed change than
  employees
• Institutional commitment to patient safety above
  all other tactical issues
• Addressing costs and resources
• Acknowledging impact and expecting benefits

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Overcoming Barriers

• Strong Leadership Commitment to Vendor
• Presence of house staff and hospitalists
• Leveraging voluntary physicians
• Institutional commitment to patient safety above
  all other concerns

Adoption
Attending Physicians
Leadership
Medical Board Mandate
Stellaris Implementation Strategy
Large Medical Groups and Volunteers
Hospitalists
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Adoption at Stellaris

• Physician Champions bench test the assumptions
• Hospitalists adopt and improve the new
  processes
• Volunteers and large Medical Groups increase
  the numbers
• Mandate by Medical Boards (mid 2008 2009)
• All Attending Providers

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CPOE Adoption Across All Hospitals

• Stellaris as of Jan 2009 100 of all providers
  are required to enter orders electronically
• Where we dont use CPOE
• Chemotherapy Orders
• TPNs
• Pre-admission Orders
• Others by policy
• Benefits Realized
• Legibility
• Accessibility
• Accuracy and Timeliness
• Completeness and Compliance
• Decision Support for Med Safety

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Challenges of CPOE Alerts finding the balance

• Over alerting is where a combination of
  critical medical alerts and a volume of
  marginally inconsequential alerts can lead to
  Alert Fatigue
• Typically due to
• Formulary vendors providing an extremely
  conservative approach for defining alerts
• Different disease states and multiple diseases
  (co-morbidity)
• Superfluous warnings for common interactions that
  have little risk
• Awareness or varying knowledge across physicians
• Redundancy of alerts
• Different expertise across physician specialties

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Alerts finding the balance

• De-sensitivity to CPOE generated alerts increases
  the risk that an important warning will be
  dismissed and may compromise patient safety
• Guide physician ordering practices
• Use of Order Sets and Favorites has clear safety
  and workflow benefits AND can lessen alerts by
  providing associated data and best practice
  standards of care
• Minimize alerts, turning off when the risks are
  minimal
• At specific test level, turn off alert
• Use pharmacists, who have been using alerts for
  years
• Elect to continue to have pharmacy responsible
  for specific types of alerts
• Formulary revisions
• Revise the formulary to reduce non-essential
  alerts (classes, etc.)
• Provide a vehicle for physicians at time of
  entry, to provide justification for an override
• Create override category to indicate that the
  provider requests review of the alert
• Develop a forum (medical staff-directed) to
  review all overrides and feedback for on-going
  analysis and improvement

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Be Prepared for..

• Unintended Consequences
• Loss of story when moving from paper to on-line
  (sometimes not as good a read)
• Some loss of communication (physicians at
  computer instead of talking to nurses)
• Process flaws
• Defects hidden by human workarounds and subtle
  fixes that the computer cannot replicate
• Missing the Nursing touch
• Nursing interaction in the ordering process
  somewhat lessened (smoothing the way so more
  bumps will be seen)
• Clicks Matter
• Efficiency is of greatest importance, where each
  keystroke is time spent away from patient
• Expectation that the computer will process
  information faster than the provider
• Greater Needs
• Once used to the technology, medical staff will
  demand more complex and specialized decision
  support, such as alerting based on results,
  specific diseases, etc.
• Ongoing QA and Intervention
• Medical staff leaders, Pharmacy and Nursing will
  continually need to monitor and assess workflow,
  functionality and process to achieve desired
  patient safety state

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In Conclusion.

• Computerized physician order entry in a community
  hospital with voluntary physicians is achievable

• Introducing CPOE to a healthcare setting is a
  complex imitative, fundamentally changing the
  delivery process of care.
• The benefits of safety, efficiency and potential
  effect on outcomes greatly outweigh the
  challenges of re-engineering and anticipated
  impact to the physician community.
• Despite advances in the solution and successes by
  early adopters of this technology, there is no
  one approach or perfect solution.
• Support of patient safety, at all levels of the
  institution, above all else, is critical.
• Requiring a long-term commitment to advancing
  patient safety and performance through the use of
  an emerging solution is the certainty.

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• Special thanks and recognition to hospitals
  dream team of dedicated physician liaisons.
  Without their efforts, POM adoption would not
  have been possible.
• Marcia Blieden White Plains Hospital Center
• Jane DAmbrosio Northern Westchester Hospital
• Linda Daniels and Mary Roeder Lawrence Hospital
  Center
• Anu Singh Phelps Memorial Hospital Center