Computer Provider Order Entry CPOE

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Computer Provider Order EntryCPOE

• The First Step in Computerized Decision Support
• Bruce Slater, MD, MPH 263-8242 - Pager 9015
• DGIM Primary Care Conference 4/14/2004

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Learning Objectives

• Be able to
• describe what CPOE is
• describe proven advantages of CPOE
• describe what is expected of attending physicians
  using CPOE
• articulate advantages of CPOE for physicians at
  UWHC

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Financial Support

• No outside support

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Introduction

• Definitions
• Clinical Decision Support (CDS)
• Not Continuing Medical Education (CME)
• Computer-based Patient Record (CbPR)
• Clinical Data Repository CDR (WISCR-IT)

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Background

• CPOE is the infrastructure for CDS
• Why arent we there yet?
• Security, Standards and Simplicity
• What it cant do

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The CbPRS as Car
Cockpit
Lubricants
Driver
Fuel to Engine
Transmission
Accelerator
Brake
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(No Transcript)
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How it works 1
Paper Orders
A2K terminal (HUC)
MD-paper orders
Action 2000 Orders
CPOE
CPOE
MD-on Web Browser
Future 2 way interface
WISCR-IT CDR
RxTFC
Accuscan
Med Orders
Intermediate Document
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How it works 2
Personal Computer
Web Browser
The Network
WISCR-IT
Java Virtual Machine
CPOE
http
Screen Painter
Form Printer
Dialog Boxes
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How it works 3
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How it works 4
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How it works 5
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How it works - 6
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Evidence-based Informatics - 1

• Tierney, et al. JAMA 1993
• Financial
• Total Charges 6964 v 6077 12.7 less (p.02)
• Test Charges - 1852 v 1621 12.5 less (p.006)
• Drug Charges - 1181 v 1001 15.3 less (p.008)
• Time
• Minutes writing orders 25.5 v 58.5 more (plt.001)
• 5.7 minutes less writing scut cards (p.02)
• Acceptance
• 52 of housestaff users thought it made work
  easier

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Evidence-based Informatics - 2

• Kuperman, et al. Annals 2003
• Review article
• Time entering orders 3 studies summarized
• Shu 2001 (9 v 2.1) minus 2 5 more time
• Bates 1994 (10.5 v 5.3) minus 2.7 4.5
  more time
• Overhage 2001 6.2 overall pNS. Experienced
  users neutral.
• Drug monitoring and preventive care
• Overage 1997 46.3 v 21.9 plt.001
• Lab Orders
• Tierney 1990 13-14 fewer tests and charges
  plt.05

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Evidence-based Informatics - 3

• Kuperman, et al. Annals 2003 (continued)
• Medication Errors
• Bates 1998 55 fewer non-intercepted serious
  med error, p.01 17 less ADEs pgt.2
• Shojania 1998 32 fewer Vanco orders p.04
• Bates 1999 81 fewer non-missing dose errors
• Evans 1998 86 fewer Antibiotic ADEs, 94 fewer
  mismatches, also fewer excess doses

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Evidence-based Informatics - 4

• Mekhjian 2002
• Process variables
• Med turn-around time 64 reduction plt.0001
• Radiology completion time 43 reduction plt.05
• Lab result reporting time 25 reduction p.001
• Un-countersigned orders reduced 34
• Length of stay decreased .2 days in acute
  hospital, no change in cancer hospital

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The Leapfrog Group

• 145 large healthcare purchasers
• Safety Leap forward in health care quality
• Pay (more) for (higher) performance
• Consumer education and report cards
• First 3 Safety standards
• CPOE
• Evidence-based hospital referral
• ICU physician staffing

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The Institute Of Medicine

• To Err is Human 48,000-98,000 lives/year
• Exact figure is controversial, but not idea
• 17-29 Billion in cost per year
• Under-use, Overuse and Misuse
• System problem NOT bad apples
• Systems can be designed to make it easier to do
  the right thing than the wrong thing

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CPOE at UWHC

• Workflow, workflow, workflow
• Wetware more important that hardware or
  software.
• Rollout schedule pilot until all bugs out
• No firm schedule for subsequent units
• Swarming support 24/7 for 6 weeks
• Daily status meeting, weekly feedback

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Microscope Effect

• Nursing sign-off and acknowledgement
• Multiple wrist band printing
• Nurses feel monitored
• Height not measured
• Verbal order policy misunderstanding

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Inpatient before Outpatient

• Error prevention more crucial
• Costs higher
• Costs accrue to bottom line
• Hospital infrastructure ready
• Less diverse infrastructure
• More experience around the country

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What we have found so far

• Positive Issues for Attendings
• Orders available quicker
• Able to see all orders
• Able to check orders offsite
• Able to check if certain labs ordered instead of
  paging houseofficer

• Positive Issues for Housestaff
• Speeds up intern work
• Charts more available
• Less call back
• Antibiotics hung quicker

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Challenges

• Some decrease of communication between physicians
  and nurses
• Mixed environment (paper/CPOE) unsatisfying to
  HUC and RN, they prefer all CPOE!
• CPOE process will force difficult issues to be
  addressed before implementation can proceed
• Some errors introduced during transition
• Pharmacy work load has increased

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Obstacles expected but not seen

• Response time was not too slow
• Software was not difficult to understand
• There were not excessive warnings
• Orders were not hard to find
• CPOE does not prevent any order being written

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Cedars-Sinai Medical Center

• 877 Bed hospital in Los Angeles
• 1800 physicians mostly attendings
• CPOE part of system removed after 4 months due to
  revolt of 400 physicians
• 2 week pilot in OB in July, 2 weeks per floor
• Human factors, workflow not adequately
  considered.
• Software had functionality issues
• Inadequate education of physician users

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What is Expected of Attendings

• Ask residents about non-formulary medications
  written
• Ask residents about DNR/DNI order changes
• Encourage residents to use CPOE as intended and
  not work around it
• Listen to residents comments and concerns about
  CPOE and let me know
• Let me know of your own comments or concerns

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Questions and Comments
Bruce Slater 263-8242 - Pager 9015