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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Car Part Function CbPR Part Function
Dashboard Status Display Screen Status
Steering/Pedals Control Keyboard/Mouse Control
FuelEngine Propulsion CDR Clinical Data
Accelerator Move forward Reminders Do things
Brake Stop Alerts Dont do things
Transmission Transfers power Standards Transmits messages
Lubricants Reduces friction Terminologies Reduces misunderstanding
Driver In Charge Provider In Charge
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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