CPOE… Not just a Four Letter Word!!!

1. CPOE… Not just a Four Letter Word!!! Richard MacKenzie MD FACEP Chair DEM, LVHHN richard.mackenzie@lvh.com

2. Overview • LVHHN Case Report • Review the literature on CPOE

3. Objectives • Discuss the controversies in CPOE • Understand the lessons of one institution’s successful implementation of CPOE • Imagine the Future of CPOE in Improving ED Care

4. Abbreviations • HIS = Health Information System • IDX/Last Word = our HIS • CAPOE = Computer Assisted Physician Order Entry • EMAR = Electronic Medication Administration Record • AP = Administrative Partner (aka Unit Clerk)

5. Problems • Assessment and Accountability 1988 Relman NEJM • Evidence Basis only ~ 50% 2003 McGlynn NEJM • Large # errors 2005 Rothschild Crit Care Med • Regional, racial, and ethnic inconsistency or disparities 1999 Wennberg NEJM & IOM 2002 • Leapfrog – 3 initIal 3 “safety leaps” 2003 Eikel Joint Commission Journal Quality and Safety

6. Solutions • Develop Critical Care Paths • Develop Case Managers to assure EBM • Specialty societies clinical pathways • Improve access to the literature via internet • Bring EKG’s & prior transcriptions to provider • CAPOE

7. It’s Time To Make The CAPOE! The LVH Experience

8. CAPOE at LVHHN • Project started in 2001 • Physician led and advisory • Trauma first • ED and Peds last • “Required” Jan 2006 • 99% compliance today

9. CAPOE in the ED • Not now • Not now… • OK but don’t make me work in paper and computer • Look for clipboard and computer = excesssive work • Must use HIS CAPOE • Many Ordersets Developed.

10. The LVHHN ED Experience • Starts August 2003 • Strategic Initiative – super capital budget • New tool that redefines work • 3 sites phased implemention • Fully implemented July 2005… • ONGOING Operationally!

11. Preparation6 Cannot overemphasize the collaboration necessary

12. Vision • Stagger Implementations • Use Paper CAPOE • CAPOE, EMAR, EMR Implementation. • Complaint Specific Order Sets. • Diagnosis Specific Order Sets.

13. Define Problems • Research • What EMR provides what you need? • How are people and institutions constructing order sets? • How are the orders sets going to look and function? Easy, Fast, Intuitive. • How can you use these order sets to change physician practices to be more in line with hospital protocols

14. Workflow Analysis • Understand the work of all staff in ED • Especially the shortcuts & data use • One test is rare • AP • Real time abstractor for PI • Interface with community • Census screen in HIS = action location

15. Support • Identify Your Physician Super Users. • Collect Information From Current Users of CAPOE and the EMR you are planning on implementing

16. Work Groups • Steering Committee • ED administration • IS administration • Pharmacy • Billing • Medical Records • Subcommittees: • CAPOE • Many others

17. Pharmacy • Compendium additions • Pyxis • Floor stock • VTs • Trade and Generic • Common dose

18. Process • How do nurses know there are orders? • Limited verbal communication • Doc to Nurse and Nurse to Doc • Pop up’s on “assigned” patients

19. Hardware • Use Lastword and T System • SSO (Single Sign On) • Various devices • Speed • Mobility • Battery life • Charging • Support

20. Hardware • Different area = Different needs • Different ED’s = Different needs

26. Ordersets Are Key • Initial work in collaborative fashion • Match to T-system templates • Working with incomplete information on workflow • Diagnosis specific developed later

27. Development: Order Sets • First Nurse Order Sets • Protocol driven

28. Development: Order Sets • First Nurse Order Sets • Protocol driven

29. Development: Order Sets • Structure of the order sets • IV, O2, Monitor…. • “Different Physicians do things differently” • Editing content was the responsibility of the subcommittees.

30. Development: Order Sets • Complaint Specific Order Sets Modeled After T-system Complaint Specific Templates. “One Stop Shopping”.

35. Development: Order Sets • Diagnosis Specific Order Sets Modeled After LVH Treatment Protocols. • Common ED Order Set

38. Pre-implementation Resistance is … inevitable!

39. Staff Support • Positive environment for change • Upstaff! • Residents trained and already using CAPOE on other floors

40. Implementation!

41. Go-live • Phased • Paper CAPOE • Screen shots complaint specific ordersets • CAPOE & EMAR • Management on the floor • Support on the floor • Up staffed • EMR

42. Tasks • CAPOE face • Don’t drift • To old • Or create new • Take the feedback • Empathy • This is really tough • Yes it is complex… • Do this when you want that

43. Post Implementation

44. Post-Implementation: • Two-Week Tweak • The “Stat Sheet” • Feedback

45. Post-Implementation:

46. Post-Implementation:

47. Post-Implementation: • Quick changes • Set standards for communication, changes, and feedback. • Always things to add • Additional first nurse guidelines • Communication • On-Going !!!

48. Post-Implementation: What Really Helped? • Interoperability essential - SSO • Implementing at one site at a time. • Identified process issues that were not anticipated…..only one site felt the pain. • Paper Capoe • Physicians became familiar with the “look” of the order sets. • CAPOE feedback, “Stat Sheet” , Two Week Tweak

49. Post-Implementation: What Really Helped? • Nurse and physician super users present at go-live to provide education and relieve some of the clinical pressures. • Steering Committee oversight.

50. Positives • Billing and revenue • Hospital’s contribution to margin 8.5% • ED as well but has a documentation system as well. • Speed to testing • Length of Stay • Down @ LVHM – up @ others • Census up @ all • Tracking Orders