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Conversion to CPOE – Evidence Based Medicine. Mike Gorczynski, D.O. Director Medical Informatics Aurora Health Care. Regional User Group 10:00am May 1, 2007 M:\MIKEGSKI\Demos\RUG Order Sets May 2007.ppt. Who is Aurora Health Care?. Integrated Delivery Network 13 Hospitals (40-600 beds)

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Conversion to cpoe evidence based medicine

Conversion to CPOE – Evidence Based Medicine

Mike Gorczynski, D.O.

Director Medical Informatics

Aurora Health Care

Regional User Group 10:00am

May 1, 2007

M:\MIKEGSKI\Demos\RUG Order Sets May 2007.ppt

Who is aurora health care
Who is Aurora Health Care?

  • Integrated Delivery Network

    • 13 Hospitals (40-600 beds)

    • 120 Outpatient Clinics

    • 140 Retail Pharmacies

    • Long Term Care

    • Home Health Services

    • Hospice Services

    • Laboratory Services

    • One of the nation’s “Most Wired” hospitals in 2004 & 2005 & 2006

  • Private, non-profit, teaching organization:

    • 684 employed physicians

    • 3,200 physicians on staff

    • 27,000 employees

    • $2.9 billion annual revenue

    • 0.5 million IP days/year

    • 2.3 million OP visits/year

    • 0.25 million ED visits/year

    • 0.3 million Home Care visits/year

    • 5.6 million retail Rx/year

Emr applications at aurora
EMR Applications at Aurora

  • Hospital “Core” systems implemented from 2000-07

    • Patient Access (Registration & Scheduling)

    • PowerChart Orders, Results, Charges

    • Radiology, Surgery, Emergency Dept

    • Pharmacy

    • Interfaces: Lab, Transcription, Dietary, Digital Imaging

  • “Advanced” product implementations under way

    • PowerChart Office in Clinics (75% done)

    • Multidisciplinary Clinical Documentation & eMAR (85% done)

    • Barcode Medication Administration (new)

    • CPOE (Pilot = May 2006, rollout Feb 2007)

  • C omputer p hysician o rder e ntry
    Computer Physician Order Entry

    The Vision

    • 1995 - Computer-based Patient Records (CPR), including CPOE

      The Urgency

    • 1999 - Institute of Medicine - “To Err is Human”

      The Impact

    • reduce morbidity, mortality, and costs

      The Challenge

    • engage physicians in computer dialog without adversely impacting productivity



    Order sets choose a strategy
    Order Sets  Choose a strategy

    • Hospital-specific

    • Region-specific

    • Enterprise standard with boundaries

    • Enterprise standard

    Aurora Health Care wide order sets.

    CPOE Physician Champion Council



    1.Approve the strategic approach to safety

    2.Approve goals

    3. Strategic monitoring of Patient Safety Program and team recommendations

    1. Communicate Vision, and implementation plans to each Medical Department

    2. Assist soliciting participation in Evidence-based Order Sets Development process.

    3. Enthusiastic user and vocal champion

    4. Along with lead hospital administrators, identify challenges and plan change management tactics



    1. Oversight of Care Management and Patient Safety strategies

    2. Participate in development of strategic approaches to quality and safety

    3. Review and approval of specific goals and objectives

    4. Direct successful accomplishment of goals and objectives



    Quality Council

    1. Benchmarking

    2. Data management

    3. Performance measures

    4. Facilitate project teams

    5. Education



    Clinical Informatics SubCommittee

    1. Provide direction for Clinical Information technology efforts to ensure business objectives for CM, Patient Safety, and clinical process improvement

    2. Identify and sponsor projects that promise value, identify barriers, and suggest measures of success

    1. Communicate Vision, and implementation plans to each Medical Department

    2. Assist soliciting participation in Evidence-based Order Sets Development process.

    3. Enthusiastic user and vocal champion

    4. Along with lead hospital administrators, identify challenges and plan change management tactics

    CPOE Physician Champion Council


    Expectations wide order sets.

    Attend meetings

    Communicate with all relevant medical staff

    Communicate back to IS

    Use CPOE when your hospital is implemented

    Compensation for your time

    Communications wide order sets.

    • System Leadership 21

    • Physician 198

    • Regional/Hospital Leaders 36

    • Care Management/Quality 19

    • Other 12

      TOTAL 286

    Recruit clinical subject domain experts aka medical facilitators
    Recruit Clinical Subject Domain Experts wide order sets.aka“Medical Facilitators”

    “Believe” in EBM and in CPOE

    Respected by medical staff

    Review literature when necessary

    Encourage participation by all members of medical staff

    The standard aurora process
    The Standard Aurora Process wide order sets.

    Zynx Templates and Evidence

    Existing Order Sets

    Internally developed EBM citations


    Development Session

    Rendering for CPOE and ePPO

    Expert Panels

    Departments Review

    All Physicians Invited

    Expert Medical Facilitators Selected

    Pharmacists, Nurses, Care Managers Invited

    Guides to order sets topic selection
    Guides to Order Sets Topic Selection wide order sets.

    • It is a problem...

    • …that is commonly occurring

    • ...for which the interventions ordered vary widely

    • ... though uncommon, has a widely accepted though complex medical management approach

    • ... for which interventions ordered require time-consuming human-computer interactions

    • ... where there is a goal to improve a minimum service level

    • ... for which there is a high likelihood of achieving consensus regarding medical management

    • ... for which scientific rationale exists

    Order set development guidelines
    Order Set Development Guidelines wide order sets.

    • Orderables compliant with 90 – 10 rule

    • Mandatory, default, or optional

    • Comments on orders

    • Links to evidence – Zynx and non-Zynx

    • Suggestions for interruptive alerts

    • Support system Care Management initiatives

    • Support regulatory requirements and CMS requirements

    Links to evidence from within patient chart
    Links to evidence from within patient chart wide order sets.

    Links to evidence


    Zynx summary and rationale
    Zynx Summary and rationale wide order sets.


    Keeping track of order sets
    Keeping track of order sets wide order sets.

    Some statistics 200 standardized order sets
    Some statistics… wide order sets. ~200 standardized Order Sets



    Number of Drs participating 73 165

    Number of Nurses 33 69

    Number of Pharmacists 11 70

    Number of CM 17 41

    TOTALS 134 345

    Physician specific statistics
    Physician-specific statistics… wide order sets.

    Physicians participating OS development 73

    Supporting physician leaders 200

    TOTALS “informed” and/or participatory273 (38%)

    Physicians comprising 85% of admissions 722

    Therefore, 273 of 722 “busiest” physicians are well-informed and/or have particpated (38%) .

    Do’s wide order sets....

    • Do get pharmacy input for every session, they are INVALUABLE

    • Do recruit physicians with a 1:1 conversation

    • Do explain “critical mass” as sum of {system + personal}

    • Do figure out who in your organization will do the work

    • Do encourage suggestions for Comments, Alerts, and Horizontals

    • Do keep track of sessions with detailed instrument

    • Do develop a migratory deployment plan

    Cpoe full house go live
    CPOE Full House Go-Live wide order sets.

    • All departments beyond pilot Units (Peds, OB, ED, Anesthesiology)

    • February 12, 2007

    • Exempt: Milwaukee Cardio Group, Interventional Radiology

    • Exempt providers still expected to electronically sign verbal orders

    33%ile 50%ile 85%ile 90%ile wide order sets.

    • Utilization is underestimated by: wide order sets.

    • Exempt physicians (imminent retirement, locums)

    • Orders that spawn increases to denominator (e.g. range orders, sliding scales)

    • Learning curve data included in cumulative stats

    Assuring safety and quality
    Assuring Safety and Quality wide order sets.

    • AMCO Benefits Measures

    • CMS, Premier Measures

    • Medication Orders Monitoring

    • IS Issues Database

    • Incident Reports

    Amco benefits measures tbd
    AMCO Benefits Measures - TBD wide order sets.

    * Data will be indexed by number of discharges

    Cms premier measures
    CMS Premier Measures wide order sets.

    Medication orders monitoring
    Medication Orders Monitoring wide order sets.

    Summary pharmacy interventions logged:

    Drug dose 35

    Start and Stop dates 14

    Duplicate Drugs 13

    Allergies 7

    TPN problems 7

    Drug Interactions 6

    Others 39

    Totals 121 (38 days  3.1 per day)

    Benchmark = 170 (90 days 1.8 per day)

    Is issues database
    IS Issues Database wide order sets.

    Discontinue PowerPlan on Pt XXX (2)

    Orders placed on wrong visit (2)

    RPh needs to change time of Rx order

    PCA ordered on hold x 24 hrs

    RT documentation not adequately descriptive

    The vision did we achieve it
    The Vision – did we achieve it? wide order sets.

    Success – a negotiated entity

    • Utilization


    • Clinical transformation

    The vision
    The Vision wide order sets.

    The most important outcome for Aurora’s first sites is that we be successful.

    Success is most tightly linked to utilization by physicians.

    Utilization versus clinical transformation
    Utilization wide order sets.versus Clinical Transformation


    • Change behavior without adversely impacting productivity

    • Legibility

    • Remote ordering capability in context of clinical data


    • Order Sets preferable to no Order Sets

    • EBM OS’s preferable to OS without EBM

    • Standardization – even in absence of EBM leads to improved outcomes

    Order sets usage 2 12 4 10 07
    Order Sets Usage wide order sets.(2/12 – 4/10/07)


    8%opportunity to move to standards


    N = 3798