Atlanta healthcare organization follows the beat of a different drummer in achieving 100 percent CPOE adoption.
Leave it to a southern healthcare enterprise to develop the “Yo’ Mama” test—and then make passing it mandatory for all healthcare improvements initiated. That’s what Piedmont Hospital in Atlanta did. Simultaneously, the organization also: 1) succeeded wildly at implementing computerized physician order entry (CPOE); 2) put teeth behind otherwise flabby buzzwords like “vision” and “ownership;” 3) appeared to have fun doing it, along with a learning moment or two.
Atlanta healthcare organization follows the beat of a different drummer in achieving 100 percent CPOE adoption.
Leave it to a southern healthcare enterprise to develop the “Yo’ Mama” test—and then make passing it mandatory for all healthcare improvements initiated. That’s what Piedmont Hospital in Atlanta did. Simultaneously, the organization also: 1) succeeded wildly at implementing computerized physician order entry (CPOE); 2) put teeth behind otherwise flabby buzzwords like “vision” and “ownership;” 3) appeared to have fun doing it, along with a learning moment or two.
“Everything we do must pass the Yo’ Mama test,” says Piedmont’s Chief Medical Information Officer William M. McClatchey, M.D. “It serves as a litmus test, and 99 percent of the time, it will move an organization in the right direction. Put simply, would you want this procedure or process or technology used to treat your own mother?”
When it came to handwritten orders and progress notes—and earlier in Piedmont’s history, to medications dispensed without the benefit of automated bar-code scanning and “five rights” validation—the answers were always and decidedly no. No clinician would want his family exposed to these preventable risks.
Unfailing Vision
Piedmont Hospital, with a 100-year history in the Buckhead community of Atlanta, is part of the multifacility Piedmont Healthcare enterprise. The hospital itself is a 500-bed acute care facility with 3,000 employees and more than 800 board-certified physicians.
McClatchey is a believer in the power of vision, especially where implementation of new workflows based on new systems are concerned. “To any organization, I would say: Develop a sound vision, and then keep repeating it over and over again,” he advises. The drivers of Piedmont’s vision were patient safety and quality of care. To achieve the best of both, Piedmont Hospital’s senior executives decided it was essential “to make all clinical information available to any appropriate provider in any geographic location,” says McClatchey. “No one stays in one location. If a physician spends one hour a day in the hospital and 11 hours a day elsewhere, access to data needs to be elsewhere. We need to push information to wherever the clinician is.”
So entrenched and pervasive is the Piedmont vision, with its unwavering focus on patient safety and quality of care, that it serves as the foundation of an ongoing enterprise transformation. “CPOE alone was never the vision,” says McClatchey. “CPOE is part of the larger tapestry, and at Piedmont, the tapestry is a project known as QUEST,” an acronym that stands for quality, uniformity, efficiency and safety through technology. QUEST includes CPOE, computerized clinical documentation by nurses and physicians, automated medication administration, pharmacy robotics and remote access to data by all affiliated physicians. It also represents, year after year, the veritable destruction of paper-based forms and workflow that depend on them, as well as adherence to automated standards of performance.
As noble as patient safety and quality of care are, utilizing them as the cornerstones of Piedmont’s vision wasn’t a fait accompli; it was a reasoned decision. McClatchey says that the efficiencies and cost-savings gained by automated clinical systems, while verifiable in most healthcare organizations and touted by vendors as a reason for purchase, “won’t make physicians climb the mountain they need to climb” to switch from paper to computers. But improved safety and quality of care will.
Beat of a Different Drummer
Piedmont relies on clinical systems and the Sunrise Clinical Manager suite of products from Eclipsys Corp., in Boca Raton, Fla., for a healthy portion of QUEST, especially CPOE and physician and nurse documentation.
Once the Piedmont vision was cemented, “we needed to get physicians invested in it and owning its organizational structure,” says McClatchey—and that’s when the organization also began marching to the beat of a different drummer. Unlike most organizations with typical steering committees and representation from multiple departments, Piedmont hand-selected physicians to join a physician user group (PUG)—and then paid them for their participation.
Nearly 30 physicians were selected for the PUG, chosen for their diversity and professional interests, and from an array of medical disciplines, and McClatchey spent time individually with each physician to ensure that he understood the nature and goals of the QUEST project. Paying them was incredibly smart. “Do we value their participation? Of course,” he says. “We value their expertise, we hold them accountable and we compensate them for their contributions.”
McClatchey says while physician compensation for participation in a PUG was “chicken feed” compared to the overall costs of QUEST, it sent the right message throughout the enterprise: Piedmont was serious; patient safety and quality of care were drivers of QUEST; and physicians were the owners of the CPOE system.
The PUG physicians organized into four groups, each with a chairman, and the four chairmen constituted a physician executive committee that met weekly for tactical decision-making. “It’s a very different experience having doctors drive the process, rather than administrators,” says McClatchey. Because the physicians were hand-picked, formally aligned into user groups, compensated and committed to bringing all other Piedmont doctors into the circle, “we were able to shift the cultural norm, to gain physician interest and leadership beyond the PUG and to use peer pressure in a positive way.”
No Mandatory Adoption
Many healthcare organizations purchase CPOE systems, only to experience a two- or three-year gap between purchase and go-live. That’s because some products require substantial customization of alerts and decision-support warnings to prevent physicians from abandoning the products early.
Not so with the Eclipsys CPOE software. The hospital did commit nearly a year to up-front customization of the software, but McClatchey says the application always felt more like a toolkit that allowed end-users to construct functionality to meet department and specialty needs, rather than having to first bypass or workaround alerts to arrive at the desired level of functionality.
That forward-moving style of customization fit Piedmont to a tee because of its incremental implementation approach. “We decided against the big bang approach,” says McClatchey. “Big bang assumes you know what you’re doing from the get-go. We were convinced we needed the opportunity to pilot new workflows, processes and systems on a unit basis—and to refine and enhance at that level, too.”
The orthopedic unit was the first site for CPOE rollout because of the prevalence of tech-savvy nurses. “It was the right decision,” says McClatchey. “The enthusiasm of the nurses was key to success in that area; it set the tone of success from the start.” From the outset, Piedmont made it clear to physicians: CPOE adoption was not mandatory. Individual departments could run parallel systems, and physicians who preferred paper orders could continue generating them. “This approach let us focus on the physicians who embraced CPOE, first making sure they were able to maximize it. We knew we might have to deal with resisters later.”
The Physicians’ Own Manifesto
Three months later, with orthopedics on board, Piedmont turned its attention to the OBGYN area where, again, CPOE had been advertised as not mandatory—and again, the beat of a different drummer surfaced. Two weeks before go-live, one OBGYN physician suggested that CPOE should be mandatory from day one. “I never expected to see that happen,” says McClatchey, “but the word was out: CPOE was the safer, smarter approach.”
McClatchey himself was nervous; the PUG didn’t necessarily support an instant metamorphosis in workflow and procedures; and no one was sure how much support IT staff could render on a dime. The OBGYN doctors voted and decided to implement CPOE optionally for two weeks, and then to make it mandatory throughout the department. They also decided that running parallel systems was an invitation for error, opting instead for a mini-big bang at the departmental level after the two-week optional period.
Simultaneously, three OBGYN physicians presented themselves to the physician executive committee and offered to work full-time with their colleagues during the optional period. They were immediately absorbed into the PUG where their expertise and enthusiasm were capitalized on and where they were compensated. Two weeks later, the OBGYN department achieved its objective without the use of parallel systems.
“It took us about 15 months to roll through the institution with CPOE,” says McClatchey, noting that every subsequent department’s rollout resembled orthopedics rather than OBGYN. He says, he was not bothered by the temporary and initial spike in potential errors as the software gained users and advocates. “The introduction of CPOE will initially produce a higher error rate as clinicians learn the system.” Physicians and hospitals need to expect that, he cautions. “Then it drops, then eventually we see a reduction in error rate. For a brief time, it can produce organizational chaos, but everyone has to climb the mountain to get to the valley on the far side.”
Paper Crashes and Burns
Unlike many organizations in the midst of automation transformation, Piedmont elected to launch Eclipsys’ CPOE before rolling out computerized clinical documentation for physicians and nurses. “Most organizations embrace clinical documentation first,” he says, “to have it available at the time of ordering. We decided to pursue CPOE first, because we had numerous data driven elements in the system from day one,” such as radiology, pharmacy robotics with completely bar-coded and unit-packaged medications, plus an automated medication administration system.
“If you look at most institutions, pharmacy management and delivery is a prime area for error. Our error rate, in terms of duplicate medications or misdosing, has been significantly reduced.”
Piedmont interfaced its pharmacy system with the Eclipsys CPOE software. “With CPOE, we present physicians with an inventory of standardized orders. They have a series of choices and lists of opportunities, but the series and lists are finite and based on standards.”
Like vision, workflow is another hot item with McClatchey. The American healthcare system, he says, “is sloppy. Doctors have not been held to standards of performance around workflows. For example, there is little consistency from one institution to another about how clinicians hand off care to other clinicians. Automation compels doctors to examine workflows, to articulate clearly what their workflows and processes are, and to collectively move toward the best ones.” When it comes to reducing errors, “workflow analysis is everything, and technology’s purpose is to serve workflow,” he says.
Piedmont began its CPOE rollout in January 2004, with limited software activation, no pharmacy interface and only about 5 percent adoption. Six months later, the software was fully activated, the pharmacy interface had been built and CPOE adoption exceeded 50 percent. By July 2005, adoption was at 85 percent, and by March 2006, it was 100 percent. But even with 100 percent adoption in less than two years, the best metric for Piedmont is zero, because it represents how many paper orders still exist. “On March 1, we incinerated them all,” says McClatchey. “No one writes any orders on any kind of paper anymore.”
That’s a paradigm shift that would pass the test with any activated patient—and especially with a physician’s mother.
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June 2006
