Rolling out computerized physician order entry (CPOE) in one hospital is challenging enough, let alone in 26 hospitals over 28 months, like the Adventist Health System (AHS) accomplished earlier this year. AHS (based in Orlando at its flagship, Florida Hospital) achieved this feat by engaging hospital leadership at each institution and adhering to a consistent CPOE deployment methodology.
This rapid CPOE deployment earned AHS recognition as a finalist in the 2011 Healthcare Informatics Innovator Awards program. That program recognizes leadership teams from patient care organizations—hospitals, medical groups, and health systems—that have effectively deployed information technology in order to improve clinical, administrative, financial, or organizational performance.
In order to enhance its system for CPOE support, AHS invested in more than two years in development of evidence- and expert-based content through an ambitious project led by the AHS Office of Clinical Effectiveness in collaboration with three other large faith-based, community hospital health systems and its vendor, the Los Angeles-based Zynx Health. “We spent three years prior to kicking off our first project in developing corporate content around order sets and using Zynx and also 10 physician teams, where we looked at content and not only leveraged our Zynx relationship, but also created a collaborative with a couple other health systems to develop content like in pediatrics where we needed to supplement,” says Phil Smith, M.D., vice president and CMIO.
In addition to creating a robust content catalogue prior to CPOE rollout, AHS invested four years starting in 2004 to migrate all of its hospitals to the same core clinical system from the Kansas City, Mo.-based Cerner Corporation. In May and June 2009, AHS Health System Information Services (AHS-IS) piloted CPOE at Takoma Regional Hospital (Greeneville, Tenn.) and Florida Hospital Zephyrhills (Zephyrhills, Fl.). Smith says Florida Hospital Zephyrhills was chosen as a pilot site partly because he had previously served as CIO there and partly because it was close to the flagship hospital. Takoma was chosen because it was last to go live on the system’s core clinical system. “[Both hospitals] had had very good successes with leadership teams, and we really believe that the executive teams are the key to successful CPOE,” says Smith. “We surveyed all our executive teams who wanted to go first, and they rose to the top.”
The first pilots were used to test and build the intricate methodology that would allow the AHS system to continue its rapid CPOE deployment. “We did two pilots because we wanted to have one pilot to test the build and one to test our methodology, which is, can you bring up a hospital one month later and do that 25 times,” says Smith. A few months after the two hospitals went live, his system waited a stabilization period of a few months before tackling the third hospital in April 2010.
Lessons Learned from CPOE Pilots
The Takoma and Zephyrhills pilots helped the AHS-IS team further identify lessons learned that were incorporated into planning for the system-wide rollout. Some of those lessons include:
- Multiple processes have been found that are frequently less than ideal prior to CPOE and become magnified when CPOE is implemented. It is imperative that the sites understand the actual current state of these processes, and the gap between how they think they function, and how they will function in a CPOE future state. These investigations must involve end users and their daily reality, and not rely on management’s perception of what the processes are (i.e. medication reconciliation).
- The facility must invest time to understand how CPOE changes some major common processes such as direct admissions, ED admissions, ED holds, consultations, compliance with co-signing verbal/phone orders within 48 hours, admission process, transfer and hand-off processes, chart reviews (abstractors, quality, HIM, etc.), chart orders review (shift review of orders by nurses), discharge process, and initial medication history.
- Proper usage of clinical tools such as the patient access list (PAL) and the multi-patient task list is key.
- Well-trained and engaged physician liaisons and super-users (the latter on each unit/department) are extremely important for process reviews, training, activation support, and ongoing support of all users, including physicians.
- Health information management (HIM) and coding processes, as well as concurrent scanning and impact of physician documentation on HIM processes, are important to review.
Through the two pilots, AHS refined it complex deployment methodology, which allowed for a 7.5-month engagement window before go-live. AHS identified one of the critical success factors for CPOE would be the change management efforts around the deployment. Using this methodology, each hospital meets 90 days prior to kickoff for a four-hour executive workshop that includes key directors from ICU, pharmacy, quality department, IT, as well as physician champions and clinical informatics. The group is taken through several change management exercises and 10 champions, who are all responsible for a different area (i.e. training/knowledge management, workflow, stakeholder analysis, employee engagement) are selected to lead the project. Over the following 24 hours, the 10 champions are interviewed and asked questions like: how do you feel about CPOE?, what is the business case around CPOE?, what are the current obstacles and resource problems?, how would you respond to angry physicians? This interview is followed up by administration of a survey, the Denison Organizational Culture Survey, which in 64 questions gives managers a glimpse of what is needed to emphasize and improve on at an organizational level.
The team then creates a theme for the CPOE kickoff (past themes have included NASA, cattle drive, Top Gun, and Transformers). At the kickoff the CEO does a 20-minute presentation on the CPOE process and solicits questions. Then over the next three months, the hospital will present two “sneak peeks” that are day-in-a-life workflow scenarios at town hall meetings. Training begins eight weeks prior to go live, with an active support model of super users and 10 additional support personnel at go-live.
Earlier this year AHS did a behavior analysis of CPOE usage for January and February and found that clinicians made 650,000 orders, with 68,000 alerts firing that resulted in a change to the order. “We thought that was pretty amazing that we were changing behavior on one out of every 10 orders, and we were actually seeing a change in behavior based on clinical decision support,” says Smith.
On the other hand, there were also about 10 percent of alerts that are not acted upon, says Smith, so AHS is working with its vendor to roll out a rules engine to filter out false-positive or “nuisance alerts” in October. “We’ll be the first in the industry to take [the rules engine] live across all of our hospitals, which we think will revolutionize alerting,” says Smith. “And we were able to get the leverage to get that engineering done since we have so much data on alerts because we have been willing to stay the course and understand what’s going on.”
Through Oct. 1 of this year, AHS physicians created a total of 13.3 million CPOE orders and 4 million medication orders, with 400,000 alerts firing that changed ordering behavior. There has been a 95 percent reduction in call backs from pharmacists calling physicians to clarify orders since CPOE activation. Overall corporate CPOE order rates are between 87 and 88 percent, with all but three hospitals being on 100-percent electronic documentation in the ED. The system just completed analysis on its top 10 diagnosis-related groups (DRGs), and among heart failure cases alone, there has been an 11-percent length of stay decrease and a 16-percent decrease in cost-per-case from those physicians using the corporate evidence based content.
Smith admitted a challenge from the beginning was the possibility of alienating a few physicians at each hospital who criticized the method of system optimization through rapid deployment. Smith says that it was difficult to change the methodology mid-stream since there was always three hospitals in various stages of deployment at one time. “We decided to move forward and make it happen because we were seeing so many patient safety gains that we felt it was more important for our patients to benefit from CPOE rather than stopping to leverage everything we could to make the system as great as it could be,” he says. “We settled for ‘good’ and moved forward.”
Smith says that CPOE is a major disruption and emphasizes that deployment is all about change management, which requires lots of training and investment. “I think the biggest thing is you need to incorporate your local executives at the hospital level because major change initiatives are really about disrupting the hospital environment,” he says. “When you’re at a large health system I think you’re doomed when you manage these like IT projects. They are really change management projects that require executive oversight at the highest levels.”