Three healthcare organizations see reduced costs, enhanced efficiency and increased compliance with CPOE systems.

Ten years ago, the healthcare industry as a whole was actively debating the merits of computerized physician order entry (CPOE) systems for hospitals. Today, that debate has changed, thanks to a growing body of evidence that points to fewer complications, lower death rates and increased efficiency for hospitals that use CPOE.

Three healthcare organizations see reduced costs, enhanced efficiency and increased compliance with CPOE systems.

 Ten years ago, the healthcare industry as a whole was actively debating the merits of computerized physician order entry (CPOE) systems for hospitals. Today, that debate has changed, thanks to a growing body of evidence that points to fewer complications, lower death rates and increased efficiency for hospitals that use CPOE.

A study recently published in the Archives of Internal Medicine, titled “Clinical Information Technologies and Inpatient Outcomes,” stated that hospitals using automated notes and records, order entry and clinical decision support recorded 55 percent lower odds of death for patients undergoing surgery for coronary artery bypass grafts; 9 percent lower odds of death for patients with myocardial infarction; 16 percent reduction in patient complications; and lower adjusted costs for all hospital admissions.

In addition, the newly signed American Recovery and Reinvestment Act of 2009 (ARRA), is expected to increase the adoption, use and resultant value of CPOE.

Stimulating Deployment

Early IT adopters have the opportunity to reap the benefit of millions of dollars in government funding from ARRA, while late adopters will begin to pay penalties starting in 2015. The difference between payment and penalty will be “meaningful use.”

Many industry experts say that CPOE use will be required for hospitals to qualify under meaningful use. For most hospitals, the new financial incentives, coupled with the expanding data that validates CPOE’s numerous quality and safety benefits, have changed the question of CPOE deployment from if to when.

While healthcare has been slow to move to CPOE, the industry finally appears to be close to a tipping point for adoption and use. According to the KLAS “2009 CPOE Digest Report,” 9.6 percent of U.S. hospitals reported some level of CPOE use in 2008, up from the 6.8 percent reported in 2007 and well ahead of the 3.5 percent reported in the 2003 study. An estimated 17.5 percent of large hospitals (200-plus beds) now have some level of CPOE use.

A paper-based transfusion order form that requested the hemoglobin value provided some initial success — until physicians stopped filling out the form. CPOE fixed that.

CPOE is a process improvement and information communication tool that helps minimize the potential for medication and treatment errors through the entire care process. When hospitals embed best practices into their CPOE systems and make that information actionable for physicians, it becomes a tool for achieving healthcare’s full potential, while also reducing its costs.

Three Illinois organizations that understand the tangible clinical and financial return on investment from CPOE include: Decatur Memorial Hospital, Decatur, which improved the blood prescribing habits of its providers, reducing risk for patients, while reducing costs for the hospital; Dupont Hospital, Fort Wayne, Ind., which enhanced efficiency in its obstetrical unit by improving medication/order turnaround times, reducing STAT medication overrides, and freeing nurses to spend more time in direct patient care; and WellStar Health System, Marietta, Ga., which increased compliance with the national “Surviving Sepsis Campaign,” and decreased the risk-adjusted mortality index and cost per case.

Making Every Drop Count

Decatur Memorial Hospital proved the value of CPOE in the appropriate utilization of blood. Because blood transfusions save countless lives, the use of blood is seldom restricted in clinical practice. There are compelling reasons, however, to monitor and guide the use of blood products, particularly in the patient safety arena. In short, if patients do not need blood transfusions, they should not receive them.

In 2006, hospital staff researched and settled on evidence-based guidelines for the appropriate use of blood. The goal was to reduce the use of blood in patients who had a pretransfusion hemoglobin of eight or more. A paper-based transfusion order form that requested the hemoglobin value provided some initial success — until physicians stopped filling it out. The use of CPOE prompted improvements.

First, the hospital created simple transfusion order sets in the system, with an option to order one unit at a time and get new blood counts before ordering more. Next, they created an “iForm” that required clinical reasons for transfusion and set a threshold of eight grams per deciliter to guide physician decisions around the need for transfusion. The iForm gives physicians easily retrievable lab data for clinical reasoning, while embedded logic justifies ordering and creates a feedback loop to help determine the need for additional units.

Despite some early resistance, Decatur Memorial achieved universal use of the transfusion iForm and saw the following results over a two-year period: Blood use decreased from an average of 290 to 245 units per month; mean hemoglobin values decreased from 8.25 to 7.9; hemoglobin after transfusion decreased from 10.1 to 9.7; and financial savings of $126,000-$270,000 per year were realized.

Although its obstetrics unit consistently achieved a high level of patient satisfaction, Dupont Hospital decided its birthplace unit was a starting place to improve the timeliness and efficiency of care. CPOE proved to be the right means to that end.

The Dupont team saw CPOE as the tool to help reduce the time spent transcribing medication orders, faxing them to the pharmacy and deciphering illegible handwriting — streamlining the ordering process to reduce the time between physician order and patient receipt. Dupont went live with physicians using the CPOE system in May 2007.

When hospitals embed best practices into their CPOE systems and make that information actionable for physicians, it becomes a tool for achieving healthcare’s full potential, while reducing its costs.

With 127 physicians and mid-level practitioners entering an average of 60,000 orders each month, CPOE has practically eliminated delays caused by illegible handwriting; reduced the time from when a physician orders a medication to when it is administered to the patient by 49 percent; and reduced the need for nurses to use STAT overrides in medication cabinets by getting medications to expectant mothers faster by 24 percent — a key factor in improving patient safety.

Stamping Out Sepsis

At WellStar Health System, improving care of sepsis patients began as a hospital-based initiative to implement guidelines approved by the Surviving Sepsis Campaign, a partnership of the Society of Critical Care Medicine, the European Society of Intensive Care Medicine and the International Sepsis Forum. Teamed with the Institute for Healthcare Improvement, the Surviving Sepsis Campaign set a goal of reducing sepsis mortality by 25 percent within five years of its inception in 2004.

As the 10th leading cause of death globally, sepsis has a mortality rate of 30 percent to 50 percent and as high as 60 percent when shock is present. There are approximately 750,000 new sepsis cases each year, with at least 110,000 fatalities in the United States alone. Challenges in prompt diagnosis mean that more than 10 percent of sepsis patients experience delays in treatment, with a resulting increase in mortality.

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WellStar deployed CPOE initially in the emergency department of its Kennestone facility in Georgia. It incorporated sepsis bundles (groups of interventions related to a disease process) and a comprehensive clinical process within its CPOE system to put best practices and clinical content at the clinician’s fingertips.

By building order outlines that document WellStar’s clinical treatment approach, physicians were able to order the correct antibiotic regimen. With a single click, a physician can order the right antibiotic and the right dose, coupled with support that warns of allergies or potential drug interactions. Consensus-driven content developed by the Surviving Sepsis initiative, combined with guidelines developed by WellStar’s own sepsis committee, ensures the interventions continue without interruption when septic patients move into intensive care.

Leveraging order outlines, WellStar increased the effectiveness of emergent interventions, ensuring that all required diagnostic measures were initiated upon each patient’s arrival. By taking a systematic and evidence-based approach to diagnosing and treating this deadly and often under-recognized condition, WellStar achieved significant improvements in patient safety, including: saving 11 lives, reflecting a 14 percent decline in the ratio of observed-to-expected deaths; reducing risk-adjusted mortality index for septic shock by 17 percent; reducing length of stay for severe sepsis and septic shock by 10 percent; and, decreasing the cost per case for severe sepsis and septic shock by 4 percent.

Achieving the Full Potential of Healthcare

There is still much to be sorted out regarding how physicians and hospitals will qualify for the economic stimulus funds. Improving patient safety, supporting evidence-based care, providing continuity across care transitions, and meeting regulatory requirements will surely play a role. If you ask the clinicians and staff at Decatur, Dupont, WellStar and many more, they’ll tell you that you can’t do it without CPOE.

Gerry McCarthy is VP, Product Strategy, Health Systems Solutions for McKesson Provider Technologies.

June 2009

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