Don't Forget CPOE

June 24, 2011
It's difficult to pick up a trade journal these days without finding an article on EHRs or community data-sharing initiatives now being called RHIOs.

It's difficult to pick up a trade journal these days without finding an article on EHRs or community data-sharing initiatives now being called RHIOs. Of course, some may wonder what ever happened to computerized physician order entry (CPOE) and if the new EHR/community data sharing movement is just a fad.

The truth is that CPOE is still as relevant as it was five years ago, and that EHRs and clinical data sharing initiatives are really just the next logical step in terms of widening the vision and the use (read, "value") of information system technology.

No one debates that CPOE at this point is still not widely implemented, as reported by anyone's survey you choose to look at, but the reasons for promoting its use have not faded at all. Certainly the industry has learned that patience has to be part of the implementation process, and that the goal shouldn't be to be 100 percent CPOE in some pre-determined timeframe. The initial efforts at Los-Angeles-based Cedar Sinai and, more recently, at Children's Hospital in Pittsburgh have taught us that.

The study done at Children's was significant in pointing out that, at the end of the day, workflow has to be taken into consideration when implementing CPOE, but that CPOE still holds tremendous promise. After implementing CPOE, Children's reported a 75 percent decrease in adverse drug events in 2004, for example. I've often thought that the adoption of an application like CPOE would be evolutionary as opposed to revolutionary, and that a facility didn't need to be 100 percent CPOE, or even near 100 percent, to start seeing some tremendous benefits.

The Arnot approach

As a facility that functions in a very competitive environment — with five other facilities within a 25 mile radius that share many of the same providers — our approach to CPOE has been to allow providers to use as much or as little as they choose to, and working with them to identify ways that we can make it more productive and efficient for them, and drive the clinical benefits as a by-product. With a core group of slightly more than 50 providers utilizing CPOE now, we have seen the volume of medication orders with this group grow from an average of 20 percent at the beginning of 2005 to over 55 percent by year end. One physician in particular likes to tell his peers that he can "do rounds from the comfort of his home while sitting around in his underwear."

The experience of this group has generated additional interest from other non-participating providers, so we expect both the number of users as well as the volume of orders to continue to increase. We still do not have an "end date," though, mainly because we have chosen not to mandate its use, and also because we want to avoid any of the issues that others have encountered trying to do so.

Of course, part of the strategy behind increasing the utilization of CPOE is to increase the amount of useful patient information providers can access online, and from locations where it can be of the most value. That means being totally sensitive to the workflow of the providers, and not creating unintended obstacles that make it harder to use the technology. Granted, sometimes this is a balancing act, because very often you have to modify the workflow itself to maximize the gain, and some providers will resist this unless the efficiency gained is overwhelmingly apparent, and not achieved at their expense.

Workflow and the EHR

If workflow is important for CPOE, it is perhaps even more important to EHR adoption, which impacts providers in the environment they spend most of their time in — their offices.

Our experience with the use of the Raleigh, N.C.-based Misys Healthcare Systems CPR system with CPOE and acute-care clinical automation led to interest in automating the clinical record in the ambulatory environment, where the provider's objective was to achieve the same level of efficiency and convenience they enjoyed with the acute-care system.

The process started with a group of 65 affiliated providers. One thing we decided to do when we conducted our review of vendors was to invite all of the independent providers in our community to the system demos, so that they could begin to see what systems were available, and how these systems could impact their practices. Even though the independent providers knew they would have no vote in terms of what system our affiliated group selected, we had a tremendous response to our invitations to attend the demos.

Our affiliated group, after an exhaustive search, finally selected the Misys EMR system, and we began implementing that system in their offices in 2005. Now, less than a year later, we have it live in 12 of 22 office locations, and perhaps more importantly — as a result of including the community-based independent physicians — we now have two other practices that signed contracts with Misys for their systems, and two others that are interested in implementing the system in their offices.

So now, with this interest, initially created through the success of the Misys CPR system, along with our invitations to attend the demos for the ambulatory systems, we have an informal community EHR effort being created, and have subsequently filed for a New York State Department of Health grant with a group of four providers to help offset the initial capital costs of their ambulatory clinical system.

We now plan to also work with the local Independent Practice Association to keep the independent providers current with our progress and future grant opportunities. We are also working with Misys — a partner in the Integrating the Healthcare Enterprise effort of interconnecting different vendor's products — to provide a seamless connection between disparate information systems, including order entry, results return, pre-registration functions, and sharing clinical information between the two venues of care. This will provide tremendous levels of benefits to patient-care providers that will be able to retrieve patient information on any given patient from both environments.

For example, emergency department physicians will be able to see a patient's complete medication profile — both from prior inpatient stays — as well as their current profile with their primary care physician. Our hospitalists will be able to see a more complete medical record for the patients assigned to them, and primary-care physicians will also be able to see both the acute-care and ambulatory clinical records for their patients.

While implementing acute-care clinical information systems is viewed as being a requirement for promoting the use of applications like CPOE, there is a natural evolution and logic from CPOE towards creating a demand for ambulatory clinical information systems, and subsequently, data sharing between physician practices and the acute-care environments. They are not mutually exclusive, but interconnected and related, and focusing on workflow in the EHR environment may be equally, if not more important, than it is in the acute-care environment. Keeping this in mind will be essential as one moves towards a RHIO/EHR vision.

Author Information:Gregg Martin, MBA, CPHIMS, is CIO at Arnot Ogden Medical Center, Elmira, N.Y.

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