Winchester Hospital (Winchester, Mass.) is a not-for-profit, acute care, independent community hospital that includes a 229-bed facility as well as 17 clinical locations. In compliance with the Massachusetts Hospital CPOE Initiative, a statewide mandate issued in 2008, Winchester is currently implementing computerized prescribed order entry throughout its organization. Recently, HCI Associate Editor Kate Huvane Gamble spoke with Greeley the implications involved in a significant roll-out, particularly for a smaller organization.
KG: And what you’re also dealing with are preferences that differ from one person to the next, one department to the next. That can’t be an easy thing to balance.
GG: Preferences are always going to be different. One thing I’ve heard multiple times is that in a totally paper system, clinicians would pull the order sheet out of the chart, flip through the chart, look at progress notes, look at lab results, etc., and then while they’re reading the orders, most of the applications tend to put the order screen in one place and the data in another. So they actually have to flip back and forth between the order screen and where the patient’s information is located.
One of the hospitalists really wants to get the handheld working so that he can view data on the handheld while entering orders into the stationary PC. So I think it’s going to be an interesting combination. Even when we first rolled out to the hospitalists, even in that small of a group, we had a couple of them who wanted things to be on a handheld-type device and I had another physician whose description was, I want it set up like I’m a day trader at home. I want one screen that has the information of what’s going on with the patient on it, and the other screen to be where I’m entering orders. So we’ve got quite a wide spectrum.
KG: As far as making sure that the wireless network was strong enough to support all of the applications, how did you address that?
GG: We actually put the wireless infrastructure in place for the nursing documentation, really anticipating it to be for the entire project. But it was definitely required with nursing. We expect nurses to be at the bedside and to be documenting at the bedside. So we required that the wireless infrastructure be there for them, and we’ve had that in place for now a little over four years and we’re actually doing a major upgrade to the whole wireless infrastructure this year, because the technology has changed. Before we concentrated very much on the clinical areas, but with CPOE, the doctors may be in lounges, they may be in the lobby, they may be in other areas of the hospital when they want to place orders. So we need to expand our wireless now to basically cover the entire campus versus just concentrating on the inpatient floors.
KG: What type of networks are you looking at?
GG: We’re looking at trying to be ahead of the curve a little bit with the different bandwidths that would be available. So we would be upgrading the entire infrastructure. We are looking at the traditional Cisco-type access points, and we’re also going to be talking to some of the other vendors who have distributed antenna systems to see if that’s something we want to look at. It’s expensive, but if we could put one antenna to the building that would do IP voice data as well as telemetry and cell phone signals, that’s something we’re looking at now. So if we do a major upgrade, we will be considering those distributed antenna systems as well as the traditional access points.
KG: Is this something you did in-house, or did you seek help from a consultant or vendor?
GG: We have been looking at it on our own and we’ve also engaged a consultant to help us. We’re looking at it from a point of retro-fitting the current structure, as well as the perspective that we’re building a new building. So we did engage impact advisors to help us look at that across both places.
KG: What advice can you give CIOs at other community hospitals when it comes to implementing CPOE?
GG: As all of these kinds of projects go, especially in the advanced clinical systems world, you need to know why you’re doing it. Simply telling the physicians that they have to do it is never going to work. We worked hard to create a multi-disciplinary team and it is a quality initiative; it’s not an IS initiative. The goal of this is to reduce medical errors, and in particular medication orders, in the ordering and administrative process. So that’s our goal. It is a quality discussion, not an IS discussion. Building that team is key.
And as far as from the technical side, it really is anticipating all of these things. Being able to build an infrastructure that can adapt to it and then knowing you’re going to have to reinvest in it like we have. We built it four years ago and it’s time to reinvest in it. And it’s a substantial reinvestment. The other thing is to make sure that people don’t sort of sell it as a one-time project, because it’s not. It requires ongoing structural, infrastructure-type upgrades, and it requires considerably more support staff. These physicians are not going to sit around and wait for someone to respond to them. They expect instantaneous support when they have a problem with order entry.
And that support is not your traditional help desk support either, because they may be calling and asking a very clinical question. It’s not, ‘the mouse doesn’t work’. It’s ‘I’m trying to enter a steroid paper on this patient and I haven’t done it in six months. How do I do this’. So it requires a much more clinical level of support, whether that comes from the IS department or from some other structure is one of the key things that needs to be discussed upfront, again knowing that it’s going to increase operating costs to do this. But it’s a requirement of the system.