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: When did the CPOE implementation first begin at Winchester Hospital?
GG: For CPOE, it was two years ago in January. In the total migration to an inpatient EMR, that was one of the steps. There was nursing documentation, medication administration, and then CPOE was sort of the next step in that process.
KG: Which system are you using for CPOE?
GG: Meditech is our core system.
KG: What phase is the implementation in right now?
GG: Our hospitalists, of which there are 10, are live on all floors. And we actually have started a pilot with moving the next phase of non-hospitalists. There are five physicians who were selected.
The hospitalist group is a medical group, so the evidence-based order sets and other things we built for them lend themselves to other medical specialties. We won’t bring surgeons and the surgical folks online probably until the spring. But we’re now recruiting the community medical specialties to join us.
KG: So there are certainly multiple phases in the roll-out. When do you hope to complete it?
GG: There’s actually a mandate. Blue Cross Blue Shield of Massachusetts has set a 2012 mark, and the state board of registration of medicine jumped on with that and basically said that a condition for licensing in Massachusetts in 2012 will be proficiency in CPOE, so the physicians have stake in the game too. We hope to have our roll-out completed by the end of the calendar year 2010.
KG: It’s really interesting what Massachusetts is doing. I’m anxious to see if more states are going to follow suit. Is this something that can be attributed to the culture among Massachusetts healthcare organizations?
GG: It is, somewhat. I think part of it is the academic places are doing it just because they can, but I think they also see the benefits of it. But I think the community hospitals now, through payer incentives like this, are saying hey, ‘this is the right thing for us to be doing as well.’
KG: As a community hospital, what are some of the biggest challenges you’ve experienced?
GG: I think that for the community-based physicians who just don’t spend that much time at the in-patient facility it’s a huge challenge. So that’s why having the hospitalists as the first group, and sort of the champions of this, is hugely important. I think that if we were trying to bring this up prior to this wave of hospitalists, it would be much more difficult. On the medical side, we have physicians who may admit two patients a month sometimes. So if they haven’t been here for a month and they come back, it’s going to be challenge to keep them up to speed on changes that happened with the system, whereas surgeons tend to be here to operate on a regular basis, so they’re here. Some of the other specialties are onsite a lot, but some of the primary care physicians — who, by nature of medicine now, don’t admit that many people — are really the big challenge. So having the hospitalists go first has been a huge benefit.
KG: What about having a solid infrastructure in place — how big of a factor is that in rolling out CPOE?
GG: If you mean from the point of view of the number of places available to them, it’s hugely important. The nursing stations are pretty small in some of the older community hospitals like ours. When we rolled out the nursing documentation, we put the workstation on wheels on wireless carts out in the hallways, but they tend to migrate back to the nurses’ station inevitably. And finding more space for one, sort of trying to move the nurses out of the nurses’ station and make room for the physicians and making more devices available to the physicians, is a huge component of CPOE.
Our physicians to date have not necessarily wanted to use tablets. They prefer the desktop; they prefer to see the patient and then come back to the desktop in the nurses’ station. I think we’ll see that change a little bit over time as some of these tablets become more functional, but having enough room for them to work in the nurses’ station is probably one of the key components.
KG: I imagine that being able to anticipate what devices clinicians will want to use is a pretty significant challenge for CIOs.
GG: It is, and I think it needs to be on everybody’s radar. I’ve heard stories from other places that put a device in every room and nobody used it. They’ll put devices in the hallway between rooms and it gets used occasionally, but inevitably, people want to flock back to the ER, back to the nursing station. Redesigning those, putting as many devices as possible in there, is a challenge, but one that I think everyone needs to recognize.
And the other is that I don’t think any one size fits all. Some places just by the nature of the medical staff, may want to use tablets. For instance, with a lot of the office-based EMR systems people are getting used to using tablets in their office. So now when they come to the hospital they’re actually going to be looking for that. So I think the trend will move more toward those kinds of devices. But right now, the preference of most of our physicians is to be at a stationary device.
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.
