All or Nothing

June 24, 2011
Computer-based provider order entry (CPOE) continues to be implemented at a fever pitch, but many hospitals are finally beginning to understand

Computer-based provider order entry (CPOE) continues to be implemented at a fever pitch, but many hospitals are finally beginning to understand that CPOE is not an end in and of itself. Yes, CPOE impacts patient safety, hospital performance and streamlines the delivery of care, so we can't minimize its importance. However, successful CPOE implementation should be the culmination of a multi-year process that involves smaller steps and measurable wins along the way.

Hospitals can build a better vision for achieving CPOE implementation. They first need to decide what they want to achieve long-term and how IT will help achieve these ends. In my work with customers, I have observed that frequently CPOE is the end goal, but many steps need to be identified in between.

Three main problems have been uncovered as hospitals rushed CPOE. First, physicians have been hesitant to buy-in to the new system. Why? Because physicians will only use a system if they see value in it. And the value for them is getting information they need out of the system easily and quickly.

This leads us to the second problem. Physicians can't get all the information they need out of many CPOE systems, because they have been layered on top of disjointed, disparate systems, which usually include a mixture of electronic and paper-based records. So, in the end, physicians end up frustrated by having to run around and check different charts and systems to gain a full patient picture.

Finally, after a CPOE implementation, the reality of what it takes to make it work sets in. Vendors can be strong partners, but their incentives are to get the software into productive use and move on to the next project. The technology might be in place, but a multitude of other procedural changes and retraining must go on to accommodate the new software. CPOE invariably is a multi-year, arduous process that can end up being one of those "bet your job" projects based on its success or failure.

Go for the early wins

CIOs traditionally shy away from — or vehemently oppose — transitional technology. A long-term, grand vision is usually set forth and communicated to all staff and anything that slows that down is seen as a waste of time or money. But that line of thinking trips up perfectly reasonable executives, because affordable, practical solutions are often overlooked.

When a hospital and its IT department start a multi-year CPOE project, momentum will be strong and buy-in vigorous. But you can only feed people the dream for so long before they get weary of the daily struggle and don't experience the value they were promised.

Working towards a CPOE goal should involve smaller, practical projects that generate wins and immediate value to hospital staff along the way. These smaller projects are milestones on the path to full CPOE implementation and help ensure continued buy-in and job security.

Overlooked step

CPOE is a steady and pragmatic progression up a pyramid. This pyramid, also called the IT planning pyramid (see following diagram), outlines the steps, or framework, for achieving a fully developed CPOE system. You need to start with a vision and then work towards that vision with a series of projects.

As an example, a fundamental step that is frequently overlooked is document imaging. Many hospitals like to think that paper is going away very soon. We've all been hearing that for many, many years. The fact is that as an organization moves towards an electronic health record (EHR), it needs to aggregate and collate the paper-based data to have a complete, useful and valuable system.

Whether it's old records, insurance documents, information generated internally — such as EKG strips and OR notes, or other externally generated materials such as referrals or advanced directives — paper-based documents continue to flow into the hospital system and every hospital needs to accommodate and integrate this information for a complete electronic medical record (EMR). It's not an either/or discussion.

Information can be electronically generated and digital in nature from beginning to end, and you can simultaneously turn paper-based information easily and cost-effectively into an electronic format. The bottom line is that hospitals need to have a strategy for incorporating paper-based data that is crucial to presenting the full EMR picture.

When you look at the CPOE pyramid, scanning- and imaging-type processes are really an important step in getting physicians to effectively use CPOE. Scanning non-electronic documents allows the physician to find all the information they need in one place — the electronic chart — thereby moving the organization to a truly efficient paperless environment.

One transitional technology that is getting a second look is the tried and true concept of computer output to laser disk (COLD) feeds for data management. Known for almost 20 years as a way to capture information on laser disk for archiving, COLD feeds have undergone a transformation and are now being used by hospitals for single source, data management. COLD feeds allow hospitals to capture data residing in different systems and convert all those formats — even proprietary ones — into one, common format.

Document imaging and a number of other projects at the bottom of the pyramid are fairly quick to implement, provide healthy financial return, and help convince stakeholders, be it nurses, physicians or the board, that progress is underway.

One large hospital in Pennsylvania opted to implement an ADT (admission, discharge and transfer) interface to populate the electronic record automatically and allows 56 COLD feeds to flow into its system, removing the need for paper scanning.

This type of approach has led to short-term results, giving stakeholders immediate results and what they like to call a "practical EMR," paving the way for a longer-term move to EHRs.

In the end, CIOs need to face the fact that, one, paper is going to be with us for some time and, two, we are in a transition towards CPOE and a paperless environment.

For this hospital, the cost/value ratio is pretty impressive: reduction in full time equivalents and ability to outsource coding, 100 percent jump in medical record access by staff throughout the hospital, 53 percent increase in coding productivity and 50 percent reduction in DNFB (discharged, not final billed).

Don't cut corners

Unfortunately, many big IT vendors are weak in these transitional solutions and want CIOs focused on the large, expensive projects. CIOs should consider looking at vendors and document management solutions that deliver immediate value at little cost — especially compared to the larger, budget-hungry projects.

In the end, CIOs need to face the fact that, one, paper is going to be with us for some time and, two, we are in a transition towards CPOE and a paperless environment. For a full-fledged use of EMRs, cutting corners never works, and in healthcare IT, that's most definitely the case. Transitional technology, such as document imaging and COLD feeds, aren't sexy, but these and other projects at the bottom of the pyramid are underused but powerful tools for scoring early wins for CIOs.

Author Information:Jim Oakes, Jr., is a principal with Health Care Information Consultants, LLC (HCIC), Baltimore.

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