Tip:
Highlight text to annotate it
X
CPOE in Rural And Critical Access Hospitals MALE SPEAKER: Welcome to Computerized Physician
Order Entry in Rural and Critical Access Hospitals. During this session, participants will learn
best practices when implementing new CPOE processes, participants will learn strategies
to address rural environmental factors for critical access in rural hospitals, and participants
will learn about strategies for proper automation of prescription work flows. Iíd like to now
give our panelists an opportunity to introduce themselves.
TAMMY FLICK: Hello, my name is Tammy Flick. I am a registered nurse by background. I am
the Lead Health IT Advisor for Telligen, which is the regional extension center for Iowa.
I have worked in the hospital setting for 17 years, including working for a critical
access hospital as the Director of Informatics. My clinical background includes: in the emergency
department and the intensive care departments. PAUL MOORE: Hi, Iím Paul Moore, and I have
the privilege of serving as the Senior Health Policy Advisor for your federal Office of
Rural Health Policy. Probably more important to this audience today is that I am a former
critical access hospital administrator. Iíve been where many of you are, and I look forward
to sharing with you today. SCOTT PETTIGREW: Hi, Iím Scott Pettigrew.
I am a Medical Practice Consultant at HealthBridge in the tri-state regional extension center,
located in Cincinnati, Ohio. I have 15 years of medical IT experience, and more specifically,
15 years in experience in helping clinicians and -- utilize CPOE in their practices. I
started out with PocketScript, which was one of the nashunt [spelled phonetically] e-prescribers,
coming out in the late 1990ís and in the early 2000ís, and did implementations all
over Massachusetts, Texas, California, and basically all over the United States. Iím
currently working, as I said, as a Medical Practice Consultant in the regional extension
center here in Cincinnati, helping practices achieve meaningful use with -- and I specifically
focus on IT issues. MARY ZILE: And this is Mary Zile. Iím a registered
nurse as well, with a Masterís in Health Services Administration. I have extensive
experience in cardiac surgical intensive care at various hospital settings, occupational
health, urgent care, primary care offices. And I implemented an EHR [spelled phonetically]
in 2001. And I have extensive experience in regional quality improvements that weíve
had in the Cincinnati region, including patients that are medical home or public reporting
pilots, health measures and Bridges to Excellence, and the Primary Care Innovation Group through
the Robert Wood Johnson Foundation. And I implanted an EHR in 2001 in our rural critical
access hospital located over an hour from Cincinnati.
MALE SPEAKER: Okay, thank you. And Mary Zile and Scott Pettigrew will present first.
MARY ZILE: Okay. We are presenting on the critical -- CPOE barriers and best practices
for rural and critical access hospitals specifically from the physician and provider viewpoint.
I will be addressing barriers, and then Scott will follow up with best practices.
When you ask -- when you talk about CPOE on clinicals, when you talk about CPOE, you have
to understand what has been the problems in the past with the paper-based medication prescriptions.
The Institute of Medicine of the National Academy of Science has had -- done extensive
studies to show that 7,000 Americans die annually due to preventable medication errors, 1.5
million are injured, 1.5 to four percent of prescriptions are in areas -- are in error,
which result in serious health effects, and five to 18 percent of ambulatory patients
experience adverse drug effects. This costs in excess of $2 billion per year. This is
because of patient safety errors, which include: illegible hand writing, incomplete order,
inappropriate medication selection, dosing, or frequency of medication administration,
or the inability to check electronic interactions such as drug-to-drug, drug-to-allergy, drug-to-disease,
and drug-to-lab interactions. And I have specific examples of patients who
were on Coumadin from us and Dicoumarol from the specialist, or Lasix from us and Furosemide
from the specialist, or an actual patient death resulted from a Penicillin allergy because
the specialist did not have interactions with the electronic CPOE. So, itís very important
to me to be a part of this process to help educate people, especially with the limitations
in the critical access hospital communities. Another problem for paper-based medications
is thereís a reduction in provider and prescription -- prescriber and pharmacy efficiency. Pharmacies
get over 150 million calls per year. These calls [inaudible] physician practices, and
Medical Group Management Association says that thereís over $19,000 associated with
the practice in receiving these pharmacy calls. And thatís for manually processing refills,
resolving issues related to formulary, and resolving issues related to dosage and legibility.
Thereís also unnecessary variations in care, unnecessary adhering to medication and treatment
guidelines, and difficulty adhering to a formulary when youíre on a paper system. More than
3.52 billion prescriptions are written annually within the United States, with an expected
growth of over 4.3 per year. And so, you can see in a paper system, this becomes untenable,
undoable, and an unsafe environment for patients. So, why use computerized CPOE? In addition
to the statistics that Iíve already quoted, the Institute of Medicine reports, through
the Harvard Medical Practice study and the Colorado and Utah Hospital study, in addition
to the New York studies, indicate that 44,000 to 98,000 Americans die each year as a result
of medicine errors. This makes this the eight leading cause of death, and more people die
from these medical errors in a given year than from motor vehicle accidents, breast
cancer, and AIDS. So, going to the CPOE definition, itís a
system for direct entry of one or more types of medical orders by a physician into a system
that transmits those orders electronically to the appropriate department. It includes
alerts, drug information, access to evidence-based clinical guidelines, and some degree of decision
support functionality. It includes physicians, but it also includes other practitioners,
like nurse practitioners, who are able to write prescriptions. And so, when you discuss
CPOE, you need to include all practitioners in that category.
As a summary of Stage One and Stage Two for eligible hospitals and critical access hospitals
regarding CPOE, the Stage One objective says to use CPOE for medication orders entered
by licensed healthcare professionals. And the measure states for more than 30 percent
of unique patients with at least one medication in their medication list admitted to the eligible
hospital or critical access inpatient or emergency department.
The differences in Stage Two shows that the medications CPOE goes up from 30 percent to
60 percent, and then it also adds laboratory CPOE for a 30 percent threshold, and radiology
CPOE for a 30 percent threshold. Now, you have a CPOE conundrum. If processing
a prescription drug order through a CPOE decreases the likelihood of error on the order by 48
percent, why is everyone still on paper and why isnít everyone using CPOE? There was
a study done from AMIA, American Medical Informatics Association, co-authored by David Blumenthal,
that talked about the major barriers to CPOE implementation in hospitals, specifically
in critical access hospitals. The two major barriers for CPOE implementation
are: costs, and the major strategy for overcoming this barrier is by prioritizing patient safety
at the top of the agenda. The second major barrier is physician resistance, and the major
strategy for dealing with that is to leverage strong leadership, external influence, vendor
commitment, and the presence of house staff and hospitalists.
So now, Scott and I will be addressing the barriers and best practices. Despite the CPOE
systemís effectiveness at preventing medication errors, adoption and use in the United States
still remains modest. As of 2003, only 5 to 10 percent of U.S. hospitals had implemented
these systems. Again, going back to the American Medical Informatics Association, major barriers
are costs, as high as $10 million to $30 million for large hospitals, lower, $3 million to
$10 million for smaller hospitals. Uncertain return on investments. Thereís a potential
negative workflow on physicians -- negative impact on physician workflow concern about
physician rebellion, especially in smaller hospitals that donít have as much staffing
or that donít have hospitalists. And then thereís difficulty training physicians, particularly
at community hospitals. So, according to findings through the overcoming
challenges to achieving meaningful use through the CMS -- CMMS, the findings showed that
hospitals that had difficulty meeting CPOE requirements were 18 percent less likely to
receive incentive payments than hospitals that cited difficulties with other criteria.
Said in a different way, if the hospital had CPOE barriers, they were less likely to achieve
meaningful use. The other barriers, aside from CPOE, were easier to circumvent. So,
CPOE was the biggest barrier for meaningful use attestation.
As far as lags in rural and critical access hospitals, specifically, thereís workforce
shortages in critical access hospitals in rural areas. Through the U.S. Department of
Health and Human Services, it shows a shortage of -- shortages of these providers in rural
communities even as the demand for health care services increase. Many of these rural
communities continue to struggle to recruit and retain an adequate number of primary health
care professionals. These rural communities generally have fewer hospitals, fewer physicians,
nurses, specialists, IT resources, and other healthcare workforce. And a smaller population
size and scale makes a loss or shortage of a single practitioner a greater impact in
these small, rural communities. So, in summary of this, the population of rural American
constitutes 20 percent of the total population, but only 11 percent of the physicians practice
in these areas. Regarding the expense of CPOE in the rural
areas, especially because of enhanced functionality and the costs, thereís a dramatic increase
in the operating costs for rural and critical access hospitals. And this is in the absence
of substantial cost-savings associated with improved efficiency or improved patient safety.
For critical access hospitals, thereís estimated implementation cost of 19 percent of the current
operating costs, as high as 30 percent. So, this is a significant financial barrier for
these critical access hospitals. In addition to barriers for critical access
hospitals, thereís limitations and lags in the internet. The FCC found that the rural
internet access is still lagging. Out of the 19 million Americans that have no access to
high-speed internet, three quarters of these live in rural areas. And in this FCC report,
they showed that internet providers that do not -- internet providers do not offer these
services in rural areas because thereís no business case to offer broadband.
Okay, so as far as other area -- other COP lags in rural and critical access hospitals,
the rural emergency departments were much less likely than those in the urban hospitals
to have the CPOE systems; six percent in rural EDs, 20 percent in rural EDs close to cities,
wherein the urban areas, CPOE was at 40 percent. So, itís anywhere from five to -- two to
five times higher chance of using CPOE in a hospital in an urban area.
In addition to the rural facilities, they have difficulty training IT staff, they donít
-- and they have limitations in staff IT coverage. Itís harder for them to find this staff,
compared to a sizeable IT department in a rural area. And itís -- for a small critical
access hospital, itís hard for them to even have one to two technicians, and they have
an inability to cover 24/7. Another major barrier for ED CPOE in the rural
community is the complexity compared to other ED software. EDs have a passive functionality
which require little or no change in workflow, and then contrast computerized paths, such
as data collection and CPOE, alter the workflow extensively and they require additional effort
from staff and the clinicians. As a result, physicians find this even more critical in
the higher stage of health IT adoption. And these workforce necessary for this are just
not available in the rural communities. As far as from a physician standpoint, thereís
a higher proportion of near-retirement primary care physicians in a rural community. And
so, thereís less younger physicians, which have more technology experience. And so, this
helps -- also helps inhibit the CPOE implementations in rural communities. This also gives more
pressure to the existing physician rural workforce who work longer hours, see a greater number
of patients, they have a greater number and greater variety of procedures, and they have
to exhibit a broader range of competencies. So, theyíre maxed out as far as their work
time already. So, within a critical access hospital, you need a physician champion, and
this is difficult because the physicians are already working many hours.
So, as far as the CPOE barrier categories, and we wonít cover each of these in detail
because weíll have a follow-up hour presentation thatíll cover these barriers and best practices
in more detail. But, the major categories that we havenít already discussed include:
additional barriers on vendor, hardware, software, administration, staff and provider, workflow,
patient safety, and patient perception. And to summarize this section, 56 percent
of critical access hospitals have electronic viewing of laboratory test results, and this
is compared to 91 percent of non-critical access hospitals. Twenty-two percent of critical
access hospitals use electronic clinical reminders, compared to 44 percent of non-critical access
hospitals. So, the critical access hospitals are one-half to two-thirds of functionality.
So then, just to give you a couple brief points as far as other barriers that weíll discuss
further with our next webinar. Vendor barriers may include: inadequate or misappropriated
training for CPOE, or poorly defined CPOE workflow. We also have software barriers that
we will discuss, which include internet access limitations, or the expense and access to
wireless networking, and the reduction of broadband in rural areas. Software barriers
will be discussed further. And this has to do with the managers who are unable to purchase
a fully-functioning CPOE from their primary vendors, or they may have to sacrifice between
buying the CPOE from their primary vendors, or building a IT infrastructure around those
CPOE vendors. And then, to summarize then, the administrative
barriers beyond cost and physician rebellion, thereís also an uncertain return on investment,
negative potential impact on physician workflow on an already taxed physician staff, and then
difficulty training physicians, especially in these community hospitals. And because
of this, administrative barriers include: reluctance in policy priority, reduced administrative
support, and no clear plan or process. And so, with that I will turn it over to Scott
Pettigrew, who will discuss some of the best practices to circumvent these barriers.
SCOTT PETTIGREW: Thanks, Mary. Weíre going to talk about best practices categories for
rural and critical access hospitals. And the major areas were going to focus on are: training,
workflow, system configuration, goal attainment, and change management. With regards to training,
Iím only going to hit a couple of these -- of these bullet point items. Again, weíre going
to have a, kind of, deeper dive scenario later and weíll cover each of these in more detail
there. The first one I wanted to cover here was project
management strategy. It is extremely important along these projects -- along these implementation
projects, and also the training, to have a very clear communication style of project
management. Sometimes, project management tends to falter in communications, and this
can really hinder uptake and acceptance of CPOE within the clinical environment.
Secondly, these -- you need to provide the physicians and all of the providers a summary
of benefits, including: the order sets, decision supports, and alerts. You really have to outline
to these providers why we are changing the paradigm under which they do their jobs, stressing
the tools that will provide them with ease of use in their everyday job. You have to
really sell this product, you have to sell the -- you have to sell the benefits.
Lastly, on this slide I wanted to cover the conversion of order sets, standing orders,
and best practices from paper to electronic. We are not changing the job that these providers
are doing on a daily basis; we are changing a little bit of the paradigm under which they
perform their job and weíre definitely changing the tools that theyíre using to perform their
job. And so, itís important to stress the similarities, that weíre really not changing
too much, weíre just changing how itís documented. Weíre also providing a safer environment
for them to actually perform the best medicine that they can.
Continuing on training, the first bullet point: the CPOE super user staff shadowing across
all locations and all shifts. Very important, especially on go-live [spelled phonetically]
to have a -- almost a hand-holding type atmosphere. I worked at Cincinnati Childrenís Hospital
as we went live on an electronic medical records system and we utilized the super user staff
shadowing across all locations and all shifts very well. And as a matter of fact, Cincinnati
Childrenís took the extra step of going live with very visible bright red tee shirts for
all of the super users so that any user who was in trouble knew exactly whom they could
seek out in order to find help. And this really raised the comfort level of everyone involved,
and really helped our go-live process be much more smooth than it would otherwise have been.
Along the same line, cross training of agically [spelled phonetically] educated staff for
building and keeping order sets up to date. Youíre going to hear me talk a lot about
quality improvement processes, particularly PDFA cycles: Plan, Do, Study, and Act, which
is a quality improvement type of methodology. And this is the type of item that really supports
that quality improvement mentality. It may require some reports to find out what prescriptions
and what orders are being -- are being called most common, in order to put order sets and
to really tailor orders sets to the roles and to the particular providers so they can
be used very, very efficiently. And this also may change based on seasonality. For example:
during flu season, you may have a very different order set that you want to have highlighted
at the top of your list than you would during the rest of the year.
The accessibility of webinar and written training materials is very, very important. We all
have times where we walk away from something for a little while and come back and try to
remember where we were and step into it. And this actually gets exacerbated for doctors
who may go on vacation and come back, and just need a little brush-up on what needs
to be done in order to maintain the documentation and maintain their CPOE.
Reviewing physician issues, problems, and gaps in CPOE compliance to determine gaps
in knowledge. Again, this goes back to that quality improvement mentality. We really need
to follow through with these physicians to see what works, what doesnít, and find out
why. And that follow-through is critical to maintain a trusted advisor role, which is
really going to maintain credibility for the project.
Moving now into workflow issues, workflow best practices. One of the most important
things that you can do is to define your leadership. And you have a critical decision to make:
internal leadership versus external facilitator for workflow lead, possibly a combination
of the two. And hereís why this is important: internal leadership, of course, provides you
with that link between the old way of doing things and the new way of doing things. You
have an established leadership chain. However, an external facilitator can be absolutely
critical to bringing fresh eyes, and also providing suggestions that may actually transcend
the political boundaries that exist within your organization. Itís often times easier
for someone outside the organization to point out flaws in methodologies, flaws in training,
and to -- and to really allow those suggestions and requirements to be met much more readily
by staff. Also, we want to look at analyzing the organization
steps necessary to support the CPOE workflow chain. This really comes down to gap analysis.
We need to say, where are we at when we start this process or at any particular time, and
where do we need to go to facilitate our goals? Stepping down the list towards the bottom:
evaluating barriers related to individual versus system issues. We need to consider
the ability of our users prior to training and prior -- and actually during the go-live
process. Often times when users say, ìThe system doesnít work,î theyíll throw up
their hands, and really whatís happening here is that the system -- the user may have
reached saturation during training, and may just need a little more in the training realm
in order to overcome these workflow issues. It may also point to, rather than a systemic
view, a systemic problem, it may point to a more of an individual misunderstanding of
how to actually perform the workflows involved. Best practices for system configuration. One
of the most important that I can think of is making the standard or canned order sets
available. Now, Iím going to, kind of, combine this one with the next bullet item, which
is that these have to be role based and specialty based so that we can take a look at -- it
doesnít do a lot of good for a OB/GYN provider to have a general practitionerís order set,
and vice versa. So, we really need to make sure that the order sets are tailored to each
individual user. And these seem like common sense items, but often times they are overlooked
in the configuration process. Focus on security and data integrity. One
large crash, one big downtime, especially at a critical point like go-live or in a bad
situation, can actually ruin all of your hard work and make subsequent implementation efforts
that much harder because your credibility has been tanked. So, focusing on security
on data integrity and one more thing that Iíd like to drop in there is also training
users on what to do when things go wrong so that if the computer system does go down,
there is not this panic of, what do we do? Itís a knowledge of, okay, our downtime forms
are here, and here are the processes that we do in order to keep going. This training
should happen, at the very least, on a twice-yearly basis, and actually I would actually push
more towards a quarterly basis. With regards to CPOE goal attainment, I would
love to say, ìCelebrate your successes,î but you also need a physician champion for
empowerment, involvement, and leadership, that internal rock, that bedrock of your system
that people will turn to, both for support when things are going right but also to help
when things are going wrong, to get them through some of the harder times. Backing up that
physician champion should be a physician advisory group with team representation. So, you have
all of the stakeholders from the entire -- from the entire organization that are helping to
give their input with regards to the utilization of the CPOE.
Now again, order sets, the role, the location, and the provider order sets, you can actually
come to a large amount of consensus with this physician advisory group. So, itís great
-- itís a great tool to utilize and it really does smooth things over.
All right, and finally the best practices for change management. You really need to
communicate your change management processes. One of the things we do at the regional extension
center here in Cincinnati is that we actually go and involve everybody in the kick-off process,
not just a leadership team. We actually have a kick-off meeting with everybody. We get
barriers out of the way, as far as personal and opinion barriers out of the way by involving
these -- by involving everybody in the organization. And they come together, what do you -- what
do you know about CPOE? What do you know about these systems? What are you afraid of? And
letís address these issues right off the bat. We also want to engage patients and staff
in patient safety. So, we want to have an understanding that everybody here is involved
in the patient safety and involved in the best -- providing the best medicine that they
possibly can. With regards to our part of this presentation and best practices, weíll
be going into a lot more detail during the deeper dive that weíre going to do. Iíll
turn it back over to Mary. MARY ZILE: Thank you, Scott. And Tammy Flick
will now go forward with her portion of the presentation.
TAMMY FLICK: Perfect. Thanks, Scott and Mary, thank you very much. Again, this is Tammy
Flick and I do work for Telligen, which is the regional extension center here in Iowa,
and I have worked in critical access hospitals. So, Iím going to do a little bit of a deeper
dive into a nursing perspective on CPOE. So, weíll go ahead and move forward here.
A little bit of a background related to nurses and CPOE, and I wanted to reiterate that with
CPOE it isnít just physicians, it is providers who enter these orders. So, most of the time,
nurses and ancillary staff assist those providers with CPOE usage and training. These nurses
have to perform multiple roles, especially in critical access and rural hospitals. And
so, the onus of having to educate these providers can be difficult at times as to finding them
in the right place at the right time to provide that education and training.
Nursing staff is also able to enter orders via CPOE whether those be verbal orders or
phone orders, and they are often looked to as the teachers for all the providers in their
organization. I know, personally, that thereís a huge change in workflows related to going
from paper to electronic, and sometimes this can really be difficult. I think everybody,
being a human, are -- weíre creatures of habit. And so, changing that workflow and
changing that process can be very difficult for people who have been doing it for many,
many, many years. I did have a provider, one time, that he was going to retire, and hunt,
and live off the land with his dogs, rather than use an electronic medical records. So,
sometimes thatís a barrier that you run up against when youíre working in these smaller
settings. I did review a study from HIMSS, and I wanted
to touch base with you on this because I -- although this is a larger facility, thereís a lot
of takeaways that were found in this study that I really think are applicable to even
a rural and critical access hospital setting. This survey was done on a CPOE implementation
that happened in 2008, and they did this survey about four to 10 months post-implementation.
And there were 28 nurses and five physicians that responded. What we did find from this
survey is that they recommended several things: setting some realistic expectations, trying
to be at 100 percent CPOE usage immediately after implementation is not necessarily the
best practice. We want to make sure that everyone is onboard and using it effectively, and appropriately,
and safely. Training time does tend to take a lot longer than what is anticipated, so
making sure to have that in the back of your mind as you implement.
Itís really important for those providers and nurses to regularly round and have those
discussions that happen in the hallways so that they can keep up to date on whatís happening
with their patients. And the providers can, you know, say, ìHey, Iím going to put this
order in for a CBC, and a few other lab tests, and some medications on this patient because,î
and explain that to the nurse. So those dialogues still need to happen in the hallways.
Teaching the physicians not only how to enter orders, but how to manage orders, how to change
them, how to correct them, how to cancel them: those are pieces that are important. Itís
not just putting the order in and having everything go perfectly. Think about the areas where
they may not happen to go in correctly, or errors that are made commonly, and have education
on those pieces to the providers and staff.
Also, training on some basic computer skills. There are some providers who really just donít
feel comfortable with computers. And so, making sure to take them into an environment that
doesnít feel like they are put under a microscope, or nurses that donít feel comfortable with
it, taking them aside and really saying, ìHey, do you feel comfortable with a computer? Do
you feel comfortable with using a mouse?î Going through some basics with them so they
donít have that anxiety and anticipation of this implementation, causing them to feel
even more aversion to implementing the CPOE. And moving on into another piece again, is
this planning process, engaging those providers and users in the development of the process.
How does the workflow happen currently? What is your ideal state? And how can we make this
happen electronically? Helping them to take around -- take out those areas of rework and
wasted time, and doing workflow analysis can really, really make the project go much smoother
for everybody involved. It is a team project, and so, again, just reiterating what was said
in the previous presentation with Scott and Mary, that you need to approach this as a
team and involve all those stakeholders for this process. And Iíll go a little bit further
into who should be included in that process on the next slide.
Also, creating a new hire checklist for orientation. We always jokingly said, ìWe want our nurses
to use their powers for good and not evil.î And so, making sure that the nurses arenít
passing on bad habits to others. One habit that was being passed on that we had to take
care of in one of the organizations I worked at was the barcode scanning on the bracelets.
They didnít like, on the night shift, to -- that when they would scan the barcode,
it would beep and wake the patients up when they were getting ready to hang a new IV bag,
which could normally take place without waking the patient if they didnít have the noise
factor. So, they were printing off extra labels with a ID band on it and scanning that instead
of scanning the patientís actual band. And obviously, thatís a workflow issue, thatís
a safety issue, thatís just not compliant with their policy and procedure for the organization.
So, we had to go through and find a way to fix that issue with the beep happening on
the night shift, and so, that it would scan the barcode and they would get a flash on
the wands that they use to scan the barcodes versus having that beep happen. So, making
sure to keep tabs on those pieces and making sure that theyíre not passed down to other
staff as they move through their implementations and orientations. I think itís really important
to have open communication and develop processes in a way thatís conducive for all involved
to do their job quickly and safely. And again, going back to engaging all staff
thatís necessary, this is just a starting point of a list that all other -- that staff
should be involved in the planning process. And something as simple as, you know, bedside
glucose testing, they might do a quick accu-check on a patient thatís in the emergency department
and really not think outside of their department, ìWell, how would that impact anyone else?î
But, what can happen is the billing can be affected. The lab can be affected because
they donít have the results that are entered in the correct place to have that information
to carry on further into that patientís medical record. If theyíre admitted, it also can
impact the inpatient setting, it can impact the emergency department if those orders and
those results are not entered correctly. It could also impact the coders in the medical
records department because, if those are not entered in the appropriate era -- excuse me,
area, then those coders will not be able to have that information available for their
coding process. And again, also, with the pharmacy because many diabetic patients are
on medications related to their diabetes. And so, the pharmacist having access to that
information can also be extremely important. Another piece for nursing and providers is
downtime procedures and pick lists. And again, this is just a reiteration of what Scott and
Mary had discussed, but I do want to make sure that you realize how important this is.
Having those downtime policies and procedures in place -- in certain facilities, they may
have a red notebook that has everything they need to have for downtime procedures. It might
have their paper order forms, it could have policies and procedures, it could have instructions,
and all the resources necessary for them to utilize during downtime procedures. And again,
educating them so they know where itís at. You know, staff get very used -- again, the
creatures of habit, they get very used to having their processes work a certain way.
And when it doesnít work that way, it can cause a little bit of panic and anxiety in
the staff. So, having that information there, training the staff on it to make sure that
they have everything accessible and so that they can continue their work is very, very
important. The other piece is creating those pick lists
of favorite orders. This really, really makes a huge difference for providers. Weíve had
several different hospitals that we have gone through this process with, and itís kind
of funny, one hospital said that they wanted to make as few keystrokes as possible. So,
they numbered the providers by: one, two, three, four, five, and so on and so forth.
And then they had to go back and revise those pick lists to go by the providerís last name
because certain providers got a little upset that they were number three instead of number
one. And it seems kind of silly, but those are truly barriers that do happen in certain
facilities. So, taking into consideration some of those reworks that might have to happen,
should you decide to -- you know, they had the best interests in mind of reducing keystrokes,
but then you run up against these kind of silly barriers that you never could anticipate
coming. Also, a piece that I found to be very, very
helpful is when you do create those pick lists and those order sets, making sure to break
them down into departments such as: pharmacy, lab, radiology, ancillary as headers and keep
that same format for all orders, especially order sets, so that a provider goes into an
order set knowing that first heís going to order his medications, or sheís going to
order her labs, then radiology, then ancillary. And it also helps the nursing staff to make
sure that when those orders come through that they have a logical flow that theyíre used
to in all of those order sets. I think consistency is really the important thing to do.
Moving on into access, really having different types of workstation on wheels, or tablets,
or PCs, or thin clients available. Staff have different preferences, and in the facilities
that Iíve worked in and worked with, what we did was a survey, and we did a few demos,
and we let them look at different pieces of equipment and try them out. And honestly,
what happens often times is they think theyíre going to use a tablet, when in reality they
would rather take the computer on wheels or workstation on wheels into the room because
itís easier for them to use. So, maybe not necessarily ordering all tablets initially
during the implementation, and, kind of, ordering a few of -- different types of methods for
them to use and play with. And then after you really find out what theyíre going to
use, then you order more of those pieces after the process has been implemented and are able
to get a better idea of what works for them. There is a high level of frustration if they
donít have access to the appropriate equipment. And so, making sure that access is available
and that people are not waiting in line to use the computer, very, very important. Patience
is probably not many medical staff, nursing, providers virtue, myself being one, of course.
Again, another piece that I would like to discuss is order sets and best practices.
So, considering tracking the order sets, and best practices, and verbal orders, and telephone
orders, track them pre- and post-implementation to see where youíre at. Also, doing a time
study is really helpful because often times providers and nurses perceive that it takes
longer to use CPOE, but if you follow the actual placement of the order through the
carrying-out of the order, it can actually reduce a lot of time in that workflow and
make things better for patients. So, for example, if a provider orders Lasix for a patient,
if they write it on paper and then take it to the desk, and then flip over the page,
and then the, you know, secretary or work clerk has to take a look and find out, ìOh,
itís a medication order.î So then she faxes it to the pharmacy, then the pharmacy has
to wait to get that order off the fax machine, and so on and so forth. And what happens behind
the scenes is not perceived by the providers often times, or the nurses often times, because
they didnít actually have to go through the rest of the work flows. But if you actually
do some time studies and show that when a provider puts an order in or a nurse puts
an order in for Lasix, and then a patient is given the Lasix within 15 minutes versus
when it was on paper it took 35 minutes, that really speaks volumes to all your nurses and
providers to get them more engaged into using CPOE.
Moving on into another piece that I feel is very, very important and it has been very
successful in the CPOE implementations that Iíve worked through, and both personally
with my hospitals and our clients here at the REC, is creating these cheat sheets. And
what it is is, kind of, a quick and easy reference, that -- card that people can use for common
things that people may forget to do. Or they donít use it very often, and so they like
to have that quick reference. And the way itís laid out here is each piece is a click
that they will have to do. So, theyíll click on patient chart, and then theyíll click
on order entry, and then theyíll click on the order entry tabs and meds, select meds,
process, sign. So, this is the process theyíll have to go through for a medication order.
You can create these quick and easy ones. What we did in some of our facilities is we
would make them pocket-sized. And so, often times you can find those little purse-sized
photo albums that have the laminated sheets, and you can just print off a quarter sheet
of a regular 8.5 by 11 piece of paper and put these in there, and then slide them into
the photo albums and they can carry them in their pockets. And the nurses really love
that because then they can make their own individual notes and cheat sheets on that
-- on those pieces, and carry it with them until they felt comfortable. And then they
can keep them by the computers and workstations as well.
I also think itís very important to create the full process with screen shots and be
able to show the entire process, so that if they really canít get what they need from
the cheat sheets that they can go into the full detailed description of how to do these
processes, and have some screen shots in there. So that then, when the nurses are looking
at the instructions and looking at the screen, theyíre like, ìYeah, Iím on the right page.
Okay, this looks like the same thing as the instructions, so I know Iím doing the right
thing.î Super users are super important. And most
facilities that have used super users and brought this into play have been very successful
when they make them easily identifiable. This is actually one of my clients, a hospital
here in Iowa, and they wore these brightly colored t-shirts during the implementation
of CPOE and they were easily identifiable when a provider or a nurse is in the hallway
and they take a look and they see a yellow shirt, they know that they are able to call
that person and say, ìHey, will you -- hey, please help me. I know how to -- I donít
know how to do this.î So, I think this is a really great idea. Whether it be the tee
shirts or a vest, whatever makes them easily identifiable to help those people get that
instant assistance for their CPOE orders is very important.
Another piece that I wanted to touch on again is just making that as simple and easy as
possible for the nurses and providers, avoiding those alert fatigues and, of course without
compromising patient safety. But, making sure that the alerts that are coming up are really
relevant and important, and that they donít just impede the workflow and cause a slowdown
in how theyíre ordering their medications and different ancillary orders for their patients,
and nursing staff also taking that into consideration. Reducing that number of passwords and logins
for those end users, so obviously, single sign on could be an extremely important piece
of that as well if itís possible to do that. Or else, some facilities are using the proximity
badges that log them in for single sign on. Planning and training is extremely key in
this process. So, establishing training methods for this, and trainers for new employees that
will be consistent, again. And then, planning for that staff turnover. Especially in a smaller
hospital, like a critical access and rural hospital, sometimes there is loss of knowledge
because a person may quit, or take a new job, or go to a new department, or start working
in the clinic instead of in the hospital, and they lose that knowledge base and then
things fall by the wayside, and the processes donít happen the way they should. So, making
sure to have that happen. Also, pairing staff with a super user when theyíre ready to use
CPOE to ensure new employees receive appropriate training and assistance to use the system
correctly. And then, preparing multiple people to perform the same role so there will not
be a risk of losing that critical knowledge should an employee leave.
Another piece thatís really important for nursing staff and providers is being able
to discuss issues and provide feedback from these end users. We used a suggestion box;
we had a telephone line that they could use to call in and tell any issues theyíre having
with CPOE. Also, e-mail or just regular phone lines to a certain person that they could
get in contact with, and making sure that they had the availability to give that feedback
in whatever method they choose to. Communicating also, consistently, with the
person who submitted the issue, and providing them updates if the issue cannot be resolved
immediately. The perception of customer service can be imperative to the end user. So, if
they believe the issue has been submitted and not being actively investigated and worked
towards a resolution, then they will often stop communicating issues. So, in other words,
if they donít feel like anyone is taking a vested interest in what theyíve communicated
to you, then they will stop communicating and things will fall by the wayside. And there
wonít be any knowledge of issues that they may be having. So, delegating a staff person
to monitor the issue log and ensure that the issues are being addressed and resolved so
that the staff does feel like their opinions are important.
Again, back to training, this process is never complete. So, ensuring that there is frequent
training and retraining offered. Somebody -- I had someone say -- equate it to tending
a garden. You will need to look for weeds and pull them, and give them consistent attention
-- consistent attention to the project over the long term. Thereís always going to be
maintenance, so -- also budgeting-wise, ensuring that there is budget for the staff to receive
that education as well. And really evaluating how things are going, looking at both positives
and negatives to ensure that youíre addressing any issues. And then, also highlighting successes
and celebrate. There -- this is a big process; this is a big change; this is a big implementation.
And whether you are just going live or youíve been live for six months or a year, celebrating
those successes and encouraging those people who are using the system well. Nurses and
providers can be competitive. So, you know, just giving them a little feedback: how are
you doing in comparison to other providers and staff as far as those pieces go, can be
really encouraging and, kind of, instill some of that competition into all those who use
the system. And most importantly, and last but not least,
itís about the patient. We want the patients to receive good quality of care, safe care,
and timely care. So, making this process as easy as possible and keeping the patient safe
is very important. And so, I always like to reiterate that as the focus on use of an electronic
medical record in general. And hereís my contact information if you would like to contact
me or have any questions, Iím happy to have you call or e-mail me on this information
here. And I will now pass the ball on so we can get a pharmacy perspective. Paul?
PAUL MOORE: Thank you so much, Tammy. And thank you for those real-life anecdotes. I
found them -- some of them quite entertaining. And Mary and Scott, thank you for the insights
that you shared and the strategies that you shared with us.
What I want to reemphasize in this short time that we have together here -- what I want
to reemphasize in this time that we have remaining is that medication management and patient
safety is a huge challenge for all hospitals. And even more difficult in small rural hospitals
due to restricted resources. I want us to remember that CPOE is a powerful tool for
improving medication management and reducing medication errors, a tool with both advantages
and limitations. And then I want us to explore strategies and solutions to addressing those
challenges and limitations in a way that makes sense for critical access hospitals.
Now, this quote from the IOM report back in 2006 was, and is still, our call to action.
Because if we are serious about improving quality and patient safety in our hospitals,
we must deal with the number one cause of harm: medication errors and adverse drug events.
You would think that -- or would hope that the problem has gotten better with time, but
we found in the OIG report in 2010 that we have yet to move the needle very far when
it comes to preventing harm. Youíll see there that the most frequent problem
out of that report was related to medication errors. And so, weíre asking critical access
hospitals to make a priority to address medication management and medication-related patient
safety. Because, as you can see with this chart from AHRQ, that medication-related adverse
drug events are still the most frequent of the health care acquired conditions. And thatís
especially in smaller hospitals where we may not have an OB department, or a very robust
surgery program, or only that rare ventilator patient. Even -- the percentage will even
get higher as the percentage of total harm in our smallest hospitals.
Now, one solution to reduce this harm is to utilize technology to reduce the errors. Evidence
suggests that processing a prescription drug order through the CPOE system cuts the likelihood
of an error on that order by almost half. Now, thatís a significant reduction. And
that should drive us to increase adoption of the technology, technology which could
likely prevent millions of additional medication errors each year. Now, while implementing
this technology may seem like a no-brainer, we are seeing that adoption and use in U.S.
hospitals remains modest. So, we still have some work to do, especially in the smallest
hospitals across the country, hospitals facing low patient volume, and limited financial
and work force resources. So the question is, how do we make it happen? How do we increase
adoption and utilization of computerized order entry?
Now, while the challenges, and therefore the solutions, will vary from hospital to hospital,
there are proven strategies to help the process along. First of all, we need to engage leadership.
Now, this is usually talking about your board, your C-suite, your medical staff. We need
to develop and share a positive vision of how the technology will improve patient care
with these folks. We also need to enlist champions; and you notice thatís plural. Now, this is
usually a clinical person, but it can be a CEO, a physician, another practitioner, a
nurse, a pharmacist, but they must be a health IT champion. It can be multiple folks, but
these need to be folks who get it, who understand the capabilities there, folks that must be
capable of adapting methods and workflow, and that are always consistently, trustfully
there. We need to communicate the advantages and that goes beyond just telling them what
it is, but also explaining the advantages and using CPOE over and again, if necessary.
And we need to set realistic expectations, you see, while being realistic about the limitation
of the technology. You donít want to undermine the success of your implementation by overselling
the expectations. We want to define some facility-specific measures of success and then we want to strive
for those. And then most importantly, we want to show
how the technology can be leveraged to access work force that would otherwise be available,
adding a valuable partner to your medication management team at your facility that wasnít
there before, or it wasnít there in a very robust way.
There are definite medication management and patient safety advantages inherent in using
a computerized order entry. You know, Mary mentioned some of these advantages: legibility.
There was a study of inpatient medication errors found that approximately 90 percent
occurred at either the ordering or transcribing stage. Now, these errors can be due to a variety
of causes, including poor handwriting, but also ambiguous abbreviations, simple lack
of knowledge on the part of the ordering clinician. Now, some other advantages of CPOE include
the ability to screen for potential drug-drug interactions, for drug allergies, or even
lab values. An example would be warning a clinician before ordering a nephrotoxic medication
in a patient that had an elevated creatinine. In addition, some systems include clinical
decision support. This type of information suggests drug doses, routes of administration
or frequency. Some systems may offer more sophisticated drug safety features, preventing
not only errors of commission, an example: ordering a drug in an excessive dose or a
setting of a serious allergy, but also errors of omission. For an example, an alert may
appear, such as: You have ordered Vancomycin, would you like to order serum Vancomycin level
after the third dose? But even while the technology continues to
improve, technology by itself is not enough. There are still limitations. In one simulated
test of the Computerized Physician Order Entry system at 253 hospitals, more than a third
of them missed routine medication orders. And including just over one percent missed
medication errors that would have resulted in a fatality. This is because there are other
factors beyond the technology which come into play, factors such as: the increasing rate
of introduction of so many new pharmaceutical products, products which have increased the
difficulty of pharmaceutical management of patients and has amplified the importance
of expert pharmaceutical consultations with resulting increased reliance upon pharmacists.
Additionally, most electronic systems are not yet sophisticated enough to identify situation
when doses of medication should be adjusted based upon the patientís renal or hepatic
function, or fluid status. For these reasons, pharmacist review of orders will continue
to serve an important role in ensuring patient safety.
And I think Tammy also mentioned that thereís this thing of alert fatigue. The technology
is improving, and many potential medication errors such as allergic contraindications
or adverse drug interactions will be automatically detected at the time of the order. But, there
is this phenomenon of alert fatigue, occasionally causes prescribers to miss important warnings,
or just not to see them or to ignore them. And a pharmacist review of the order provides
a crucial stopgap in these instances. I just want to make a side note here, as Iíve
travelled this last week. And it occurs to me, an autopilot, especially the new generation
of autopilots, are capable of flying a passenger jet with great precision. But, you know, I
still donít want the captain and the co-pilot to come back and help serve the snacks and
drinks after they reach altitude. I donít. I want them in that front cockpit and I want
the experts monitoring the process. So, even with CPOE, medication order review
by a pharmacist remains the standard of care. And our patients donít want different standards
based on the size of the facility. When I see these larger hospitals like the one Tammy
referred to there, Iím jealous because there are -- there are resources there, and thereís
the ability to do things there so many times that we struggle with in small rural hospitals.
But from a patientís perspective, I expect the same standard of care at the small rural
hospital that I go to as if I went to one of those large hospitals.
So, the question is, how do we maintain that standard, especially in small rural hospitals?
The solution is to find a way to engage the medication experts, the pharmacists, in the
process in a way that makes sense, in spite of the challenges. Now, we know that due to
fewer resources and lower patient volumes in these facilities, rural hospitals face
many more challenges in implementing technology such as CPOE. And as a result, these very
same clinical, financial, and demographic constraints may even predispose rural facilities
to higher incidences of medication errors. But the challenge is not just limited to implementing
the technology. Due to the same recruitment and retention issues faced by rural areas
with all health care providers, there are also work force issues with pharmacist oversight.
And as a result, many small rural hospitals have limited hours of onsite pharmacist coverage.
And the result is not only are these hospitals finding it almost impossible to provide prospective
review of medication orders before they reach the patient, only about one in five of the
nationís smallest hospitals have a pharmacist review of orders within 24 hours.
So, if we know that implementing CPOE technology is an evidence based method to improve medication
management and patient safety, but we also understand that technology in and of itself
will fall short of where we need to be, in other words the standard of care, then how
do we move the needle in patient safety and medication management? Well, one solution
is we marry the capability of the local health information technology with the medication
expertise of the pharmacist, and we do it remotely. Now, I want you to know for just
a moment, this is not a new concept. I want you critical access hospital administrators
to think about teleradiology versus the circuit-riding radiologists of yesteryear. Itís not only
a marrying of the technology to the expertise, it is actually a matter of leveraging that
very technology itself to access the remotely located pharmacist, to provide enhanced medication
management and patient safety for the patients of your low volume rural hospitals in a way
that makes sense clinically, financially, and demographically. Itís, sort of, a conduit,
if you will: moving the resource to the need, providing better care and better outcomes
at less cost. The technology makes it possible. You as leaders in your facilities must provide
the leadership to actually make it happen. Now, this first webinar has been an overview.
It is, if you would, a 30,000 foot view of the entire issue. And itís pointed out the
advantages and limitations of CPOE as a tool for improving medication management and reducing
medication errors. Itís to help us recognize the challenge for all hospitals in the area
of medication management and patient safety, but especially the challenges for small rural
hospitals in implementing CPOE and accessing pharmacist resources.
Now, during the future webinars that weíre planning to engage with you, we will explore
different models of remote pharmacist services. We will discuss policy and regulatory issues
around the use of remote pharmacist services. We will examine existing guidelines for implementing
the service. And we will discuss programs and initiatives moving us toward enhanced
medication management, a reduction of adverse drug events, and better care, better health,
and less cost to our health care system. I appreciate you being with us today, that
moving forward will be leveraging health information technology, the CPOE, to access remote pharmacists
and improve safe and effective medication. Thereís my contact information. I appreciate
this time being one of you to share with you the importance of this issue, and for your
participation in this webinar. Thank you very much.
And the HITRIC training team would like to thank Mary, Scott, Tammy, and Paul for providing
their insight on this important issue. Weíd also like to thank you, the learner, for viewing
this recorded webinar. We look forward to your feedback and your participation in future
training events.
[end of transcript]
HHS: 091010 More Magazine Interview 2 6/14/13
CPOE in Rural and Critical Access Hospitals 1 6/14/13
Prepared by National Capitol Captioning 200 N. Glebe Rd. #1016
(703) 243-9696 Arlington, VA 22203
Prepared by National Capitol Contracting 200 N. Glebe Rd. #1016
(703) 243-9696 Arlington, VA 22203