What Comes First? Second? Third?

Howard J. Anderson, Executive Editor
Health Data Management Magazine, June 1, 2008

When it comes to clinical automation, there’s certainly no checklist for which tasks come first, second and third. But many hospitals choose to implement some or all of the components of an electronic health records system before even attempting to roll out computerized physician order entry.

At 550-bed Piedmont Hospital in Atlanta, however, the checklist of automation priorities was shuffled based on perceptions of which steps would yield the quickest patient safety benefits.

“Our whole initiative was driven from the board on down as a patient safety issue,” says William McClatchey, M.D., the hospital’s chief medical informatics officer. That’s why the hospital tackled medication administration first, CPOE second, decision support third and clinical documentation last, he says. Executives concluded that this sequence would yield the most rapid—and significant—patient safety gains and build momentum, he adds.

Many hospitals save CPOE for the end of their clinical automation projects because automating orders poses major challenges, says Lucy Mancini-Newell, president of The Stellar Group, a Chicago-based consulting firm. For example, extensive physician education is required to build full compliance with a shift from paper to electronic orders, she says. And for many organizations, building clinical order sets—standard protocols for placing orders electronically for specific cases—can take many years because of the need to build consensus, she adds.

“Hospitals have to assess the strategic and tactical value of CPOE” when carefully setting a timeline for overall clinical automation, Mancini-Newell adds. But the hard work involved can reap great rewards.

By implementing medication management and CPOE, Piedmont Hospital has seen its acuity-adjusted mortality rate decline by about 40%, McClatchey says. “That’s the equivalent of about 130 people still walking the streets of Atlanta today,” he estimates.

A year before it began the rollout of CPOE, Piedmont, a tertiary care referral hospital, implemented several technologies designed to make medication management more efficient.

The hospital’s pharmacy uses a robot from McKesson Corp., San Francisco, that selects unit-dosed drugs with bar code labels. The robot is far more accurate in completing this kind of repetitive task than a pharmacist, McClatchey says.

Nurses giving patients medications make extensive use of bar coding. Using McKesson software on PDAs from the Symbol Technologies unit of Motorola Inc., Schaumburg, Ill., nurses scan the patient’s ID bracelet, scan their own ID badge, and scan the drug to confirm it’s the correct one. All this information is automatically recorded on the PDA, which displays a red light if the drug is not the one ordered, McClatchey explains.

Logical First Step

Medication management was the logical first step in the hospital’s patient safety initiative because “it is the easy first thing to do to prevent drug errors,” the CMIO says.

The hospital then spent four years rolling out CPOE software from Eclipsys Corp., Atlanta, involving physicians every step of the way. For example, the hospital paid 28 doctors to attend committee meetings and an offsite CPOE retreat. Paying highly involved physicians is essential, McClatchey argues, because the process requires time-consuming “grunt work” that takes away from the practice of medicine.

“The key to success for clinical automation is getting the clinicians engaged by painting a vision around quality and safety,” McClatchey stresses. “It’s the only concept that unites all physicians. If you automate just for economic reasons, the project will fail.”

Physicians ultimately developed 500 order sets for use with the CPOE system. One physician has oversight responsibility for each order set. When changes are requested, this physician convenes a group of appropriate specialists to review the change, which must ultimately be approved by others on the medical staff leadership team, McClatchey explains.

“One challenge has been that it’s difficult to keep track of what protocol was changed by whom and when,” the CMIO notes. “We would like to be able to track that better.”

Turning Off The Paper

Once the CPOE system was live in all the hospital’s units for a full year, the organization alerted physicians that it would no longer allow paper orders. The hospital’s medical executive committee determined that if the organization allowed both electronic and paper orders, the risk of errors would be unacceptably high, McClatchey says. “It would require parallel work flows, and that’s inherently dangerous.”

Virtually all of Piedmont’s physicians now use CPOE to place orders for medications and tests. A handful of doctors, including some cardiologists and orthopedists, have delegated the task to a nurse practitioner or a physician assistant.

The hospital test-drove a number of hardware options before ultimately installing numerous thin client workstations on every unit. The thin clients, primarily from Hewlett-Packard Co., Palo Alto, Calif, are linked to servers via remote application delivery software from Citrix Systems Inc., Ft. Lauderdale, Fla.

Doctors and nurses alike concluded that wireless notebook computers were too clumsy to use. The hospital also determined that pen-based Tablet PCs were unacceptable because “we found that our doctors and nurses wanted to sit down in front of a keyboard,” McClatchey says.

And by relying on Citrix technology and thin clients, the hospital found that it could hold down costs and provide a consistent desktop appearance to all caregivers, the CMIO says.

Physicians who want to access systems remotely can gain access using a hardware token security device that generates random passwords. The device is from Secure Computing Corp., San Jose, Calif.

Decision Support

The hospital now is refining the clinical decision support components of the CPOE system, developing alerts to guide physicians treating patients with certain conditions. “I had assumed that both vendors and CPOE users had vast experience with decision support,” McClatchey says. “But nobody had much experience.”

Developing decision support “is an ongoing process that will never be completed,” the CMIO says. “And decision support is the real reason we installed CPOE.”

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