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From the February 2004 Issue |
Safety First IT has made huge inroads into improving patient safety. Four healthcare end-users discuss their organizations’ latest IT adoptions of patient safety technologies. By Richard R. Rogoski While securing patient information has grabbed the spotlight in recent years, ensuring patient safety is still a priority for physicians, nurses and CIOs. Medication errors have been addressed publicly by the Institute of Medicine and by the Joint Commission on Accreditation of Healthcare Organizations, which recently issued more stringent guidelines covering the way drugs should be ordered and patients identified. New technologies, available for use at the point of care, are also becoming more popular with clinicians and are assuming a larger role in the strategic planning of healthcare organizations.
Physicians at Loma Linda University Medical Center in Loma Linda, Calif., have been actively and enthusiastically involved in rolling out a computerized provider order entry (CPOE) system, slated to go live in April, says Bob Blades, vice president and CIO. “We have 580 residents, and in an academic medical center, about 80 percent of orders are written by residents. They’re comfortable with computers and eager to get the automated support. But we’re cautious. We want to make sure CPOE adds value to their work and doesn’t slow them down. When we started, it was too slow and too complex, and we thought it wasn’t going to work. But we listened to physicians’ feedback, and kept customizing and simplifying it for them.” Blades says it was never the intent to turn physicians into unit secretaries, but to improve workflow, streamline processes, and provide more input and access at the point of care. “In a hospital, the bedside is where patient care occurs, so it must also be where documentation and orders occur.” He says Loma Linda physicians want to use the CPOE system, and “we have taken the time to make sure it works the way they want it to work.” Yet for Loma Linda, which boasts 265 ICU beds out of a total of 800, choosing Cerner’s PowerOrders CPOE was “the icing on the cake,” says Blades. The organization implemented a five-year strategic plan in 1997 and targeted the clinical side of healthcare as its top priority. “CPOE figured early on to play a big role, but it was only one piece of the pie,” Blades says. In 1997 and 1998, Loma Linda inventoried its systems, partly in response to the Y2K threat. In doing so, the organization determined which systems could be modified and which needed to be replaced. The organization updated the plan again in 1999. In the course of upgrading, Loma Linda replaced its old radiology system with a new radiology management system, implemented a Web-based PACS, rolled out a new laboratory information system in 2002 and is currently installing a new pharmacy system—all with the goal of creating an easily accessible repository of digitized information and decision support capability. “CPOE is the piece that makes the whole system fit together,” Blades says. “We had to make the pieces fit so clinicians would want to access information digitally, especially at the bedside.” One of the biggest benefits of the new CPOE will be felt in the pharmacy. Loma Linda had a third-party pharmacy system that it wanted to replace, but it chose to wait for the new Cerner Millennium system, knowing that fully integrated pharmacy and CPOE systems made more sense than interfacing a new CPOE to the old pharmacy system. Customized for Physicians Return on investment was not a major consideration when purchasing the CPOE. “We put ROIs on the radiology, lab and pharmacy systems, as well as clinical data capture,” Blades says. But CPOE by itself translates into improving quality of care rather than saving money, he notes. The choice of Cerner’s PowerOrders system also provided Loma Linda with the features it was looking for. The product’s evidence-based diagnostic and treatment knowledge, along with patient and plan information, is readily available at the bedside. Since orders and charges are captured at the point of care, there are also fewer lost orders and legibility issues. The system has built-in safeguards. Alerts and reminders allow clinicians to avoid duplication of orders or potential problems caused by allergy, food or drug/drug interactions. Its constant clinical monitoring feature allows doctors and nurses to access, in real time, clinical data from other departments that could affect ordering decisions. Dosing errors also are reduced through the system’s dose range checking and complex dosing features. One feature which physicians especially like is the system’s pre-built order sets, which allow them to move quickly through the ordering process. Since all ordering is done in real time, associated tasks are automated so that all appropriate clinicians and departments are immediately notified when an order is written. But the system also is customizable. “A physician can customize his own favorites. Disciplines are different. Physicians’ screens display functions they normally handle first and tests or medications they frequently order, and this differs from one clinical specialty to the next,” says Blades. He admits that some physicians can be overwhelmed by too many rules. “They don’t want to have a question facing them every time they document or write an order,” he says. “Every rule we put in has to be accepted by the medical executive committee and has to be medically sound. At the same time, we have to streamline the system for physicians so it doesn’t question every routine order.” Nurses also have to be trained on the system, Blades notes. “If the nurses aren’t on board, it will fail. If a physician doesn’t understand, he will turn to the nurses for support.” For more information on PowerOrders from Cerner,
To ensure patient safety when administering medications at the point of care, hospitals need to meet five “rights”: right patient, right medication, right dose, right time and right route. For Spartanburg Regional Healthcare System in South Carolina, the solution was to implement a bedside bar coding system. According to Ray Shingler, senior vice president and CIO, going live with McKesson’s Horizon Clinicals documentation system in 1997 was just one step in a long-term medication management strategy. Spartanburg consists of three hospitals, including a teaching hospital with 730 licensed beds, 485 staff physicians, 28,000 inpatient admissions and 160,000 outpatient visits per year. Before Shingler was hired, the organization had already begun looking for ways to improve clinical workflow and streamline the administrative processes of charting and filling prescriptions. When Shingler arrived in 1996, he began looking for ways to streamline the pharmacy’s inventory. Influence of Strategic Planning Between 1997 and 1998, Spartanburg added McKesson’s Care Manager, which allowed nurses to document care at the bedside and made it easier to implement bar coding technology. “We figured, if we can get a bar code onto the patient’s wristband and then get a bar-coded medication packet out of the robot, all we needed to do was answer, ‘Are you the right patient for this drug?’” Shingler says. “We needed to identify a scanner that would do the job, and also make sure that we got the right patient bracelet.” At that point, nurses’ badges were not bar-coded, so only the drug packets and patient wristbands could be scanned. Even so, Shingler says, “We were running about 50 percent of meds ordered from our pharmacy through this system.” After going live with Care Manager in 1998, Spartanburg updated its personnel ID badges by putting bar codes on the back of each, and the scanning rate went up to between 60 percent and 65 percent. With the addition in 1999 of McKesson’s AcuDose-Rx secure cabinets, Spartanburg was able to increase the number of medications it could deliver with bar codes on them. At about the time the organization went live with Care Manager, it also implemented an enterprisewide wireless system, so nurses could use cart-mounted, wireless laptops for bedside documentation. But this new technology presented a challenge. In the neonatal ICU and in critical care units, the amount of equipment already at the bedside made it difficult to get the cart-mounted laptop close to the patient. Plus, the bar code scanner that was attached to the laptop had a short cable. Now, Spartanburg is testing an integrated, handheld, wireless scanner that can do everything the laptop can, Shingler says. While medication scanning still is not being done in these critical care units, Shingler notes that “more than 90 percent of patients are scanned in compliance with our medication administration system.” He attributes the ease of integration to the fact that Spartanburg has had a long-standing partnership with McKesson, having opted for a single-vendor strategy rather than a best-of-breed approach. As a result, the organization recently integrated existing McKesson systems But Shingler also praises the role that Spartanburg’s nurses and physicians have played in improving efficiencies, cutting costs and preventing medication errors before they happen. “We have nurses and pharmacists who feel better about the quality of care they can provide,” he says. “We’re lucky to have a forward-looking nursing community and medical staff.” For more information about medication management solutions from McKesson, www.rsleads.com/402ht-208
—Paul Fu Jr., M.D. Los Angeles County Department of Health Services For the 22,000 employees of the Los Angeles County Department of Health Services in California (LACDHS), having a myriad of drug-related reference materials just a mouse click away is proving to be a boon. Although not everyone will need to access all 14 components of the Thomson MICROMEDEX system the department has deployed over its corporate intranet and as a PDA option, Paul Fu Jr., M.D., the medical director for information systems in the office of the CIO, says, “We’re getting an increasing number of people using it. Acceptance has been excellent. It quickly caught fire and spread rapidly.” As a municipal entity, the department’s network consists of five For those on staff who need information stat, Fu says the MICROMEDEX system “provides them with updated pharmaceutical information they usually wouldn’t have.” He says the MICROMEDEX system is a comprehensive evidence-based reference system from which LACDHS uses more than a dozen components. Together, these components give LACDHS affiliates information on:
In addition, the system provides electronic versions of MARTINDALE Complete Drug Reference and the PDR. Forsaking All Others The decision to forsake all other reference systems for MICROMEDEX was based on a number of factors, Fu says. “We had been using both MICROMEDEX and Lexicomp. Lexicomp was used mainly for formulary management. MICROMEDEX was being used in a couple of hospitals.” In 2002, the decision was made to deploy MICROMEDEX throughout the healthcare network. Fu says the wide area network was insufficient to support the information system and, as a result, old T1 lines were replaced with an ATM and frame relay network that allows access not only within LACDHS facilities, but also from physicians’ homes. Fu also says LACDHS wants to “focus more on the patient as a partner” and intends to begin rolling out MICROMEDEX’s information components designed for patients. However, he notes that this presents a cultural challenge, since “seven threshold languages represent more than 5 percent of our patient base, and a lot of patients don’t have PCs.” For more information about products from MICROMEDEX,
Getting a Palm Pilot as a gift from his boss opened a new window on information for Mark Cohen, M.D. He soon discovered the wealth of helpmates, like a maximum heart rate calculator, that could be downloaded from the Palm Web site. “Anything I found, I downloaded,” he says. So, when he began getting e-mails from ePocrates Inc., advertising a downloadable formulary system, he jumped at the opportunity to download this free software. Subsequently, when the company launched a premium version called ePocrates Rx Pro for Palm, Pocket PC and Mac operating systems, and began charging an annual fee of $59.99, Cohen bought it. Board-certified in both internal medicine and pediatrics, Cohen is the chief of professional technology and chief of AfterHours Medical Care for Lifetime Health in Rochester, N.Y., where he splits his time between a three-physician practice and administrative duties overseeing care at three urgent care centers. Given this kind of patient load, Cohen admits that having a detailed formulary at his fingertips comes in handy, and that he uses ePocrates about 20 times a day. “I like it because it’s extremely portable. I use it in the office and the hospital. Anything I can look up in the PDR, I can look up in ePocrates.” But ePocrates Rx Pro is more than just a handheld version of the PDR. While it contains more than 2,800 drug monographs, it also features an infectious disease guide, clinical tables and treatment guidelines, a MedMath clinical calculator and DocAlert messages. Cost Comparisons In addition, Rx Pro has a MultiCheck function that allows physicians or pharmacists to check interactions between several medications at one time, Cohen says. Because drug formularies are available from a number of insurance carriers, Rx Pro can save time and money when drugs are being ordered. “We’re capitated for the care we give our patients, and ePocrates gives us cost comparisons,” Cohen says. Another important feature of both Rx Pro and its slimmed-down version, Rx, is that all the information is accurate because it can be automatically updated by hot syncing, Cohen says. Each day when he recharges the battery of his PDA, he simply puts it into a cradle attached to his PC and the synchronized folder on his PC’s hard drive connects directly to the ePocrates Web site, from which any new or updated information is downloaded. Once the download is complete, the software “lets you know what was updated,” he says. While it’s obvious that all the features of Rx Pro can provide a safety net for clinicians on the go, Cohen stresses that those who treat pediatric patients can greatly benefit from the software. “You’ve got to dose by weight,” he explains. Because Rx Pro includes pediatric dosages based on weight, “You can look up the dose and be sure you’re right.” For more information about clinical reference tools from ePocrates, Richard R. Rogoski is a free-lance writer and a contributing editor to HMT. Contact him at rogoski@ aol.com. © 2004 Nelson Publishing, Inc |
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