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From the February 2003 Issue |
Pain-Free CPOE Following the right protocol is a critical step for encouraging physician adoption. By George Marshalek and Steve Casey When you get down to it, practicing healthcare and managing IT are similar endeavors. Both involve developing and implementing strategies to optimize the quality and efficiency of an extremely complex system; one happens to be the human body, the other an information systems network. While the former is a more intricate and vulnerable system, the latter—the healthcare information enterprise—is more frustrating and mystifying to care providers, especially when easy-to-use computerized physician order entry (CPOE) is the goal. The challenge is to create user-friendly, seamless systems for charting, clinical results retrieval and order entry. Linking all critical disparate systems throughout the enterprise—including pharmacy, lab, radiology and computerized patient records— is strong medicine for reducing medical errors while streamlining and improving patient care in general. But pulling it off successfully requires physician support and adoption, which directly correlate to the integration of systems so they are easy to use, fast and efficient. To completely replace numerous legacy clinical systems with a single-vendor, monolithic solution would be expensive and likely unnecessary to accomplish effective CPOE. As an alternative, developing an integrated systems approach to meeting physician usage goals requires planning, but it’s typically less expensive, less risky and available in a much shorter time frame. Physician-Friendly CPOE Throughout the course of Daou’s nationwide CIO forums, participants repeatedly tell us that improving physician relationships is one of their organizations’ biggest struggles. Yet the very nature of healthcare and the myriad of different clinical information systems create strain on the doctor/healthcare organization (HCO) relationship. The physician must coordinate care with multiple parties throughout the health system, some of whom he may never see. Caseloads are overwhelming. The delicate timing of every step in the care process matters. Finally, today’s clinical information systems are not typically physician-oriented and proven to streamline care. When implemented properly, CPOE positions the HCO as physician-friendly and patient-centered, thereby increasing its value by providing an infrastructure that facilitates efficient, doctor-driven care delivery rather than just offering a place for care providers to work. Physicians haven’t welcomed CPOE, in its current manifestation, with open arms. Concerns about training time, security, ease of use, system response times, the challenge to effectively use mobile devices and the need to stay within an existing comfort zone have created barriers to acceptance of these solutions. The real challenge for CIOs and IT strategists is not just to conceive and implement a CPOE system that connects the enterprise, but to make it an unobtrusive, reliable, secure, efficient and overall superior alternative to manual order entry. There are very real hurdles to achieving this vision. The prognosis is good for the best-of-breed, multiple vendor systems environment when thoughtful consideration is given to how—and how fast—users can access the systems, gather relevant clinical information and input orders quickly. Here are several critical issues to address when developing the physician portal and CPOE solution. Simplify access to multiple systems. Anything but single sign-on (SSO) creates a significant obstacle to broad-based adoption. If physicians are required to go through separate logon screens and passwords as they move from the ADT system to the lab system to the pharmacy system to the radiology system, integration is devalued because it is cumbersome, time-consuming to use and requires either generic IDs, a cheat sheet or mnemonics to keep track of passwords. Today, SSO technology exists that simplifies physician interaction with multiple clinical systems. Besides granting authorized users enterprisewide access in one step, with one unique password, SSO mitigates the use of generic, universal passwords, which are inconsistent with HIPAA’s security and auditing directions. Authentication must be absolute, yet not impeding. In conjunction with SSO, a best-practice CPOE strategy should also include advanced security and authentication technologies that meet the healthcare system’s concerns for privacy. Though not the most widely used technologies today, these solutions offer high value in providing absolute authentication while reducing or eliminating the dependence on passwords. Examples include proximity-based systems whereby the user’s ID badge, a smart card or a key FOB activates a sensor that allows the PC to run only when the user stays in immediate range, and biometrics such as retinal scans or fingerprinting to provide for nonrepudiated authentication. With these technologies, users leverage single sign-on; activating these security checks, such as the smart card, can cause the system to automatically bring up the user’s desired view (i.e., his current patient list) as well as log all patient data accessed in the session. While offering the ultimate in sign-on ease and authentication, these advanced “physical” security systems present an integration challenge. The physician might be accessing the system from his or her home, office or hotel room, using a variety of devices including handhelds, so alternative security methods will have to be employed where sensors and scanners aren’t feasible. For maximum integration, these biometric technologies need to be seamlessly integrated into the clinical applications. Think like a physician, then design a portal that facilitates his journey through the clinical applications. This is where portal presentation and context management assume important roles (see diagram). A crucial point in the design of CPOE is to carefully consider how the physician optimally accesses and accumulates information from disparate clinical systems throughout the enterprise. For CPOE to become valuable to the clinician, the redesigned user interface needs to present information from different clinical application systems in a single window or portal that simplifies data access and, in effect, shortens the distance from one point of the care process to the other. For example, in an environment where CPOE is not integrated, the physician typically opens the patient list and then bounces in and out of applications associated with that patient’s care. The doctor might have to access the lab system, find the patient’s record and review blood work. Then it’s out of that system and into the RIS or PACS to check films, images or transcription notes, with another stop to reselect a patient ID and then open the pharmacy application where the patient’s name must be selected again to order meds. Establishing a bidirectional physician portal makes the transition between systems transparent to the user, so the above scenario now looks more like this: The physician logs onto his portal and immediately sees his patient list. He selects a name, clicks on the “lab” folder located on the portal browser, and is immediately presented with results of that patient’s blood work drawn an hour ago. Then he clicks on the browser’s radiology folder to see the patient’s MRI—and up it pops without further clicking or typing. With the results still open, the physician clicks on “pharmacy” and writes a prescription without having to identify the patient once again. On the same screen, the pharmacy system alerts that this patient is also taking another med that might interfere with this drug, so the doctor makes an adjustment. Fundamental to this less burdensome process is the inclusion of context management capabilities. As soon as the user selects a name on his or her patient list, context management systems automatically find and link that patient’s information in each of the other clinical applications, so it’s there as the user chooses that application folder without requiring him to re-identify the patient. Ideally, a fully integrated portal could provide context management by default; however, there are various middleware products and navigation tools that offer this functionality. The success of CPOE depends on bringing legacy clinical systems together in a simple, logical and clinically coherent way, making it easy for physicians to get their hands on whatever piece of patient data they need, in as few clicks and keystrokes as possible. Ultimately, the HCO’s goal should be to provide an integrated clinical view such that the user doesn’t know which system the data is coming from or going to—only that it’s there at the right moment. Prime your CPOE system for high-performing response times or don’t bother with the solution at all. All of the above technical considerations are for naught if the system doesn’t present data quickly. Simplifying access and navigation are only part of the challenge. For CPOE to serve the physician, it must present appropriate clinical and patient data quickly. In wide area or remote environments where multiple required applications are running over a remote distance, data retrieval can take so long that systems usage becomes more frustrating than valuable. HCOs can overcome this hurdle with one of two strategies: integrating the comprehensive, read-only clinical data repository (CDR) into the portal, or a clinical information “inbox,” which is useful when the CDR lacks major pieces of the patient’s clinical information. For HCOs that don’t yet have a comprehensive CDR, implementing a clinical information inbox system will create and maintain a “staging area” where patient data is securely staged, so it is immediately presented when the physician requests it. The portal caching database receives and solicits data real-time from the legacy applications (via an HL7 or XML interface engine) and delivers data to the portal, so that the CPOE system isn’t slowed by reaching into four or five different remote applications. By examining each of the above elements, HCOs ensure the viability of an integrated CPOE solution, maximize usage among providers and improve physician relationships. However, none of this will be possible if the existing legacy systems for pharmacy, radiology and lab aren’t fully implemented and clinically robust. It is surprising how many health systems want to aggressively attack CPOE when major departmental order entry capabilities are deficient. Like an arduous treatment protocol for addressing a medical condition, the process of integrating systems for optimized CPOE might, on the front end, seem painful. However, the end result is well worth the time and effort, especially when the resulting infrastructure leads to improved physician relations, reduced errors and optimized patient care.
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George Marshalek is vice president and general manager of The Daou Technology Center. 
Steve Casey is vice president and general manager of Sentient, a Daou company specializing in systems integration. Daou Systems Inc. is headquartered in Exton, PA.