Governance first, technology second to effective CPOE deployment
By Frank Fear, August 2011
Rapid development of order sets provides the foundation for CPOE, but healthcare organizations first need an effective governance plan built around clinician workflow.
The computerized physician order entry (CPOE) race is fully underway as the clock ticks for healthcare organizations to meet meaningful-use deadline requirements. And while choosing the right technology is an essential component to best-practice deployment of CPOE, it's important that a critical first step to creating a foundation for long-term success is not missed — the creation of a solid governance plan built around clinician workflows.
As healthcare organizations increase their focus on enhancing core measures performance, quality and safety, deployment and use of CPOE integrated with clinical decision support must be a central component of the overall strategy. In particular, CPOE systems must provide point-of-care access to evidence-based order sets and clinical content.
For CPOE to integrate effectively into clinician workflow, pre-identified order sets must be established ahead of deployment. Otherwise, the effort runs the risk of being ineffective from an adoption perspective because CPOE can be cumbersome.
Consider that the admission of a single pneumonia patient could potentially require 30 separate orders. Without the existence of integrated order sets, each of these would have to be looked up individually by the attending physician, ultimately disrupting physician workflow and increasing the risk that something will be missed.
A well-established library of order sets is a crucial foundational element to CPOE strategies. With this in mind, healthcare organizations will need to make the process of rapidly creating and approving these elements a priority going forward. And the first step to this process should be the creation of a solid governance plan to guide order set selection, streamline development, ensure quality and eliminate duplicates.
Memorial Healthcare's challenge
For Memorial Healthcare, a 154-bed facility based in Owosso, Mich., that encompasses more than 170 medical staff and seven satellite locations, the primary challenge to CPOE deployment was the existence of antiquated systems and processes.
Nationally recognized for its use of technology to address patient care and quality, Memorial has implemented a strategic HIT roadmap that has allowed it to reach Stage 6 of the HIMSS Analytics' EMR Adoption Model. The organization has also been named one of the Top 100 Most Wired Hospitals for the past eight years.
Memorial's detailed HIT strategy pointed to increased standardization across the healthcare network to align with industry best practices, which meant that the process for creating order sets needed to fit into these overriding goals to improve workflows.
Keeping the status quo process in place equated to maintaining a paper-based system that took a minimum of six months to finalize an order set — more than a year in some cases. The system was outdated in that it did not leverage technological advances as a mode of development. Nor did it always result in an order set based on the latest or best evidence.
Under this system, a physician would provide a nurse manager with the necessary information to create an order set, which would in turn be taken to the hospital's Forms Committee. The committee would copy the information into the appropriate format, and a draft order set would be delivered back to the original requestor for personal use, or it would be reviewed by multiple physicians and the hospital's quality review team.
This system lacked efficient use of staff time and the ability to leverage the latest clinical decision-support tools. It also created an environment where multiple order sets existed for the same diagnosis, sometimes individual to a particular physician.
Accelerating CPOE adoption through governance
Memorial has used the MEDITECH system since 1993. It also leverages UpToDate, an evidence-based, physician-authored clinical information resource from Wolters Kluwer Health, to help guide care decisions.
Within this technology-enhanced environment, the limitations of the current system were easily pinpointed by professionals at Memorial as they planned implementation of the CPOE stage of the facility's HIT strategy. It was clear that the existing paper-based system would not be adequate to get the CPOE deployment process off the ground fast enough or with the desired decision-support outcomes.
As such, Memorial executives determined that the first strategic step would be to establish a formal governance policy for creating order sets. This crucial piece of the CPOE strategy required the organization to revise its process in such a way that would guide order set selection, streamline development, ensure quality and eliminate duplicates.
Solid support for this policy started at the top, beginning with the vice president of medical affairs, chief of medical staff and an identified physician champion for CPOE. The first step was to appoint a CPOE administrator, who would be responsible for managing deployment, beginning with a determination on which order sets would be developed and in what order.
The top 25 diagnosis-related groups (DRGs) and core measures within the organization were pinpointed as a starting point, and an order set development team was put into place that consisted of: physician specialists; pharmacy, radiology and lab representatives; nurses from the impacted department who were familiar with MEDITECH; and representatives from quality improvement and risk management.
To ensure order sets were drafted in a way that best fit into physician workflow while avoiding unnecessary delays, the CPOE administrator works first with physicians and pharmacists to draft the initial order set. The draft is then sent to the order set development team, which has two weeks to review it and return any comments and one additional week to review revisions. Departmental medical staffs are then given the opportunity to review and approve the draft, which leads the document to its last stop at the medical executive committee for final approval.
Efficiently building order sets
With a formal governance process in place, the order set development team was then able to focus their efforts on moving the process from paper into an effective electronic order set solution. Not only would technology create a more efficient system for draft development, but it would open up more opportunity for leveraging clinical decision support tools.
The team identified that to meet the overall goals of the CPOE undertaking, the solution would need, at minimum:
Customizable templates that enable rapid draft development;
Virtual tools and user-friendly dashboards for faster, more efficient review and approval and enhanced project management;
Easy access to trusted clinical content, both during the authoring and review process and at the point of care;
Automatic alerts when changes are made to supporting evidence or best practices that could potentially alter usual clinical practice; and
The ability to quickly and easily perform updates across multiple order sets.
The ability of the order set solution to provide the most current information on the latest evidence was a key component to the final choice, as this piece was integral to Memorial's overall goals for the initiative. Since evidence changes over time, order sets that remain static would not fit into the organization's desire to fully leverage the quality-enhancing potential of CPOE and clinical decision support. Therefore, alerts and real-time mass updates were important functions to be considered.
Memorial ultimately selected ProVation Order Sets, powered by UpToDate Decision Support, from Wolters Kluwer Health. For Memorial, one of its primary values is the continuous updates to clinical content and medical evidence, including direct links to UpToDate.
The solution's One-Click Updates tool enables seamless integration of order set maintenance into regular workflows by automating monitoring evidence for changes that could potentially alter usual clinical practice. The CPOE administrator is alerted to evidence that may trigger the need to modify particular order sets, and in turn alerts the appropriate clinicians. The change can then be applied via a single step across multiple order sets.
The ability to easily and quickly update existing order sets based on changes to evidence and/or best practices ensures that they remain current. This instills confidence in the physicians using order sets, advancing Memorial's decision-support goals of improved care quality and safety.
Deploying the solution six weeks before the hospital went live with CPOE allowed for a sufficient number of order sets to be built into the system, making the transition much easier for physicians from a workflow perspective. In fact, within five months the development team had completed 20 priority order sets and built them into CPOE, with another 29 out for review.
The success of this roll-out is noteworthy considering that a recent review revealed that 80 percent of physicians at Memorial are now using the order sets to perform admissions. Currently, CPOE with clinical decision support is in use in five units. In all, 37 order sets are available at the point of care, a number that is expanding rapidly. Plans call for Memorial to have at least 100 evidence-based order sets within its CPOE system by mid 2012.
It is a goal that is well within reach, now that the time to develop a single order set has dropped from a minimum of six months to a maximum of eight weeks.
As important as technology was in accelerating development, it was the existence of a solid governance plan for rolling out the order set initiative that was the most crucial foundational element to the successful deployment of CPOE. Decisions made as part of this process ultimately provided a strategic pathway to rapid order set development that merged CPOE with industry best practices.
Frank Fear is VP and CIO at Memorial Healthcare.
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