The Two-way Solution

HMT It’s hard to pick up a newspaper without reading about medication errors — they happen every day. In its well-publicized 2006 report "Preventing Medication Errors," the Institute of Medicine (IOM) estimated that 1.5 million Americans are harmed every year by medication errors, with the true number being even higher. Further, the committee noted the staggering financial costs associated with these errors, "Assuming 400,000 of these events [medication errors] each year — a conservative estimate — the total annual cost would be $3.5 billion …."

These statistics, along with recent high profile cases of medication errors, are prompting many hospitals across the country to review and reassess patient safety procedures. Healthcare IT organizations across the country should be assisting in this process by working with the clinical team to develop IT strategic plans to support patient safety initiatives. And yet, one of the major challenges healthcare IT managers face is synchronizing clinical requirements with the practical realities of deploying or retooling the hospital’s technology infrastructure to support them.

The IOM report rightly called for increased use of information technology as a solution — particularly e-prescribing technology. An important IT component that gets overlooked in many industry discussions, however, is the power of Computerized Physician Order Entry (CPOE) technology, which can bolster patient safety efforts by implementing a powerful two-way communications and verification system to prevent medication errors. As a vehicle for placing patient care orders directly into the hospital’s information system, it facilitates accurate communication across clinical disciplines. And, accurate communication is critical to positive patient outcomes.

CIOs and their staffs should be familiar with The Joint Commission’s National Patient Safety Goals (NPSG) because they outline best practice goals in patient safety for all accredited healthcare organizations. The 2008 NPSGs include four sections on accurate information transfer and improved communication. Each of these sections has implications for the technology infrastructure and can form the basis for an immediate analysis to help prevent a patient safety crisis. Some goals are relatively straightforward, however, others are more detailed. Regardless, CIOs and IT managers should be working with clinicians to ensure compliance.

CPOE and the NPSGs

How Do We Verify Orders? The first goal is verification and "read back" for telephone communications to decrease verbal orders (Goal 2A). CPOE systems can help decrease the number of telephone orders and, in the process, the number of chances for miscommunication and error. In situations where it is impractical for direct physician order entry into the information system (as in emergencies or phoning from a remote location) the CPOE system can prompt clinicians to ask specific questions of physicians while they’re on the phone and would require the clinician to verify the information before processing.

Have We Standardized Terminology? The second best practice is standardizing abbreviations, acronyms, symbols and dose designations (Goal 2B). CPOE supports this goal by providing a consistent, user-friendly clinical vocabulary. The CPOE system should allow physicians to select quickly from available orders and options without pausing to consider ambiguous terminology, prompts or symbols. They also can order multiple items or sets of items immediately, which can be designed to reflect maximum choices within appropriate medical practice.

IT staff should work with representatives across the organization to develop and implement processes and tools that will result in consensus around clinical protocols and taxonomy. Then, link the remaining paper-based order sets and practice protocols with the electronic version that is resident in the CPOE system. Key participants in the process would include the hospital’s Quality Management representatives, as well as appropriate medical and clinical leaders. The resulting order sets should also incorporate nursing terminology, so that any bedside caregiver will understand clearly the physician’s orders and expectations.

Are We Providing Appropriate Clinical Decision Support? The third goal addresses improvement in the timeliness of reporting and receipt of critical test results and values through CPOE systems featuring clinical decision support (Goal 2C). IT staff should ask, "Have we built in automated two-way communications through messages back to the physician or clinician entering the orders?" These messages exist in several forms:

Order Entry Trigger. CPOE systems can trigger alerts for actual lab values, drug allergies or other alerts during the order entry session. The mechanism’s objective is to interrupt the ordering process to make an inquiry of, or suggestion to, the provider.

Processing Instructions. Processing instructions provide extra information back to the physician regarding the order, such as relevant information on timing and requirements for a diagnostic procedure.

Intelligent Order Choices. Physicians can receive a relevant but finite number of choices in the order entry menu, providing a subtle message. For example, "This drug only comes in 5, 10 or 25 mg. tablets," thus saving the physician time by prompting for a practical dose. Intelligent choices save time spent contacting the ordering physician for clarifications and further instructions when the original order is incomplete or infeasible.

Algorithms and Calculations. A screen leads the user through a complex series of decisions, orders with mandatory data elements and even performs automatic calculations. For example, order entry tools for ventilator settings, rehabilitation modalities or total parenteral nutrition. At every point, the decision remains with the authorized clinician.

Have We Standardized Order Handoffs?

Finally, IT staff should evaluate with clinicians whether or not the IT system has appropriate handoff processes and procedures, as addressed in the fourth NPSG. These are critical points for preventing errors.

Standardized Handoff Processes. The CPOE system should support clear, consistent and meaningful communication during the entry and processing of patient orders. Standardized handoffs, such as medication reconciliation, will not affect the remaining manual processes nor eliminate verbal communication during the standard shift report or transfer from one clinical area to another. But the technology can provide a checkpoint that makes the handoffs more accurate and easier to understand — another major recommendation in the IOM report.

Clinician-to-Clinician Streaming of Patient Information. "Handing off" also includes the multiple bytes of information that must travel from one department or caregiver to another during the patient’s admission. A robust CPOE system will include a "closed loop" of information that streams effortlessly and immediately to these departmental touchpoints. For example, the patient has just had surgery and is recovering in the post-anesthesia care unit. The surgeon sits at the desk and electronically enters orders to begin when the patient is transferred to a nursing unit. These orders include medications, vital sign protocols, labs, radiologic tests and required bedside equipment.

Electronic Kardex. An electronic nursing Kardex that immediately receives information of new orders enables the nurse to plan for the new care needed and any resulting follow-up well before the patient arrives from another level of care. It’s a dynamic tool to communicate patient reports from the off-going nurse to the on-coming shift. It provides printable reports of current treatments and medications should the patient require transfer to a different level of care. The pharmacy receives medication orders and can begin the process of profiling the medications. The status of this pharmacy process for each medication is electronically relayed to the nurse on the care unit, and shows up next to the medication on the electronic Kardex. The nurse then knows the pharmacy has received the new orders and is processing them.

Electronic Feedback Loops of Communication. In the example above, the pharmacy will indicate, again electronically, that the medications have been validated and are ready for distribution to the care unit and administration to the patient. Lab and Radiology orders immediately travel to these departments and the processes to execute those orders begin. The equipment order travels to materials management or the surgical supply department, and the necessary equipment is delivered to the care unit. The handoff and closed-loop mechanisms work together to provide constant, updated and accurate information. This electronic loop can help caregivers ensure the right dosage and help them prevent potentially fatal medication errors.

Critical Success Factors

With appropriate functionalities in place, how can IT staff facilitate the effective use of CPOE technology? After all, it is not intended to replace face-to-face communication or physician-nurse rounds. It is an ordering tool the IT staff can provide clinicians featuring a logical, intuitive, yet prescribed path of ordering prompts that help to prevent incomplete or inaccurate orders. Using CPOE systems in the right way can help improve clinical outcomes, and IT staff can help clinical staff in three major ways:

Help Promote Clinician Adoption. For CPOE to improve communication, IT staff must evaluate clinician adoption patterns because they correlate directly to the level of user involvement and influence. It’s not enough to buy "systems." An organization must also facilitate intensive and structured training. As more and more physicians feel comfortable with the technology, they will embrace it and use it more frequently. This enthusiasm will displace initial reluctance to use technology and eliminate this major barrier to acceptance. Training should be tailored to the needs of the physician and clinical staff. It should be provided in increments of approximately 20 minutes on an ongoing basis.

Redesign Workflow Processes. A significant benefit to CPOE is that it removes ambiguity in ordering content and in processes. When a provider electronically enters an order, it becomes available immediately for viewing and processing by the bedside caregiver. It is critical not only for STAT orders, but also to streamline overall efficiency in providing care. The quicker the orders go out, the faster they are performed — tests performed, medications administered and treatments implemented. IT staff must work carefully with physicians and other clinical staff to understand the details of order writing and work flows to support those changes in delivery of care through the transition phase.

Accurate Communication of Patient Information. CPOE not only eliminates illegibility issues but also ensures accuracy and completeness of orders. When options, routes of administration, frequency and duration prompts are appropriately built for each medication, and the units of measure are in accordance with First Databank and The Joint Commission’s regulations, there is no question as to the physician’s intentions. Pharmacy may still have questions; however, the number of calls made for clarifications (for any order component) is drastically reduced. CPOE enables accurate ordering, verification and improved turnaround time.

Patient safety requires constant monitoring. It also requires constant refinement and enhancements to stay current with best practices, such as the communication goals outlined in the NPSGs. CPOE systems are not a panacea for eliminating all errors, but they can go a long way in dramatically reducing them. At the center are the people who utilize CPOE daily to provide the safest delivery of healthcare. It’s the marriage of people, processes and technology at its best.

Elizabeth Arsenault, Alan Cudney and Jacalyn Luchsinger are members of the Provider Adoption Consulting Services Group of McKesson Provider Technologies. Contact them at 800-981-8601.