Adding Value Through CPOE

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CPOE Implementation Through Order Set
Building Critical Success Factors in a
Community-based Teaching Hospital Richard M.
Weinberg, MD CPE CQO Stamford Health
System October 2008
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Agenda

• Introduction
• About Our Hospital
• IS Development Over the Past Seven Years
• Planning and Implementing CPOE Using EBM to
  Drive CPOE
• Where We Are Today
• Wheres the Beef Starting to Assess the Value
  Added to the Health System by CPOE

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New Jersey
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New Jersey
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New Jersey
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Stamford Hospital

• 305 Licensed Bed Facility
• Fairfield County, CT (Metro NYC)
• Planetree Affiliation
• Magnet Accreditation
• 17,000 Annual Admissions
• 525 Medical Staff
• Four Residency Programs
• Initial MEDITECH LIVE in 2005

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Stamford Hospital
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Stamford Hospital History

• 2001
• Losing MMs/year
• 2008
• One of highest operating margins in CT
• Substantial and growing endowment
• Rapid growth many clinical programs and sites
• Open Heart Surgery January 2008
• Planning new tower in 3.5 years

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Stamford Hospital History

• New Leadership Team
• Aggressive, entrepreneurial
• Took over cross-town competition
• Powerhouse Board
• Mission, Vision Values
• Aligned
• Focused
• Strategy-Driven
• Goal-oriented
• Data-enabled

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• IS Development the Foundation for CPOE

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From Our Strategic Vision . .

• Culture change
• Building our saga
• Living our values
• Entering the electronic era
• IS development
• Consolidate on a common platform
• Move away from paper
• Implement an EMR
• Use IS and data as platform to improve clinical
  effectiveness CPOE and EBM

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Clinical Project Implementation Schedule

• 2005 PACS, Document Imaging, Single Sign-on,
  and MEDITECH Core
• 2006 PCS, eMAR, and CPOE Readiness Assessment
• 2007 CPOE and Adoption of EBM (Zynx)
• 2008 Extending CPOE and EBM, Iatrics Visual
  Flow Sheets and prep for MEDITECH 5.5.5
• 2009 Physician Adoption, Documentation, Bar
  coding and BMV and ? 5.6.X

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Moving Away From Paper . . .
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• Planning and Implementing CPOE

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The CPOE Physician Partnership

• The Foundation for CPOE Success
• Change CPOE Perception from a Hospital Project to
  a Medical Staff Project
• Organize and Establish Resources Physicians,
  Pharmacists, Nurses, and IS Staff
• Understand MEDITECH Workflow Changes
• Communicate Progress

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The CPOE Physician Partnership

• Ten Lessons in Implementing CPOE
• Develop guiding principles safety comes first,
  never go backwards, effectiveness governance buys
  participation
• Focus on efficiency, not speed
• Know your institutions nuances
• Nursing buy-in is critical to physician adoption
• Order sets ease the transition to CPOE
• Establish protocols to simulate the pre-CPOE
  environment
• Adequate go-LIVE support is critical and
  expensive
• Training requires a multi-faceted approach
• Transparency instills confidence
• Dont test in a LIVE environment

Kravet, Knight Wright, Ten Lessons From
Implementing a Computerized Order Entry System,
Journal of Outcomes Management, Feb 2007, Vol 14,
No. 2.
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SH Governance Model
I.T. Leadership Council
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Critical Factors For Governance Success

• IS Credibility and Respect
• Medical staff perceives high likelihood of
  success
• Effective Governance Model
• Medical staff leader and leadership group
• CIO, IS, and hospital share control of CPOE
  implementation

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MD Leadership Development

• Leadership characteristics
• Credibility
• Experience
• Tenacity
• Flexibility and firmness
• Some technical knowledge
• AVAILABILITY
• Sense of humor

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Leadership Group

• Prior work with the Leader
• Track record of effective medical staff
  leadership
• MEC, medical staff committees, hospital
  committees
• Clear understanding of their authority,
  responsibilities, and goals
• Aim is to help develop the IS plan, not just
  approve it
• Developed at the intersection of MD and
  hospital goals Evidence-based medicine

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Implementation Success Factors

• Sufficient access devices
• Sign-on management
• Support, support, support
• Physician engagement
• Order set development

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Engaging Physicians

• Requires multiple tactics
• Opportunistic and iterative
• May have to be draconian
• Helps to have a secret weapon (or two)

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Engaging Physicians . . .
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.. and Holding MD Attention
CPOE . . . Resistance is Futile
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.. and Holding MD Attention
CPOE . . . Resistance is Futile
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Stamford CPOE Roll-Out

• May 1, 2007 pilot unit
• 28 beds, predominantly medical patients and all
  hospitalists, medical residents, and FP residents
• August 1st Five additional units, 28-32 beds
  each, and surgical residents and all PAs
• August 23rd ICU, 16 beds
• September 11th Emergency Department, 22
  stretchers, and four fast-track
• November 12th ICC go-LIVE
• January 2008 Open Heart Surgery
• May 27th, 2008 Mother-Child and entire OB/Gyn
  Dept.
• January 2009 Pediatrics (anticipated)
• February or March 2009 Neonatology (planned)

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So . . . Where Are We Today?
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Status as of September 2008

• MEDITECH Order Sets (214)
• MD orders, RN orders, standing orders, Lab orders
  and others
• 30 ED Sets primarily diagnostic
• Zynx Order Sets (135)
• 64 full order sets developed in Zynx
• Medicine/Cardiology, General Surgery, Orthopedic
  Surgery, Thoracic/Vascular Surgery, Obstetrics,
  Psychiatry, Rehab Med., ED/Peds ED/Trauma,
  Cardiac Surgery, Pediatrics, Card Cath Lab
• 17 additional in process in Zynx
• for Neonatology, Card Cath, Oncology, ICU, Card
  Cath, Anesthesia
• 36 linkable subsets in Zynx
• 18 ED Order Sets
• . . . All LIVE in MEDITECH
• Started annual review of Zynx sets for updating

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Order Entry Statistics - Overall
Orders Placed in CPOE
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Orders Written vs. Entered

• Three SH hospitalists
• Overall, 10-17 being written
• Reasons unclear dialog beginning with
  hospitalists

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Orders Written vs. Entered

• Three SH medical residents
• Overall, 9-42 being written
• Reasons generally related to learning curve

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Order Set Utilization

• Now compiling order set usage by type
  standard (unmodified) order sets vs. favorites
• Varies widely
• By individuals, not by group (resident, PA,
  attending)
• ITLC beginning to lean towards elimination of
  favorite sets
• Potentially greater adherence to evidence
• Ability to utilize new decision support tools
• Easier to find and replace critical change items
• Ability to identify evidence at a later date

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Decision Support

• Most physicians like the idea of clinical
  decision support
• More sophisticated tools are needed (if A and B
  but not C, then D and E)
• Thus far we have avoided fatigue and CDS-rage,
  but physician feelings are rising
• POM rules - 197
• PHA rules - 297

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Decision Support 2
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Decision Support 3
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Resourcing CPOE Implementation

• Using EBM and order set development is a
  resource-intensive pull strategy
• During first 18 months two FTE (IS) and 0.7 FTE
  (CQO) on Zynx side (not MEDITECH team) alone
• MT staff included part of project manager, PCS
  team, trainers, PHA team, and order set builders
• Long-term estimate order set maintenance will
  require one FTE order set librarian (not IS)
  and one FTE IS, minimum

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• Wheres the Beef?

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Literature Supports Strong ROI

• The Cleveland Clinic Foundation, Ohio, USA
• At our institution as well as others,
  considerable cost is associated with
  inappropriate diagnostic coding of needed
  procedures and tests by the physician. We
  developed a series of CPOE alerts and order sets
  targeting specific tests to address this problem.
  As a result, preliminary data shows that
  insurance denials fell by up to 37 for the
  targeted tests.
• Source PMID 16779438 PubMed - indexed for
  MEDLINE
• Vanderbilt Center for Better Health, USA
• The Vanderbilt Center for Better Health conducted
  a workflow analysis study to determine the
  benefits of implementing a computerized provider
  order entry system in the adult Emergency
  Department. Translating time savings into bottom
  line savings (FTE/overtime reduction, additional
  charges) resulted in 31,424 in time savings and
  40,000 cost savings (paper forms) annually.
• Source PMID 16779368 PubMed - indexed for
  MEDLINE

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Literature Supports Strong ROI 2

• Division of General Medicine and Primary Care,
  Department of Medicine, Brigham and Women's
  Hospital and Harvard Medical School
• The authors assessed the costs and financial
  benefits of the CPOE system at Brigham and
  Women's Hospital over ten years.
• RESULTS Over ten years, the system saved BWH
  28.5 million for cumulative net savings of 16.7
  million and net operating budget savings of 9.5
  million given the institutional 80 prospective
  reimbursement rate. The CPOE system elements that
  resulted in the greatest cumulative savings were
  renal dosing guidance, nursing time utilization,
  specific drug guidance, and adverse drug event
  prevention. The CPOE system at BWH has resulted
  in substantial savings, including operating
  budget savings, to the institution over ten
  years.
• Source PMID 16501178 PubMed - indexed for
  MEDLINE
• Florida State University
• CPOE systems improve the accuracy of charge
  capture, which should result in streamlined
  billing (and payments), as well as preemption of
  billing disputes and government scrutiny.  Plus
  CPOE offers more efficient inventory and supply
  chain management.  In one randomized control
  study of CPOE usage, charges in the CPOE group
  were 12 higher and captured more accurately than
  in the control group.
• Source Journal of Medical Systems Volume
  30, Issue 3 (June 2006) Pages 159 - 168   (ISSN
  0148-5598)

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Literature Supports Strong ROI 3

• LDS Hospital, Salt Lake City, Utah
• Intervention An antibiotic management program
  that used local clinician-derived consensus
  guidelines embedded in computer-assisted decision
  support programs. Prescribing guidelines were
  developed for inpatient (N 162,196)
  prophylactic, empiric, and therapeutic uses of
  antibiotics.
• Results Antibiotic costs per treated patient
  (adjusted for inflation) decreased from 122.66
  per patient in 1988 to 51.90 per patient in
  1994. Antibiotic use decreased by 22.8 overall.
  Measures of antibiotic use and clinical outcomes
  improved during the study period. The percentage
  of patients having surgery who received
  appropriately timed preoperative antibiotics
  increased from 40 in 1988 to 99.1 in 1994. The
  average number of antibiotic doses administered
  for surgical prophylaxis was reduced from 19
  doses in the base year to 5.3 doses in 1994.
  Antibiotic-associated adverse drug events
  decreased by 30.
• Conclusions Computer-assisted decision support
  programs that use local clinician-derived
  practice guidelines can improve antibiotic use,
  reduce associated costs, and stabilize the
  emergence of antibiotic-resistant pathogens.
• Source PMID 8610917 PubMed - indexed for
  MEDLINE

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Preliminary Metrics
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Preliminary Metrics 2
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Preliminary Metrics 3
With CPOE, this 60 minutes in overall medication
ordering cycle time is eliminated.
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Preliminary Metrics 4
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Preliminary Metrics 5
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Other Measures of Value

• DVT risk assessment and prophylaxis guidelines by
  MD and diagnosis
• Now at the point where EBM order set vs. non-set
  outcomes are measurable
• Cost, LOS, resource utilization, discharge status
• Reduction in unwarranted variations in care
• Linking core measure compliance to order sets
• Compliance by measure and MD

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• Thank You.
• Questions or Comments?