Conversion to CPOE

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Conversion to CPOE Evidence Based Medicine

• Mike Gorczynski, D.O.
• Director Medical Informatics
• Aurora Health Care

Regional User Group 1000am May 1,
2007 M\MIKEGSKI\Demos\RUG Order Sets May
2007.ppt
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Who is Aurora Health Care?

• Integrated Delivery Network
• 13 Hospitals (40-600 beds)
• 120 Outpatient Clinics
• 140 Retail Pharmacies
• Long Term Care
• Home Health Services
• Hospice Services
• Laboratory Services
• One of the nations Most Wired hospitals in
  2004 2005 2006

• Private, non-profit, teaching organization
• 684 employed physicians
• 3,200 physicians on staff
• 27,000 employees
• 2.9 billion annual revenue
• 0.5 million IP days/year
• 2.3 million OP visits/year
• 0.25 million ED visits/year
• 0.3 million Home Care visits/year
• 5.6 million retail Rx/year

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EMR Applications at Aurora

• Hospital Core systems implemented from 2000-07
• Patient Access (Registration Scheduling)
• PowerChart Orders, Results, Charges
• Radiology, Surgery, Emergency Dept
• Pharmacy
• Interfaces Lab, Transcription, Dietary, Digital
  Imaging
• Advanced product implementations under way
• PowerChart Office in Clinics (75 done)
• Multidisciplinary Clinical Documentation eMAR
  (85 done)
• Barcode Medication Administration (new)
• CPOE (Pilot May 2006, rollout Feb 2007)

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Computer Physician Order Entry

• The Vision
• 1995 - Computer-based Patient Records (CPR),
  including CPOE
• The Urgency
• 1999 - Institute of Medicine - To Err is Human
• The Impact
• reduce morbidity, mortality, and costs
• The Challenge
• engage physicians in computer dialog without
  adversely impacting productivity

productivity
engage
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Order Sets ? Choose a strategy

• Hospital-specific
• Region-specific
• Enterprise standard with boundaries
• Enterprise standard

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Evidence based medicine will guide development of
system wide order sets.

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Aurora Health Care
CPOE Physician Champion Council
Aurora Board
1.Approve the strategic approach to
safety 2.Approve goals 3. Strategic monitoring of
Patient Safety Program and team recommendations
1. Communicate Vision, and implementation plans
to each Medical Department 2. Assist soliciting
participation in Evidence-based Order Sets
Development process. 3. Enthusiastic user and
vocal champion 4. Along with lead hospital
administrators, identify challenges and plan
change management tactics
Quality Committee
1. Oversight of Care Management and Patient
Safety strategies 2. Participate in development
of strategic approaches to quality and safety 3.
Review and approval of specific goals and
objectives 4. Direct successful accomplishment of
goals and objectives
Care Management/ Quality Council
1. Benchmarking 2. Data management 3. Performance
measures 4. Facilitate project teams 5. Education
CM/Q Staff

Clinical Informatics SubCommittee
1. Provide direction for Clinical Information
technology efforts to ensure business objectives
for CM, Patient Safety, and clinical process
improvement 2. Identify and sponsor projects that
promise value, identify barriers, and suggest
measures of success
1. Communicate Vision, and implementation plans
to each Medical Department 2. Assist soliciting
participation in Evidence-based Order Sets
Development process. 3. Enthusiastic user and
vocal champion 4. Along with lead hospital
administrators, identify challenges and plan
change management tactics
CPOE Physician Champion Council
1/17/03
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Expectations
Attend meetings
Communicate with all relevant medical staff
Communicate back to IS
Use CPOE when your hospital is implemented
Compensation for your time
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Communications

• System Leadership 21
• Physician 198
• Regional/Hospital Leaders 36
• Care Management/Quality 19
• Other 12
• TOTAL 286

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Recruit Clinical Subject Domain Expertsaka
Medical Facilitators
Believe in EBM and in CPOE
Respected by medical staff
Review literature when necessary
Encourage participation by all members of medical
staff
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The Standard Aurora Process
Zynx Templates and Evidence
Existing Order Sets
Internally developed EBM citations
Evidence-Based Development Session
Rendering for CPOE and ePPO
Expert Panels
Departments Review
All Physicians Invited
Expert Medical Facilitators Selected
Pharmacists, Nurses, Care Managers Invited
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Guides to Order Sets Topic Selection

• It is a problem...
• that is commonly occurring
• ...for which the interventions ordered vary
  widely
• ... though uncommon, has a widely accepted
  though complex medical management approach
• ... for which interventions ordered require
  time-consuming human-computer interactions
• ... where there is a goal to improve a minimum
  service level
• ... for which there is a high likelihood of
  achieving consensus regarding medical management
• ... for which scientific rationale exists

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Order Set Development Guidelines

1. Orderables compliant with 90 10 rule
2. Mandatory, default, or optional
3. Comments on orders
4. Links to evidence Zynx and non-Zynx
5. Suggestions for interruptive alerts
6. Support system Care Management initiatives
7. Support regulatory requirements and CMS
   requirements

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Links to evidence from within patient chart
Links to evidence
g
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Zynx Summary and rationale
g
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Clinical Decision Support - CPOE
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Tell me why your Tx varies
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Keeping track of order sets
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Some statistics 200 standardized Order Sets
All Unique Sessions
Number of Drs participating 73 165 Number of
Nurses 33 69 Number of Pharmacists 11
70 Number of CM 17 41 TOTALS
134 345
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Physician-specific statistics
Physicians participating OS development 73
Supporting physician leaders 200 TOTALS
informed and/or participatory 273
(38) Physicians comprising 85 of admissions
722 Therefore, 273 of 722 busiest physicians
are well-informed and/or have particpated (38) .
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Dos...

• Do get pharmacy input for every session, they are
  INVALUABLE
• Do recruit physicians with a 11 conversation
• Do explain critical mass as sum of system
  personal
• Do figure out who in your organization will do
  the work
• Do encourage suggestions for Comments, Alerts,
  and Horizontals
• Do keep track of sessions with detailed
  instrument
• Do develop a migratory deployment plan

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CPOE Full House Go-Live

• All departments beyond pilot Units (Peds, OB, ED,
  Anesthesiology)
• February 12, 2007
• Exempt Milwaukee Cardio Group, Interventional
  Radiology
• Exempt providers still expected to electronically
  sign verbal orders

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In Wisconsin, measures are important
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33ile 50ile 85ile 90ile
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• Utilization is underestimated by
• Exempt physicians (imminent retirement, locums)
• Orders that spawn increases to denominator (e.g.
  range orders, sliding scales)
• Learning curve data included in cumulative stats

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Assuring Safety and Quality

• AMCO Benefits Measures
• CMS, Premier Measures
• Medication Orders Monitoring
• IS Issues Database
• Incident Reports

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AMCO Benefits Measures - TBD
Data will be indexed by number of discharges
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CMS Premier Measures
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Medication Orders Monitoring

• Summary pharmacy interventions logged
• Drug dose 35
• Start and Stop dates 14
• Duplicate Drugs 13
• Allergies 7
• TPN problems 7
• Drug Interactions 6
• Others 39
• Totals 121 (38 days ? 3.1 per day)
• Benchmark 170 (90 days ?1.8 per day)

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IS Issues Database
Discontinue PowerPlan on Pt XXX (2) Orders
placed on wrong visit (2) RPh needs to change
time of Rx order PCA ordered on hold x 24 hrs RT
documentation not adequately descriptive
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The Vision did we achieve it?

• Success a negotiated entity
• Utilization
• or
• Clinical transformation

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The Vision

• The most important outcome for Auroras first
  sites is that we be successful.
• Success is most tightly linked to utilization by
  physicians.

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Utilization versus Clinical Transformation

• Utilization
• Change behavior without adversely impacting
  productivity
• Legibility
• Remote ordering capability in context of clinical
  data
• Transformation
• Order Sets preferable to no Order Sets
• EBM OSs preferable to OS without EBM
• Standardization even in absence of EBM leads to
  improved outcomes

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Order Sets Usage (2/12 4/10/07)
157
8opportunity to move to standards
143
N 3798
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Usage Distribution of System OSs 2/12 4/10/2007
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Knowledge Management

• Evidence Based Medicine (Zynx -a Hearst Company)
• Assist creation of order sets
• Assist maintenance of order sets
• Authoritative reference source for citations to
  the medical literature

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The Alternate Aurora Process
Zynx Templates and Evidence
Existing Order Sets
Internally developed EBM citations
Evidence-Based Development Session
Rendering for CPOE and ePPO
Expert Panels
Departments Review
All Physicians Invited
Expert Medical Facilitators Selected
Pharmacists, Nurses, Care Managers Invited
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Lessons Learned

• Train adequately (3 hours syllabus)
• Properly characterize order sets (standard, v1,
  personal) and favorites

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• Utilization is underestimated by
• Exempt physicians (imminent retirement, locums)
• Orders that spawn increases to denominator (e.g.
  range orders, sliding scales)
• Learning curve data included in cumulative stats

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Barriers and Incentives to CPOE

• Barriers
• Physicians Work Practices
• Current level of technology
• Status of Commercial systems
• Lack of Financial incentives
• Incentives
• ability to enter from any location
• order sets
• improved patient outcomes (decreased LOS
  increased patient satisfaction)
• Technology and Medicine, Doolan DF, Bates DW,
  July/Aug 2002

• Incentives
• ability to enter from any location
• order sets
• improved patient outcomes (decreased LOS
  increased patient satisfaction)

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and Donts

• Dont waste time on discussions with low
  clinical impact (e.g. lowfat diet vs general diet
  for cardiac patients)
• Dont forget to check that build will be
  compatible with other EMR applications that are
  intended to be integrated
• Dont think that offering some desirable
  functions will necessarily translate into a
  clinicians decision to tolerate an undesirable
  function (brussel sprouts vs ice cream)
• Dont assume physicians will respond with
  cookbook medicine argument

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IS Issues Database
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Dartmouth Atlas of Health Care 1998
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