Accreditation

Physician support crucial for CPOE success

Accreditation Connection, September 14, 2003

For facilities interested in implementing a computerized physician order entry (CPOE) system, the most important prerequisites are buy-in from medical executives and a strong support system for physicians, according to a recent report.

The report, Computerized Physician Order Entry in Community Hospitals: Lessons from the Field, was cosponsored by the California HealthCare Foundation, an independent organization committed to improving California’s health care delivery system, and First Consulting Group, a health care consulting firm. You can download the study at www.chcf.org or www.fcg.com.

It highlights the progress 10 community hospitals have made with CPOE. Key staff members from each facility offer tips and strategies for hospitals looking to purchase a CPOE system. Researchers focus on how hospitals can work toward universal CPOE adoption by doctors and how to successfully incorporate CPOE throughout the hospital.

How to structure your program
Current research on CPOE implementation focuses almost exclusively on academic medical centers, where residents write most of the medical orders, say experts. But approximately 89% of U.S. hospitals are community hospitals whose physicians have independent practices in the local area.

These doctors often admit their patients to different hospitals and spend little time at just one facility each day. Therefore, special challenges exist when training these physicians on CPOE.

In preparing for CPOE, interviewees from the 10 hospitals said the following are crucial to the process:
• Active roles for medical executives
• Doctors as decision-makers and leaders
• Active involvement of nursing, pharmacy, and other departments in making decisions

Each of the 10 study facilities also created a specific physician role or team prior to installing the system:

Physician champion: A doctor who spends a good deal of time as the contact person between the medical staff and the information services department.

Physician executive: An influential leader who supports the project, encourages others, and builds enthusiasm.

Physician advisory group: Oversees the project, makes decisions, and recommends policy to medical executive committees. Typically, a physician champion chairs this group.

TIP: Once you’ve formed your CPOE team, focus first on those doctors who express the most interest in the project and those who write the most orders. Try to get these physicians to support CPOE. Then target other groups as the project builds momentum.

Lori Yackanicz, manager of clinical applications at Lehigh Valley Hospital in Allentown, PA, recommends doing the following before bringing CPOE to a unit:
• Meet with the unit head, pharmacy, registered nurses, physician champion, and people in charge of education
• Look for unique issues on order sheets
• Create an issues list and ask nurses about medication administration
• Meet weekly to work on process and design issues
• Meet with division/unit doctors to review and improve pre-printed order sets to move them to an electronic format

TIP: To ease staff into using the CPOE system, make coaching and assistance easily available to them. Several hospitals found that classroom education was much less effective than one-on-one training.

At several of the 10 facilities, clinical analysts on the CPOE project team coached physicians. Doctors could get help anywhere and anytime for 20 minutes at a time. Nurses on the units, “super users,” and doctor peers were also important resources.

Other facilities placed cards near workstations to remind doctors how to get help and handed out laminated, pocket-sized cards with a list of tips for physicians. Some hospitals made trainers available in physician lounges and medical libraries for additional help.

Hospitals tracked doctors’ progress via usage logs maintained by the system, and they required minimal training before allowing users to access the system. To build a case for CPOE, hospital representatives found that no single medium alone was sufficient. Many also chose not to use e-mail to get the word out because not all doctors regularly use e-mail, and some don’t at all. Instead, facilities should use a mix of
• newsletters
• special mailings
• signs and posters
• presentations at staff meetings
• information at special events, such as fairs and celebrations

Make it simple for staff
Many doctors stressed the importance of easy access to the system so that wait time was low. Hospitals provided a variety of fixed devices and mobile laptops on nursing units and in physician work areas, and expected project leaders to increase the use of mobile devices as soon as possible.

“We hoped peer pressure with a slow rollout [time] and having our board adopt CPOE as the standard of practice would bring all of our doctors into the fold,” said Dr. Randy Ely, chief of staff at Alamance Regional Medical Center in Burlington, NC. “We got 85% [participation] that way, but it took two years,” he said in the report. If he had to do it again, he “would start with a mandate with the caveat that we would do everything possible to make CPOE efficient and easy.”

TIP: Other project leaders caution against using the term “mandate” when talking to employees about CPOE. Instead, work toward a hospitalwide policy for using the system.

Leaders recommend that you craft a policy when
• a significant number of doctors support CPOE and encourage their peers to use it
• you’ve made a good deal of progress toward safety objectives
• medical staff agree that using CPOE is the right thing to do

Consult the following ideas on how to get physicians to comply with CPOE:
• Encourage administrators to tie new medical staff orientation to CPOE, require new employees to sign an agreement to use CPOE in the credentialing process for new doctors, and renew agreements annually.
• Ask executives to include a statement in the bylaws that says CPOE is the accepted standard of practice in the facility. A physician who refuses to comply is working outside the boundaries of locally accepted practice.

Offer regular information, incentives
To inform and encourage physicians at her facility, Jo Facciolli, coordinator of physician network services at Community Medical Center in Toms River, NJ, created a quarterly newsletter for doctors. She sends copies sent to department chairs for distribution among staff and leaves the newsletter in the doctors’ lounges. A typical issue of the newsletter covers the following:

• CPOE user statistics that include
- the best overall user of CPOE by specialty (of doctors who enter more than 500 orders each month)
- the most improved doctors (four to six are chosen each month)
- the number of physicians maintaining personal order sets
- the number of doctors who have order sets
- the number of order sets in the system
• Explanations of changes to the system
• A help section that includes how to
- get personal order sets in the system
- print order sets for review
• A section on new developments that includes
- training instructions
- requests from employees and the progress made on those requests

Marie DiFrancesco, lead clinical analyst at Alamance, also created a special incentive for physicians. She posts a top 10 list on the bulletin board in the doctors’ lounge to take advantage of physician competition. The posting includes the top 10 CPOE users, the most improved physician user, new users, and those doctors who use the system for 80%–100% of orders, 50%–80%, 10%–50%, and 0–10%.

In 1999, to celebrate a year of CPOE, DiFrancesco recognized physicians by inviting every doctor who had entered an order to a breakfast that honored CPOE participants.

Overall, facilities participating in the study support CPOE. While many other facilities might fear that community doctors will take their business elsewhere if made to use CPOE, study participants say this has not occurred in any of their hospitals, even in the two facilities that are closest to universal adoption.



Here’s how one hospital incorporates CPOE into its policy
Excerpts from Abington Memorial Hospital’s medical staff regulations

Editor’s note: Abington Memorial Hospital is based in Abington, PA. The following is a portion of the facility’s medical staff regulations.

Enter all orders for treatment directly into the hospital order entry system or put them in writing.

The medical staff, in the interest of patient safety, will directly enter all orders through the hospital information system. Do not give handwritten, verbal, or telephone orders to nursing/ancillary staff, except in the following situations:

1. A patient emergency precludes the physician from directly entering his or her orders

2. The information system is not functional

3. The physician is away from the hospital and does not have access to the information system, or the physician is involved in a procedure that precludes direct order entry

4. The physician is performing a clinical procedure (i.e., in the operating room, cath lab, etc.)

Source: Computerized Physician Order Entry in Community Hospitals: Lessons from the Field, a study by the California HealthCare Foundation and First Consulting Group.



NY hospital cites CPOE safety and quality improvements

Many community hospitals applaud the benefits of computerized physician order entry (CPOE), saying that the system has helped improve medication safety, according to a recent report, Computerized Physician Order Entry in Community Hospitals: Lessons from the Field, by the California HealthCare Foundation and First Consulting Group. Administrators at Queen’s Medical Center in Honolulu, HI, cite the following benefits:

• A 75% reduction in transcription errors

• A 30% reduction in giving the wrong medication or administering it though the wrong route

• A 75% reduction in inappropriate vancomycin use

• A 60% decrease in time giving the first dose of an antibiotic for community-acquired pneumonia

• Elimination of missed cisplatin intravenous hydration

• A 98% compliance rate with the Joint Commission on Accreditation of Healthcare Organizations’ standard for restraint orders

• A 85% reduction in unsigned orders

• A 40% reduction in turnaround time for STAT medications  

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