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3/21/2003

CPOE Takes Time, Patience, Money, and Teamwork

Donna Young

Health systems considering installation of computerized prescriber order-entry (CPOE) systems must include pharmacists, physicians, nurses, and other health care professionals in the development process; educate clinicians about the system and keep them informed during all stages of development and implementation; and plan budgets accordingly, said Steven Meisel, director of medication safety for Fairview Health Services, a seven-hospital health system in Minnesota.

“It’s not an overnight process,” he said. “Implementation can take several months, and even years. It is very expensive and can get very messy. Something that looks relatively easy on paper can be very challenging electronically to implement.”

An estimated 5% of American hospitals use CPOE, according to a January 2003 report prepared by First Consulting Group for the American Hospital Association and the Federation of American Hospitals.

Several months earlier, the “ASHP 2002 National Survey of Pharmacy Practice in Acute-Care Settings” determined that 6.9% of hospitals use CPOE. (This figure was not reported in the article that appeared in the January 1, 2003, issue of AJHP.)

In the First Consulting report, “Computerized Physician Order Entry: Costs, Benefits and Challenges,” which was a case study of five hospitals, the firm found that total one-time capital and operating costs for CPOE ranged from $6.3 million to $27.3 million with an average of $12 million.

A Deloitte & Touche November 2002 survey, “The Future of Health Care,” found that 61% of health-system chief executive officers reported they were planning to install or upgrade a CPOE system over the next two years.

The Leapfrog Group reported in March that 4.3% of the 786 hospitals responding to its survey on safety measures had fully implemented a CPOE system and another 22% were committed to implementing one by 2004.

At least 100 Fairview staff members, including five pharmacists in the pharmacy information systems department, have been involved in the selection, development, and implementation of the health system’s new electronic medical record system, which includes a CPOE component, Meisel said.

Fairview is in the early stages of implementing its system, Sunrise Clinical Manager from Eclipsys Solutions Corp. of Delray Beach, Florida, he said. The entire process, from planning through full implementation, is expected to take two to three years.

The health system is initially using CPOE in one unit each at three Minneapolis hospitals: Fairview University Medical Center, Fairview Ridges Hospital, and Fairview Southdale Hospital.

But so far, Meisel added, in most cases physicians rarely enter orders on the system—health coordinators or nurses do the work.

“The value of this system is when physicians use it themselves and when they recognize that value,” he said. “You have to have physicians onboard, or it’s not going to work.”

Cedars-Sinai Medical Center in Los Angeles, California, temporarily suspended implementation and use of its CPOE system because of “concerns expressed by members of the medical staff and in recognition of the challenges faced during the installation process,” according to the health system’s January 22 statement. This suspension of CPOE, the statement noted, would not affect Cedars-Sinai’s use of other components, including patient management and accounting elements, of its new information system.

The Los Angeles Times had reported the same day that physicians had complained that Cedars-Sinai’s CPOE system “was endangering patient safety and required too much work.”

Cedars-Sinai’s 2002 annual report boasts that, once fully implemented, its CPOE system “will have a significant impact on patient care, patient safety, and efficiency.”

Many health systems in California are rushing to install electronic medical record and CPOE systems for legal reasons. The state’s legislature passed a law in August 2000 requiring acute care hospitals to have in place by January 1, 2005, technology that has been shown effective in preventing medication-related errors.

Rita Shane, Cedars-Sinai pharmacy services director, noted that CPOE systems are still very much in their infancy and that entering medication orders on such a system is a radical change from handwriting orders.

To be successful, she said, health systems should conduct extensive testing to identify what changes need to be made before fully implementing a system and to ensure that staff members clearly understand how to use CPOE.

Understanding how humans interact with any new technology, Shane said, is essential to ensuring that the system improves patient safety.

The Los Angeles Times quoted one physician as saying he was concerned about the amount of time it was taking to order a prescription using Cedars-Sinai’s CPOE, requiring two minutes as opposed to the five seconds it would normally take him to handwrite an order. This extra time spent on using CPOE, he complained, was time away from his reading, family, and patients.

Tailor CPOE Software to Prevent Overrides

Alicia S. Miller, associate pharmacy director for Ohio State University Medical Center in Columbus, fears that prescribers will become jaded and accustomed to overriding the "check order" alerts in computerized prescriber order-entry (CPOE) systems if those alerts appear so frequently that they become burdensome.

Miller said prescribers at her health system override CPOE-generated warnings of possible drug allergies about 80% of the time because they do not consider most of those warnings as clinically significant.

"It almost defeats the purpose of having those warnings because physicians then begin to ignore all warnings," she said.

Prescribers are particularly annoyed, she said, when several warning screens pop up in response to orders for more than one pain medication or chemotherapy treatment for a patient with cancer.

Thomas H. Payne, medical director for information technology services at University of Washington School of Medicine in Seattle, said health systems should modify the order-check software so that less relevant alerts do not distract clinicians.

Health systems should ask CPOE vendors for a list of hospital clients and contact those hospitals to inquire how often prescribers override system alerts, he said.

Before signing a contract with a vendor, Payne added, health systems should clearly stipulate in the contract that modifications may need to be made to the order-check software.

Often the problem with the databases used for order-check alert systems is that they are designed to generate an alert based on an entire class of drugs, Payne said.

"Sometimes the classification of drugs is so broad that an alert is triggered even though the chance of a drug or allergy interaction is very low," he said. "This becomes an annoyance to practitioners who pressure a hospital to deactivate an entire class of drugs from their alerts. And when they do that, the system's credibility is threatened."

Payne said a health system could design its CPOE system to generate a separate pop-up warning screen for severe or moderate warnings. Minor alerts could be noted on the order-entry screen without creating a burdensome override step when prescribers decide to stay with their original selection.

"We don't want to edit out alerts completely," he said. "We just want to change the severity level of those alerts to fit the needs of clinicians."

During pilot stages of implementation and periodically throughout the year, health systems should evaluate which drug orders are generating overrides rather than wait a year to examine the annual percentage of orders overridden, Payne said.

"If you wait, practitioners will develop habits of overriding and they will be less willing to accept and use the system," he said.

Payne and two other researchers studied overrides of order-check alerts at the Puget Sound Veterans Affairs Medical Center in Seattle. The researchers found that, of 42,641 orders for which an alert might be generated, 11% did generate an alert; many of these orders generated more than one alert.

Prescribers overrode alerts warning of drug-drug interactions 88% of the time and possible drug allergies 69% of the time during the four-week study.

In some cases, Payne noted, alerts were triggered when a prescriber ordered a hydroxymethylglutaryl-coenzyme A reductase inhibitor and ketoconazole shampoo. Taken internally with a lipid-lowering agent, the antifungal agent could cause a drug interaction, Payne noted, but when applied topically, ketoconazole more than likely would not result in a reaction.

Payne and his colleagues presented results from their study in the report "Characteristics and Override Rates of Order Checks in a Practitioner Order Entry System," at the American Medical Informatics Association's 2002 symposium in San Antonio, Texas. 

Dan Degnan, pharmacy facility leader for Community Hospital North in Indianapolis, Indiana, said that a health system’s CPOE development team needs to convince physicians that the extra time they spend on keying prescriptions into the system can, in the long run, save time that would otherwise be spent returning phone calls to the pharmacy when pharmacists have questions about handwritten orders. 

“You have to show physicians that there is added value to using the system,” he added.

A CPOE system can automatically display a patient’s medication history, alert a prescriber to potential drug and allergy interactions with certain medications, or electronically notify a prescriber that a dosage is incorrect for a patient’s weight, Degnan said.

“You have to show doctors that they can have clean orders” when using CPOE, he added.

Physicians, he said, should be included at an early stage in the vendor-selection and system-design processes.

Degnan’s health system, Community Health Network, has installed General Electric Medical System’s CPOE at his hospital and the network’s new cardiology hospital, which opened February 17 in Indianapolis.

The Indiana Heart Hospital is the “world’s first all-digital hospital,” said Steve Hultgren, Community Health Network’s pharmacy director.

Early adopters of new technology, such as clinical information systems and CPOE, pay less in overall costs because vendors can use a hospital as a test site, he noted.

“The cost to us is our blood, sweat, and tears during the development stages,” Hultgren said. “Waiting until 50% of hospitals have the technology makes sense from a point of view of having a well-functioning system. But those who wait will pay more money in the long run.”

The cardiology hospital, which is jointly owned by Community Health Network (70%) and a physicians group (30%), is using General Electric’s Centricity electronic medical record system, Degnan said.

Prescribers have received four hours of dedicated training in CPOE use from vendor and internal information systems personnel, he said, with additional ongoing training and support provided.

“But the best possible training is to use the system,” Degnan said, adding that training sessions should not be held too far in advance of CPOE implementation or prescribers forget how to use the system.

General Electric’s development and implementation team includes physicians and nurses who spend time onsite to help the hospital’s physicians, nurses, pharmacists, and other professionals use the system, he added.

The company’s use of health care professionals as consultants, he said, “lends credibility” to the product and has helped physicians at Community Health Network’s hospitals feel more at ease with adopting CPOE technology.

Degnan suggested that health systems should seek to develop a partnership relationship rather than a buyer–seller relationship with CPOE and clinical information system vendors.

In a partnership, he noted, vendors are “more motivated to make sure things work.”

The cardiology hospital’s clinical information system is integrated with the electronic medication administration record system, which includes bar-code scanners at patients’ bedsides. General Electric’s system interfaces with the pharmacy’s standalone system, he added.

The hospital’s goal, Degnan said, is to be a completely paperless facility.

Prescribers are required to use CPOE when ordering medications from the hospital’s pharmacy, he said.

“They don’t have any choice,” he added.

Health care professionals currently use a keyboard login to access the Centricity system, he noted. But the hospital is in the process of installing security scanners that read a bar code on employee identification badges.

Hultgren urged pharmacy directors to get involved with their health system’s plans to implement CPOE.

“The medication part of a CPOE’s design is the most complex and the most overwhelming,” he said. “If a hospital does not involve pharmacy, they are going to have a lot of failures. Pharmacy will eventually be involved, so it is better to have them on the front end.”

Bill Puckett, pharmacy and patient care supply administrative director for St. Luke’s Episcopal Hospital in Houston, Texas, said that his pharmacy has been highly involved in providing input about the clinical decision support component of its new system.

The hospital is using McKesson Corporation’s Horizon Expert Orders clinical decision support and CPOE system, originally developed by Vanderbilt University Medical Center in Nashville, Tennessee, Puckett said.

St. Luke’s has also implemented bedside bar-code scanning in 60% of its patient care units, he noted.

CPOE use, he said, helps resolve several issues, including problems reading a prescriber’s illegible handwriting.

CPOE also provides formulary management.

“With CPOE, pharmacists no longer have to be the formulary police,” Puckett said. “A physician can discern upfront if he is ordering a nonformulary product.”

Puckett noted the importance of having a CPOE system that interfaces with the pharmacy information system.

“With systems that talk to each other, a pharmacist can do more verifying and validating rather than entering orders,” he said.

Alicia S. Miller, associate pharmacy director for Ohio State University Medical Center (OSUMC) in Columbus, said the CPOE system must be interfaced bidirectionally with the pharmacy information system so that pharmacists can send status updates to the CPOE system.

Health systems should not expect implementation to go according to plans, she added.

Miller’s health system selected its vendor, Shared Medical Systems—now part of Siemens Medical Solutions Health Services—in 1996 but had to suspend implementation of CPOE in 1998 for 18 months to direct information systems resources to prepare for Y2K.

But, she added, the 18 months gave the health system time to consider enhancements to its CPOE system.

OSUMC resumed implementation of the system in February 2000, Miller said.

Within a few months, the health system had fully implemented its system at two of its hospitals: Ohio State University Hospital and James Cancer Center Hospital. A year later, OSUMC completed installation of CPOE at its Dodd Hall rehabilitation facility and in the women’s and infants units.

For its remaining units, the health system is in a “holding pattern,” Miller said, until Siemens completes design of its next-generation CPOE system. Once completed, she said, OSUMC plans to upgrade all of its CPOE systems to Siemens’s new Soarian system.

Implementing CPOE, Miller said, needs to be regarded as a culture change.

“It’s something that has to be discussed,” she said. “You can’t force this down people’s throats. Culture eats strategy every day for lunch.”