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How 26 hospitals deployed e-order systems in 28 months

How 26 hospitals deployed e-order systems in 28 months

The CPOE system means no more illegible notes from doctors

Concerned about patient care, Adventist Health System decided to deploy Computerized Physician Order Entry (CPOE) systems at all 26 of its hospitals in nine states. And it did so in only 28 months.

The result: an 11% decrease in how long patients stayed; a 16% drop in costs per case for heart failure patients; and a 95% reduction in call backs to doctors from pharmacists trying to clarify orders. It also reduced turnaround time for x-rays and lab tests.

CPOE systems enable electronic entry of healthcare instructions for the treatment of patients, including orders for x-rays, lab tests and prescriptions. The use of CPOE systems reduces errors that can occur because of poorly hand-written orders or through transcriptions of physician or nurse notes.

"Quite frankly, there's not a doctor in the world that disagrees with the fact that our handwriting creates problems for patients," said Dr. Phil Smith, chief medical information officer for Adventist. "We live in an environment where the Institute of Medicine says systems are causing the same number of people to die a preventable death each year as having a 747 crash every day in the United States."

Not easy, but worth it

Rolling out the multi-million dollar CPOE system across more than two-dozen hospitals was no small task. But, from January through September of this year, the system transmitted 13.2 million electronic orders and more than a million notes.

Perhaps more importantly, the CPOE system sent more than 400,000 clinical decision support alerts to physicians, which changed their prescribing behavior. That worked out to roughly 14 alerts for every 100 orders, and 10 of the 14 alerts resulted in order changes, Smith said.

Clinical decision support systems advise physicians and nurses on things such as adverse drug interactions based both on evidence-based medicine and patient information as well as problems that may result from other medical treatments.

Adventist Health System's success in quickly enabling CPOE in all of its hospitals was more about planning, commoditization and staying on task than technology execution, according to Smith.

Because Adventist was using a commoditized, standardized approach to CPOE, it spent the majority of its manpower on building out the first system, which was then used as the model for all others.

The pilot project took about 68,000 work hours before any CPOE system was even implemented. "Sixty-eight thousand hours to make the order catalog, make it physician friendly, [offer] clinical decision support, [provide] order sets and make sure orders made sense to doctors," Smith said.

Once the foundation was in place, the CPOE team was relatively small, consisting of only a medical director, a clinical director, a part-time pharmacist, three clinical informatics leads and a part-time change-management lead. The team would work with sites to get them ready and then stay for 28 days after the CPOE system went live.

"We really wanted to leverage the local super users because our model is a centralized IT office in a nine-state hospital system," Smith said. "We had to make sure the hospital could fully support themselves [sic] after they went live because we were moving our team one month later."

Adventist Health System's IT division, called AHS Information Services (AHS-IS), is a centralized shop that supports 31 of the healthcare system's 43 campuses.

Less about IT than communication

Prior to rolling out its CPOE system from Cerner Corp., Adventist Health System deployed a basic electronic medical records system also from Cerner over a four-year period beginning in 2004. That enabled the electronic records interaction. In 2008, Smith and his team worked to get hospital board members and executives to champion the cause, which limited the amount of pushback from hospital CEOs and physicians.

"At some point, we have to admit to ourselves that this is about the patient and not about the doctor," Smith said. "We're mainly putting a system in to allow the doctor to clearly communicate his or her intent about what the care plan is for the patient.

"We really saw CPOE as a change management opportunity more so than an IT project. So we did a lot of education on the front end," Smith continued. "Our process of CPOE was a 90-day engagement with the board and executive team to set the stage."

After that stage, each four-month long CPEO project would begin. During the implementation, general medical staff was involved in a frank discussion about the patient safety aspect of CPOE, including the good and bad. "We wanted them to understand where CPOE helps and where it's been over touted and where there have been problems ... and how we engineered them out. We wanted to have that honest conversation upfront," Smith said.

Six to seven weeks before a CPOE system would go live, medical staff would receive three to four hours of classroom training, followed by a competency test, as well as three to four hours of computer-based training on their own time. Most physicians ended up spending from six to eight hours in training.

Training was also specific to specialties, so as to concentrate on the workflows of the admitting physician, the ER physician, the surgeon, and other hospital personnel.

Also important to the speed and success of the project: keeping IT team members from tweaking systems as they were being rolled out.

"That was probably the most difficult, the fact that we needed to stay on task for 27 months, to keep heads down," Smith said. "It would have been nice to have been able to stop along the way, catch our breath and do some optimization of the system."

At any one point along the rollout, the healthcare system had six hospitals in active phases of CPOE deployment. Typically, as one hospital was going live with the system, two more were scheduled to do so three to four weeks later -- and three more were already in training to prepare for their systems.

When the project was completed in August, the hospital system was able to submit for reimbursement money through the federal government's EMR/EHR "Meaningful Use" program.

Under the American Recovery and Reinvestment Act of 2009, medical practices that implement EHR systems and demonstrate that they are engaged in meaningful use of such systems can receive reimbursements of as much as $44,000 under Medicare -- or as much as $65,000 under Medicaid -- per doctor. Hospitals can receive funds from both Medicare and Medicaid.

On average, hospitals receive about $4 million in reimbursements. But the largest facilities can expect to receive as much as $12 million, said Dr. Mitch Morris, national leader for health IT at Deloitte Consulting.

The government's meaningful-use reimbursements only covered from 20% to 25% of the cost of the CPOE rollout, according to Smith, who said getting those funds was never attached to the project anyways.

"You don't buy a new house to get a tax deduction. You buy it to get a place to live," he said.

Lucas Mearian covers storage, disaster recovery and business continuity, financial services infrastructure and health care IT for Computerworld. Follow Lucas on Twitter at Twitter @lucasmearian or subscribe to Lucas's RSS feed. His e-mail address is lmearian@computerworld.com.

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