Hospitals are continuing to implement computerized provider order entry systems to not only meet meaningful use requirements, but to also increase the use of evidence-based practices and improve efficiency through electronic prescribing. Altamonte Springs, Fla.-based Adventist Health System began its CPOE project to enhance patient care and to work towards becoming a paperless organization. Philip Smith, MD, vice president of information services and CMIO of Adventist Health System, explains how the organization deployed CPOE in 26 hospitals throughout nine states in only 28 months.
"Big bang"
Adventist Health System took a "big bang" approach to CPOE implementation, meaning that in each hospital, everyone went live on the system the same day. "It's not optional," Dr. Smith says. "The day we go live, every doctor and physician assistant and nurse practitioner writes order by CPOE." AHS' decision to require CPOE adoption among physicians was part of its strategic plan to improve patient care. "We decided upfront as a corporation that with evidence showing the safety and benefit of CPOE, all of our patients deserve to have that benefit," Dr. Smith says.
The system began with pilot CPOE implementations in two hospitals in May and June of 2009, respectively. AHS then waited until May 2010 to bring the remaining 24 hospitals online. "We took those 11 months to make sure our system was as solid as possible and that any issues we had could be mitigated or resolved to improve our design and improve our methodology of deployment," Dr. Smith says.
The hospitals were divided among three teams of people who led CPOE deployment in parallel in May 2010. Moving quickly and repeating the process at each hospital enabled the teams to become very proficient in their work, Dr. Smith says. This big bang approach ensures that everyone in the hospital performs a process in the same way, avoiding the complexity of managing hand-written and electronic prescription orders, which may occur if the system were adopted more slowly. "Incremental CPOE creates multiple processes in a hospital," Dr. Smith says. "You're putting nurses in a place where some orders are electronic and some are on paper. It's confusing to pharmacists and nurses, and at the end of the day the patient gets caught in the middle."
Leadership
The success of the big bang approach is due in large part to the health system's leadership at both the corporate and hospital level, according to Dr. Smith. "The single most important factor is [the system's] corporate vision that getting a clinical IT system deployed would be important strategically as we move forward with a variety of initiatives around quality, safety and satisfaction," he says. The CPOE technology at Adventist Health System includes evidence-based order sets and a clinical-decision support system from Zynx Health to improve patient safety and reduce errors. "We wanted to leverage our IT investment and make sure we were getting the full benefit of that by having our doctors placed in an environment where they could use evidence-based medicine and clinical-decision support to guide best practices at hospitals," Dr. Smith says.
Physician buy-in
In addition to administrative leadership, AHS needed physician leadership to accomplish CPOE deployment in 26 hospitals in a little more than two years. Gaining buy-in from all the physicians was one of the biggest challenges of the CPOE project, Dr. Smith says. Besides the common challenge of persuading people to change, AHS struggled to win physicians over because they are not obligated to practice at only an AHS hospital. Dr. Smith says, "Many of our competitors had either not done CPOE or made CPOE voluntary," which gave physicians an opportunity to leave the system to avoid CPOE.
To gain physician buy-in, AHS emphasized CPOE's potential impact on patent safety and provided training and support in changing to the new process. "By spending time helping everyone understand that this is a patient-focused initiative around patient safety, everyone gets involved," Dr. Smith says. The health system also communicated the potential increase in productivity and efficiency from using CPOE through reduced call-backs from pharmacies and fewer prescription errors. "By the time we had 16 or so hospitals live, we had the momentum developed where we could use the experiences and data from preceding hospitals as proof of point to subsequent hospitals," Dr. Smith says.
Resistance
When faced with resistance from physicians it was important to first identify the reason for resistance, according to Dr. Smith. "Many times, resistance is coming out of fear," he says. "Working with that fearful physician and showing [him or her] how to actually do work in a CPOE environment overcomes a lot of the resistance."
Sometimes, however, the system could not change a physician's resistance regardless of its efforts in training and support. These physicians are typically "angry about something else in their life — maybe a personal problem, a problem with their practice — and CPOE becomes the scapegoat," Dr. Smith says. "We have to accept that we can make the case for CPOE, but we can't always solve personal problems." Overall, only about two physicians out of more than 9,000 left the system due to opposition to CPOE, according to Dr. Smith. In addition, some physicians remained with the health system despite disliking the new technology. "Even a year out with some of our sites, there are still some doctors who think [CPOE] is the worst thing, yet they do it and they do it very well. You just have to recognize that like any other change, you're going to win your supporters, and you're going to win your critics," Dr. Smith says. "You have to know at the end of the day why you're doing it and have data to support the success of what you're doing."
Change management
Another strategy AHS used in deploying CPOE quickly is change management. "Change management is about working with the people and processes around the adoption of new workflows," Dr. Smith says. "It has to do with having a communication plan, a training plan, a plan for workflows and a plan for engagement of people at every level." AHS developed change management teams at each hospital to help physicians and employees adapt to CPOE. "CPOE is not really about the technology, it's about changing the way you do your work; it impacts almost every process in the hospital," Dr. Smith says. "We wanted to be able to successfully navigate through [the change] and come out the other end a stronger organization."
Results
Results from CPOE use at AHS suggest that it has indeed made the system stronger. Since CPOE deployment, hospitals have seen an 11 percent decrease in length of stay, a 16 percent decrease in cost-per-case for heart failure patients and a 95 percent decrease in call-backs from pharmacists clarifying orders.
Currently, 87 percent of orders at AHS are made through CPOE and 100 percent of physicians are using the technology. Dr. Smith says that out of every 100 orders, the CPOE system generates approximately 14 alerts due to a possible drug-drug interaction or other adverse event. Roughly ten of these alerts have led physicians to change their order, with four alerts overridden based on physicians' experience and expertise.
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"Big bang"
Adventist Health System took a "big bang" approach to CPOE implementation, meaning that in each hospital, everyone went live on the system the same day. "It's not optional," Dr. Smith says. "The day we go live, every doctor and physician assistant and nurse practitioner writes order by CPOE." AHS' decision to require CPOE adoption among physicians was part of its strategic plan to improve patient care. "We decided upfront as a corporation that with evidence showing the safety and benefit of CPOE, all of our patients deserve to have that benefit," Dr. Smith says.
The system began with pilot CPOE implementations in two hospitals in May and June of 2009, respectively. AHS then waited until May 2010 to bring the remaining 24 hospitals online. "We took those 11 months to make sure our system was as solid as possible and that any issues we had could be mitigated or resolved to improve our design and improve our methodology of deployment," Dr. Smith says.
The hospitals were divided among three teams of people who led CPOE deployment in parallel in May 2010. Moving quickly and repeating the process at each hospital enabled the teams to become very proficient in their work, Dr. Smith says. This big bang approach ensures that everyone in the hospital performs a process in the same way, avoiding the complexity of managing hand-written and electronic prescription orders, which may occur if the system were adopted more slowly. "Incremental CPOE creates multiple processes in a hospital," Dr. Smith says. "You're putting nurses in a place where some orders are electronic and some are on paper. It's confusing to pharmacists and nurses, and at the end of the day the patient gets caught in the middle."
Leadership
The success of the big bang approach is due in large part to the health system's leadership at both the corporate and hospital level, according to Dr. Smith. "The single most important factor is [the system's] corporate vision that getting a clinical IT system deployed would be important strategically as we move forward with a variety of initiatives around quality, safety and satisfaction," he says. The CPOE technology at Adventist Health System includes evidence-based order sets and a clinical-decision support system from Zynx Health to improve patient safety and reduce errors. "We wanted to leverage our IT investment and make sure we were getting the full benefit of that by having our doctors placed in an environment where they could use evidence-based medicine and clinical-decision support to guide best practices at hospitals," Dr. Smith says.
Physician buy-in
In addition to administrative leadership, AHS needed physician leadership to accomplish CPOE deployment in 26 hospitals in a little more than two years. Gaining buy-in from all the physicians was one of the biggest challenges of the CPOE project, Dr. Smith says. Besides the common challenge of persuading people to change, AHS struggled to win physicians over because they are not obligated to practice at only an AHS hospital. Dr. Smith says, "Many of our competitors had either not done CPOE or made CPOE voluntary," which gave physicians an opportunity to leave the system to avoid CPOE.
To gain physician buy-in, AHS emphasized CPOE's potential impact on patent safety and provided training and support in changing to the new process. "By spending time helping everyone understand that this is a patient-focused initiative around patient safety, everyone gets involved," Dr. Smith says. The health system also communicated the potential increase in productivity and efficiency from using CPOE through reduced call-backs from pharmacies and fewer prescription errors. "By the time we had 16 or so hospitals live, we had the momentum developed where we could use the experiences and data from preceding hospitals as proof of point to subsequent hospitals," Dr. Smith says.
Resistance
When faced with resistance from physicians it was important to first identify the reason for resistance, according to Dr. Smith. "Many times, resistance is coming out of fear," he says. "Working with that fearful physician and showing [him or her] how to actually do work in a CPOE environment overcomes a lot of the resistance."
Sometimes, however, the system could not change a physician's resistance regardless of its efforts in training and support. These physicians are typically "angry about something else in their life — maybe a personal problem, a problem with their practice — and CPOE becomes the scapegoat," Dr. Smith says. "We have to accept that we can make the case for CPOE, but we can't always solve personal problems." Overall, only about two physicians out of more than 9,000 left the system due to opposition to CPOE, according to Dr. Smith. In addition, some physicians remained with the health system despite disliking the new technology. "Even a year out with some of our sites, there are still some doctors who think [CPOE] is the worst thing, yet they do it and they do it very well. You just have to recognize that like any other change, you're going to win your supporters, and you're going to win your critics," Dr. Smith says. "You have to know at the end of the day why you're doing it and have data to support the success of what you're doing."
Change management
Another strategy AHS used in deploying CPOE quickly is change management. "Change management is about working with the people and processes around the adoption of new workflows," Dr. Smith says. "It has to do with having a communication plan, a training plan, a plan for workflows and a plan for engagement of people at every level." AHS developed change management teams at each hospital to help physicians and employees adapt to CPOE. "CPOE is not really about the technology, it's about changing the way you do your work; it impacts almost every process in the hospital," Dr. Smith says. "We wanted to be able to successfully navigate through [the change] and come out the other end a stronger organization."
Results
Results from CPOE use at AHS suggest that it has indeed made the system stronger. Since CPOE deployment, hospitals have seen an 11 percent decrease in length of stay, a 16 percent decrease in cost-per-case for heart failure patients and a 95 percent decrease in call-backs from pharmacists clarifying orders.
Currently, 87 percent of orders at AHS are made through CPOE and 100 percent of physicians are using the technology. Dr. Smith says that out of every 100 orders, the CPOE system generates approximately 14 alerts due to a possible drug-drug interaction or other adverse event. Roughly ten of these alerts have led physicians to change their order, with four alerts overridden based on physicians' experience and expertise.
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