Organizing Orders, Delivering Data: CPOE, EMRs & Integration

As computerized provider order entry (CPOE) systems come online, organizations are integrating CPOE data into their EMRs to leverage safer and more accurate ordering among providers across multiple settings. But that’s just the beginning. Facilities are finding new ways to tap that data to boost clinical decision support in other areas.

New York University Langone Medical Center (NYULMC), an academic medical center in Manhattan, N.Y., plans to integrate CPOE as a way to build clinical decision support (CDS) into its planned three-hospital EMR (Epic) deployment. The EMR has been implemented in a half-dozen outpatient settings with a seventh implementation to be finalized at the end of March. Inpatient go-live is expected in 2012 for all inpatient clinical areas including physician, nursing and ancillary documentation, pharmacy and radiology.

The medical center is moving toward a seven-day care model, which relies on integrating settings of care, says Peter M. Kilbridge, MD, CMIO at NYULMC.

This shift to a completely integrated model will move Langone toward more organized, accountable adherence to evidence-based order sets and pathways of care, according to Kilbridge.

“Years ago, CPOE was the place to leverage clinical decision support, but as organizations become more mature in CPOE function, the next level is to integrate information exchange across providers in multiple settings, and CPOE is just one component,” he says.

Langone is not alone in integrating CPOE data into its EMR to improve care across the continuum. CPOE tools within the EMR currently assist physicians at the University of Maryland Medical System (UMMS) in Baltimore to place and sign orders using more than 200 order sets enabling UMMS to demonstrate a 90 percent reduction in verbal orders, according to Mark D. Kelemen, MD, MBA, senior vice president and CMIO at UMMS.

“We have improved vaccination rates, handoff communication and compliance with national patient safety goals and core measures since going live with CPOE,” says Agnes Ann Feemster, PharmD, BCPS, assistant director of the clinical pharmacy services and investigational drug services at UMMS. “Compliance with patient weights and allergies is 100 percent in our system.”

Reducing high-risk drug orders

With 90,000 visits to the ER annually, 85 percent of orders at Peninsula Regional Medical Center (PRMC) in Salisbury, Md., a 380-bed hospital and trauma center in rural Maryland, are entered through CPOE (McKesson), says Christopher Snyder, DO, CMIO at PRMC.

The medical center has been using the system for five years. “Some of the value-added benefits of CPOE have driven appropriate utilization of medications,” says Snyder. High-risk drugs such as Dilaudid, Coumadin and heparin are the “low-hanging fruits,” and standardizing the way they are ordered throughout the institution has translated into greater safety to patients, he says.

CPOE at Work: Percentage of Sepsis Patients with Lactic Acid Checked & Mortality Trends:
Peninsula Regional Medical Center’s CPOE-based sepsis initiative has yielded a 37 percent reduction in mortality in severe sepsis patients and reduced the ICU length of stay for septic patients via computer alerts to check lactic acid levels.

Having the CPOE data integrated in the EMR enables concurrent review of high-risk medications, so Snyder and colleagues can monitor the daily use of those drugs. When a high-risk drug is ordered, a note is sent to the pharmacist to monitor the drug ordering. For example, when a lactic acid is ordered for a septic patient, four departments are notified about the patient so there is a high level of oversight on the patient to prevent adverse drug events (see chart below).

Evidence-based CPOE as CDS to guide appropriate use of the high-risk drugs is mandated protocol for ordering physicians at PRMC, says Snyder. “By using decision support to educate the clinical staff while they are in the process of ordering—whether it’s a nurse putting in a verbal order or a doctor putting in a direct order—the decision support guides them down the most appropriate use of that drug.” Thanks to the decision support, PRMC has reduced its use of Narcan, a reversal agent for opiates like Dilaudid, by 40 percent. “That’s telling us we have fewer errors associated with opiates,” he says.

The organization also has noted an increase in the use of protocols for anticoagulation drugs—from 20 percent protocol use to 100 percent. “There’s only one way to order medication,” says Snyder. “Evidence-based ordering drives standards of care. Protocols are driven out of those that help educate and modify medications based on lab values of those drugs.”

CDS via evidence-based ordering is not just limited to those drugs. PRMC’s CPOE-based sepsis initiative yielded a 37 percent reduction in mortality in severe sepsis patients, while simultaneously reducing the ICU length of stay for septic patients by almost a day and a half. The reduction was driven by computer alerts, Snyder says.

“Your CPOE initiative will drive standardization if you allow that to be the only way to order something in an institution,” says Snyder. “So you have to get consensus among the individuals [physicians]. I develop standards using evidence from organizations like the Joint Commission or Institute of Health and build it into appropriate orders. Once [we] develop the evidence, I share it with colleagues/specialists and due diligence is done. [We] rebuild the standard and then release it into the environment and then review the standard after six months.”

Integration at the bedside

“CPOE is a major transformational opportunity for healthcare,” says Phil Smith, MD, CMIO and vice president at Adventist Health System (AHS), a faith-based nonprofit health organization based in Winter Park, Fla.  AHS includes 44 campuses across 10 states with 1.3 million medication orders entered via CPOE last year.

AHS approached CPOE as a commoditized model with an ambitious deployment regimen, where hospitals achieve 90-day readiness and go live in a four-and-a-half-month implementation cycle, according to Smith. Currently, 17 hospitals are inputting CPOE orders via an EMR (Cerner) platform, and Smith expects that 14 will start using CPOE this year.

CDS is a core function of CPOE, says Smith. More than 550 evidence-based order sets are connected to decision support software engines (Zynx Health) embedded in the EMR, including alerts for drug-allergy, drug-drug interactions, drug duplication and dose-range checking.

Within the last year, the CPOE system fired, on average, 34 alerts per 100 medication orders, says Smith. “Of that average, physicians changed their ordering behavior 52 percent of the time, and when you crunch the numbers, that percentage means more than 90,000 alerts changed physicians’ behaviors at the point of care last year.”

CDS at the point of care using CPOE data integrated in the EMR works, says Smith, helping clinicians in the context of the patient. “After the doctor leaves the bedside, the clinician could potentially move on from a patient cognitively by moving on to a new patient and potentially physically by leaving the room.”

Alerts also have been set up for high-risk interventions, Smith says. Using a best practice tool (Cerner DiscernExpert), logic statements are placed in a patient’s chart showcasing potentially adverse drug events. In 2009, clinicians were warned of distinct conditions for 595 patients that resulted in a change in caregiver drug ordering behavior.

Pushing for Clinician Adoption

Data integration won’t improve care if clinicians resist using CPOE in an EMR. David E. Trachtenbarg, MD, at the Methodist Medical Center of Illinois in Peoria, and member of the CPOE Workgroup for the Healthcare Information and Management Systems Society, has some advice for transitioning CPOE implementation to the next level—adoption.   Eliminate clicks Fewer clicks makes the system more user-friendly (i.e., faster), particularly for standardized procedures. Test usage  “Are clinicians using the system and how well are they using it?” asks Trachtenbarg. To answer that question at Lutheran Medical Center (LMC) in Brooklyn, N.Y., Beth Raucher, MD, CMO at the facility, used order sets that were already in the LMC system to familiarize clinicians with a new MedSphere system during training. “Because we trained clinicians on actual order sets they would be using, they were more familiar with the new system [at go-live],” she says. Minimize the number of alerts “I think some organizations rush into installation and don’t realize to walk before jogging to the third stage,” says Trachtenbarg. Adding alerts without thoroughly vetting them among stakeholders can lead to “alert fatigue” where a clinician is bombarded with alerts by trying to place an order, he says. “It’s a common warning, but you have to be careful not to bog down physicians with so many alerts that they become white noise,” agrees Raucher. “We had to cut down on some flags, because some patients could have a dozen flags but might not be relevant to their physician.”

The most successful alerts have centered on high-risk intervention warnings for patients with sleep apnea. “Some alerts have been effective around anti-coagulation patients and at the point of ordering, if, for example, a patient’s blood is too thin,” says Smith.

Thanks to the integration into the EMR, AHS has noted a 94 percent reduction in pharmacy ordering interventions and 55 percent reduction in errors that cause patients harm, he says.

Clinical resource management

At Lucile Packard Children’s Hospital (LPCH) at Stanford University, in Palo Alto, Calif., the Clinical Resource Management (CRM) program—an initiative to use CPOE as a tool to both study and influence clinical resource utilization patterns—resulted in several million dollars in budgeted savings last year, according to Christopher Longhurst, MD, CMIO at the hospital.

Clinicians at Lucile Packard launched in 2007 a CPOE initiative with 95 percent of inpatients on the 312-bed hospital’s EMR platform. Pushing the initiative forward in 2008, Lucile Packard developed an internal initiative, called Clinical Resource Management, to use the CPOE/EMR system as an intervention tool to help inform behavior in cases where ancillary services were not being utilized at the correct level.

Taking a business perspective, LPCH looked at the EMR for ways to improve outcomes by decreasing unnecessary utilization, improving the quality of healthcare quality, or both. “Thinking about value as quality over cost, we’ve been able to see significant financial and quality improvement savings,” says Longhurst. “EHRs are a journey, not a destination.”

Using an evidence-based approach, the organization was able to publish an association of CPOE data and a decrease in mortality by 20 percent over an 18-month period last year. (Longhurst et al, Pediatrics, July 2010)

The Clinical Resource Management initiative targeting lab tests has reduced use in the pediatric intensive-care unit (PICU) by more than 50 percent, and decreased blood transfusions on stable patients on acute care units by more than 50 percent since launching, according to Eric Widen, administrative director of performance improvement at Lucile Packard.

An alert reminds the physician of blood transfusion guidelines on hemoglobin-dynamically stable patients at the time of order entry on the general acute units. This alert has resulted in a 50 percent reduction of blood transfusions, Widen says. “This means kids are not getting exposed to unnecessary transfusions,” says Widen.

Not all targeted interventions are successful, according to Widen. “In trial and error, you should fail sometimes in order to get results somewhere else,” he says. For successful patterns, “we put a rule into the system and sometimes there’s nothing to do but that. Some other times, you need physician education to get the change you want.”

All CDS outcomes hinge on the successful CPOE implementation in 2007, says Longhurst. “That was successful because we went live with the minimal amount of alerts necessary. We turned off a lot of unnecessary alerts and guided medication alerts to focus on harm reduction. By going live with the minimal number of alerts, we were able to leverage CDS to build a [Clinical Resource Management] program in a way the physicians trusted because we didn’t create alert fatigue.”

Stage 2 requirements for meaningful use will very likely call for eligible providers and hospitals to expand clinical decision support and be able to demonstrate it. Organizations on the front lines are showing how CPOE data integrated into the EMR can do just that.

Integration accomplished?

Lutheran Medical Center (LMC) in Brooklyn, N.Y., a 476-bed teaching hospital, rolled out an EMR (Medsphere) with CPOE capabilities for CDS in November 2010. CPOE data, including drug-drug interactions, allergy and dosage checking including if a patient is pregnant or not, are all integrated into the system via order sets and quick order menus. This first phase of a three-phase process will move LMC to a paperless environment, says Beth Raucher, MD, CMO at LMC. The next rollouts, expected to go live later this year, include barcode medication administration and clinical documentation initiatives. Although LMC has not yet quantified ROI, there is anecdotal evidence that since CPOE data have been integrated to the EMR, the time from medication ordering to delivery to the patient has been notably faster, according to Raucher. This has helped expedite care as well. For example, for patients presenting at the ER with chest pain, the system automatically orders blood tests for the needed three times in 24 hours. “We wrote the order set so that the system goes ahead and orders the test three times, to not over-alert the clinician with duplicate flag for this particular blood test,” she says. While the systems certainly help alert caregivers when a serious threat to a patient’s health or safety presents itself, clinicians will more than likely take the extra step to corroborate the system’s alert. “For example, with significant concern, the pharmacist will pick up the phone and alert the clinician,” Raucher says. Although 93 percent of clinicians are entering medications through the EMR at LMC, does that translate into a successful CPOE implementation?  “Ultimately, I think the system will save us money by making us more efficient and reduce medical errors especially those associated with poor handwriting and dosing errors,” concludes Raucher. “Stay tuned.”