remember ordering from catalogues? does anyone still use them? if not, why not? out of date cant...
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Remember Ordering From Catalogues?
Does anyone still use them? If not, why not?
Out of date Can’t find the order form
(some one else used it?) Legibility Have to fill out each form
every time Etc.
Fill out the form and see what happens
Remember Ordering From Catalogues?
Ordering today
Today, most everyone seems to prefer electronic (online) order entry. Why?
Order from anywhere Immediate feedback Faster Even a place to order from
the paper catalog
Real time information during order entry
Computerized Physician Order EntryComputerized Physician Order Entry(CPOE)(CPOE)
A Recipe for SuccessA Recipe for Success
Stuart M. Cohen, M.D.
Cerner Corporation
ProviderProvider
The Need for CPOE
Improved patient safety Improved quality Improved efficiency Reducing operating costs
Patient Safety
Top 10 Causes of Death 19981. Heart Disease 724,2692. Cancer 538,9473. Stroke 158,0604. Lung Disease 114,381
5. Medical Errors 98,000*
6. Pneumonia 94,8287. Diabetes 64,5748. Motor Vehicle 41,8269. Suicide 29,26410. Kidney Disease 26,295 * Estimated. Recent reports suggest this number may be much greater.
CPOE—What It Can Do? Provides Decision Support Warns of Drug Interactions
Drug-Drug Drug-Allergy Drug-Food
Checks Dosing Reduces Transcription Error Reduces number of lost orders Reduces duplicative diagnostic testing Recommends cost effective, therapeutic alternatives
EvaluatePatientStatus
Act OnOrders
CommunicateOrders
ConsiderEvidence
AcknowledgeOrders
DocumentOrderAction
EnterOrders
CheckOrders
Close the loop
CPOE Is Really Automated Workflow
Enhance with embedded clinical knowledge
Order sets with embedded evidence
Actionable Decision Support/Alerts
Clinical Evidence
Reports: Adherence to Standards
Dynamic Analysis
Enhance with embedded clinical knowledge
Order sets with embedded evidence
Actionable Decision Support/Alerts
Clinical Evidence
Reports: Adherence to Standards
Dynamic Analysis
Enhance with embedded clinical knowledge
Order sets with embedded evidence
Actionable Decision Support/Alerts
Clinical Evidence
Reports: Adherence to Standards
Dynamic Analysis
Enhance with embedded clinical knowledge
Order sets with embedded evidence
Actionable Decision Support/Alerts
Clinical Evidence
Reports: Adherence to Standards
Dynamic Analysis
Enhance with embedded clinical knowledge
Order sets with embedded evidence
Actionable Decision Support/Alerts
Clinical Evidence
Reports: Adherence to Standards
Dynamic Analysis
Adverse Drug Reaction (ADE’s)
Several studies have found a serious medication error in 3.4%-5.3% of inpatients
The cost of a single preventable ADE is $4,685 $1.3 million annually for an average 300 bed hospital
Bates et al. JAMA 1997;277:307-311
Bates et al. JAMA 1998;280:1311-1316
Bates et al. J Am Med Informat Assoc 1999;6:313-321
Lesar et al. Arch Intern Med 1997;157:1569-1576
56%
4%*
34%
LabRad
Vitals
•Comprehensive CPOE
• Patient Care, Lab, Rad Systems (CareNet, PathNet, RadNet)
• Pharmacy (PharmNet)
• Medication Administration
(eMAR/PowerPOC)
Closed-Loop Meds Process
• Transcription6%
Medication Errors
Physician drug ordering errors are most often due to one of two causes:
1. Lack of knowledge about the drug• Wrong dose• Wrong frequency• Drug-drug interaction
2. Incomplete patient information• Documented allergies• Recent lab results
CPOE Can Help Reduce Errors
Brigham and Women’s Hospital launched its first CPOE in 1993
Since then, they have documented a 54% reduction in serious medication errors
Resulted in 62% reduction in preventable ADE’s
Improved Quality
CPOE allows for physician reminders of best practice or evidence-based guidelines
Indiana University study Pneumococcal vaccine in eligible patients
0.8% 36.0% Heparin prophylaxis
18.9% 32%
Medication Cost Savings
Brigham and Women’s CPOE system includes several alerts targeted to specific high-cost drugs. The alerts provide a possible less expensive alternative
Example of savings—Zofran TID vs. QID TID dosing used 5.9% 93.5% Estimated savings: $250,000
Improved Efficiency Maimonides Medical Center (Bronx, NY) 700 bed teaching hospital After CPOE, found substantial reduction
in order processing time Physician order to receipt by pharmacy
3.4 hours 0.5 hours Physician order to Delivery to Patient Care Area
4.6 hours 1.4 hours
Estimate 12% in LOS following CPOE
But We Fail If This Is Only About Software
Workflow Optimization
Software
TransitionManagement
Knowledge and Measurement
Technology
Project Management
VisionVisionStrategyStrategy
Transition ManagementTransition Management
TRANSITION MANAGEMENT Vision Governance Adoption Communication Learning Organizational development Value Turnover strategies
TRANSITION MANAGEMENT Vision Governance Adoption Communication Learning Organizational development Value Turnover strategies
Workflow Optimization
Software
TransitionManagement
Knowledge andMeasurement
Technology
Project Management
Things That Can Help – Work in Progress
What Is Needed For Success?
Clinicians End-users (clinicians) must be willing to champion the
implementation of CPOE Clinicians must be involved in design and
implementation of the system Clinicians must be flexible and willing to change
workflow processes
‘Doctors don’t reject things like disease
management [or evidence based
medicine, or information technology, or
decision support] because they don’t care
about them, or because they don’t believe
in the principles. There is a fundamental
clash between the ways their neurons
have been rewired during training and
the ways management and new processes
want them to behave.’
1999 Disease Management Sourcebook, ‘Redesigning the Mental Model: How to
Win Provider BuyIn to Disease Management’
H. Leider, MD, MBA
Physician MindsetPhysician Mindset
The Problem(s)
We practice with incomplete informationWe have alarming error ratesWe spend 30-50% of resources on activities that produce little demonstrable benefitWe base less than 30% of our decisions on firm scientific evidenceWe cannot assess and be cognizant of all newly discovered informationWe practice in very complex systems with dependencies and poorly measured processes.90% of malpractice claims relate directly to problems with tracking or documentation or follow-up of care
Doctors love to learn, but they hate to be taught.
What Is Needed For Success?
Information Technology (I.T. Department) Ensure fast, reliable, and easily accessible system Provide ongoing support Train, educate users
Institution Commitment to workflow changes Leadership
Leadership: the most critical factorLeadership: the most critical factor
Leadership
Endorsement of CPOE Establish CPOE as an Institutional
Commitment and Goal Identify CPOE as a Quality and
Safety Improvement Initiative
Strategic AnalysisStrategic Analysis Readiness AssessmentReadiness Assessment Team IntegrationTeam Integration Deployment Strategy & DeliveryDeployment Strategy & Delivery
Stakeholder IdentificationStakeholder Identification Stakeholder EngagementStakeholder Engagement
Knowledge ManagementKnowledge Management
Communication Plan & DeliveryCommunication Plan & Delivery
Retention PlanRetention Plan
Transformation RoadmapTransformation Roadmap
Job Impact AnalysisJob Impact Analysis Competency ModelCompetency Model Organization DesignOrganization Design
Benchmarks, Benefits and MeasurementBenchmarks, Benefits and Measurement
Learning Plan Learning Plan Dev. SessionDev. Session
Post Implementation Post Implementation Measurement PlanMeasurement Plan
CurriculumCurriculumDevelopmentDevelopment
Learning TaskLearning TaskAnalysisAnalysis
Learning Solution Learning Solution DevelopmentDevelopment
End-User End-User LearningLearning
End-User End-User Conversion SupportConversion Support
Transition Management:
Month1
Month2
Month3
Month4
Month5
Month6
Month7
Month8
Month9
Month10
Planning1
Form balanced teams Clinical, operational and IT members Executive steering committee, clinical review board, functional workgroups
Engage clinicians early Physician leadership Multi-disciplinary advisory group
Communicate Explain benefits of the system Inform about timelines and progress Recognize super-user and committee members Highlight successes
Publicize in the community Consumers will want to go to the “safe” hospital Influences community docs
Transition Management Key Success FactorsTransition Management Key Success Factors
Teamwork andCommunication
Incentives Resources Cooperative
ActionUNIVERSAL
PANICVision
Skills Resources Cooperative
Action INSUR-
RECTIONVision
Skills Incentives Cooperative
Action BLAME-
STORMINGVision
Skills Incentives Resources Cooperative
Action AWESOME CONFUSION
Skills IncentivesPRISONER’S
DILEMMAVision Resources
Skills Incentives Resources Cooperative
Action TRANSFOR-
MATIONVision
“…“…borrowed PEARLS”borrowed PEARLS”“…“…borrowed PEARLS”borrowed PEARLS”
The key to my being a good manager is keeping the people who hate me away from those who are still undecided. Casey Stengel
An army of sheep led by a lion will defeat an army of lions led by a sheep. Robbins and Finley, Why Change Doesn’t Work
You can get more done with a kind word and a gun than with a kind word alone. Al Capone
If anything goes bad, I did it. If anything goes semi-good, then we did it. If anything goes real good, then you did it. That's all it takes to get people to win football games for you.
Bear Bryant