FOCUS CPOE at CedarsSinai What Worked What Didnt

FOCUS

CPOE at Cedars-Sinai What Worked, What Didn’t Paul Hackmeyer, M. D. Chief of Staff 2000 -2001 C S Cedars-Sinai Medical Center Los Angeles, California

Patient Care Expert (PCX) System • Physician Order Entry: Automated physician’s entry of orders. Med orders automatically checked for allergies, drug interactions & dose range (October 2002) • Patient Management: Admission, discharge, transfer, bed management & preregistration (May 2003) • Patient Accounting: Bills patients & insurance providers with enhanced accuracy for capturing charges (July 2003) • Contract Management: Database of contract terms to verify payment ability during preregistration & proper billing of patient accounts PBH 04/03

Patient Care Expert (PCX) System • Physician Order Entry: Automated physician’s entry of orders. Med orders automatically checked for allergies, drug interactions & dose range (October 2002) Temporarily suspended January 23, 2003 • Patient Management: Admission, discharge, transfer, bed management & preregistration (March 2003) • Patient Accounting: Bills patients & insurance providers with enhanced accuracy for capturing charges (July 2003) • Contract Management: Database of contract terms to verify payment ability during preregistration & proper billing of patient accounts PBH 04/03

PCX In the News PBH 04/03

PCX in the News PBH 04/03

CPOE What Worked PBH 04/03

What Worked The system itself • No crashes or unscheduled downtime • No lost or mistransmitted orders PBH 04/03

What Worked Oct 24, 2002 – Jan 23, 2003 • 700, 000 orders placed & transmitted • 8, 000+ patients • 10, 000 orders per day PBH 04/03

What Worked Medical Records Components (still running) • Coding & abstraction • Charge entry PBH 04/03

What Worked Education about value of CPOE re: Medication Errors PBH 04/03

What Worked Medication Alerts PBH 04/03

PCX CPOE Alert Statistics Oct 24, 2002 – Jan 23, 2003 PBH 04/03

What Worked Live Interface to ICU System MAR PBH 04/03

What Worked Preliminary. Outcomes • Decreased length of stay • Decreased mortality rate • Decreased SAEs PBH 04/03

CPOE What Didn’t Work PBH 04/03

What Didn’t Work Physician Issues & Change Management • Very difficult to get physicians to test system during development • After go-live, much angst over added time for order entry • Negative perception for ease of use • Insufficient education for optimal use PBH 04/03

What Didn’t Work Flow Change Management • CPOE affects all caregivers • Incompletely understood complex hospital procedures that affected order management • Much more operational workflow analysis required PBH 04/03

What Didn’t Work Need for System Enhancement • Hundreds of suggestions post “golive” to be prioritized for action • By its nature, CPOE is difficult to bring down even transiently • Difficult to significantly enhance system while it is running PBH 04/03

CPOE Lessons Learned • Complexity of human change management may be easily underestimated • For physicians, speed, ease of use and intuitiveness of the system are critical • Complex workflow issues affecting orders must be completely understood and incorporated in the system. Example: Patient transfers to and from procedure areas. PBH 04/03

CPOE Reimplementation Plan • Other parts of the PCX system will go-live as scheduled: Patient Management (March), Patient Accounting (July) • Workflow issues will be carefully analyzed • CPOE portion of the system will be enhanced to improve speed & ease of use • Significant medical staff input will be obtained to test enhancements • Reimplementation schedule not yet set PBH 04/03

CPOE Reimplementation Plan • PCX Advisory Task Force to the MEC • Safety Council evaluation and monitoring • Advisory Task Force and the Safety Council will advise the MEC on a monthly basis. • Reimplementation schedule not yet set, but will be fully vetted and approved by the MEC PBH 04/03

Questions?

History-Taking Obtain Medicationrelated History Medication Management Process Where the Adverse Drug Events originate Document Medication History Bates et al. ; JAMA 1995; 274: 29 -34 Medication Inventory Management Ordering Diagnostic/ Therapeutic Decisions Made Medication Ordered Formulary, purchasing decisions Inventory management Order verified and submitted 11% 49% Surveillance Pharmacy Management Incident/adverse event surveillance and reporting Evaluate order Select medication Prepare medication Dispense/ distribute medication 14% Administration Management Monitor/Evaluate Response Document Intervene as indicated for adverse reaction/error PBH 04/03 Assess and document patient response to medication according to defined parameters Document administration and associated information Administer Medication Administer according to order and standards for drug Select the correct drug for the correct patient 26% (Mostly IV) Education Educate patient regarding medication Educate staff regarding medications

History-Taking Obtain Medicationrelated History Medication Management Process Where the Adverse Drug Events originate Document Medication History Bates et al. ; JAMA 1995; 274: 29 -34 Medication Inventory Management Ordering Diagnostic/ Therapeutic Decisions Made Medication Ordered Formulary, purchasing decisions Inventory management Order verified and submitted 11% 49% Surveillance Pharmacy Management Incident/adverse event surveillance and reporting Evaluate order Select medication Prepare medication Dispense/ distribute medication 14% Administration Management Monitor/Evaluate Response Document Intervene as indicated for adverse reaction/error PBH 04/03 Assess and document patient response to medication according to defined parameters Document administration and associated information Administer Medication Administer according to order and standards for drug Select the correct drug for the correct patient 26% (Mostly IV) Education Educate patient regarding medication Educate staff regarding medications

History-Taking Obtain Medicationrelated History Document Medication History • Wireless devices for medication history capture, etc. Medication Management Process with specific technologies to reduce errors Medication Inventory Management Ordering Diagnostic/ Therapeutic Medication Ordered Decisions • Physician Made Order verified and submitted Order Entry (PCX) Surveillance Incident/adverse event surveillance and reporting Formulary, purchasing decisions Electronic Order Transfer (PCX) Pharmacy Management Evaluate order • Automated Surveillanc e Inventory management Select medication Prepare medication Dispense/ distribute medication • Robotic dispensing systems • Pharmacy Information Systems Administration Management Monitor/Evaluate Response Document Intervene as indicated for adverse reaction/error PBH 04/03 Assess and document patient response to medication according to defined parameters Document administration and associated information Administer Medication Administer according to order and standards for drug Select the correct drug for the correct patient • Bar coding administration, smart infusion pumps Education Educate patient regarding medication Educate staff regarding medications

PBH 04/03