CPOE: Why You Want It,CPOE: Why You Want It,Why You Need ItWhy You Need It

Jeff Helfand, DO, MSJeff Helfand, DO, MS

May 21, 2010May 21, 2010

EHR: Some HistoryEHR: Some History

In 2004, President George W. Bush mandated in his State of the Union In 2004, President George W. Bush mandated in his State of the Union Address that there should be “…an Electronic Health Record for every Address that there should be “…an Electronic Health Record for every American by the year 2014.”American by the year 2014.”

The Office of the National Coordinator Health Information Technology The Office of the National Coordinator Health Information Technology (ONCHIT) was established on April 27, 2004 by Executive Order #13335 (ONCHIT) was established on April 27, 2004 by Executive Order #13335 issued by President George W. Bushissued by President George W. Bush

On January 12, 2009, in a speech at George Mason University On January 12, 2009, in a speech at George Mason University President Barack Obama announces that the US will need to “…President Barack Obama announces that the US will need to “…computerize all health records within five years.”computerize all health records within five years.”

The American Reinvestment and Recovery Act (ARRA) was signed The American Reinvestment and Recovery Act (ARRA) was signed into law on February 17, 2009, and includes $19 Billion as incentives into law on February 17, 2009, and includes $19 Billion as incentives to adopt use of HIT, especially EHRs (HITECH).to adopt use of HIT, especially EHRs (HITECH).

HITECH Incentive Payment ProgramsHITECH Incentive Payment Programs

There is a four year CMS Health IT Medicare Incentive Payment There is a four year CMS Health IT Medicare Incentive Payment program for hospitals beginning in 2011 that will gradually be program for hospitals beginning in 2011 that will gradually be phased out by 2016, at which time penalties will be assessed for phased out by 2016, at which time penalties will be assessed for non-compliance.*non-compliance.*

For physicians, there is a five year CMS Health IT Medicare For physicians, there is a five year CMS Health IT Medicare Incentive Payment program for those who adopt the program in Incentive Payment program for those who adopt the program in 2011, however penalties will be begin in 2015 for those physicians 2011, however penalties will be begin in 2015 for those physicians who have not adopted the program by 2014.*who have not adopted the program by 2014.*

* * ANIA-CARING 2010ANIA-CARING 2010

Potential Incentive PaymentsPotential Incentive Payments

A total of $9.2 million in incentives estimated for a 200 bed community A total of $9.2 million in incentives estimated for a 200 bed community hospital with an estimated $3.5 million for approximately 90 employed hospital with an estimated $3.5 million for approximately 90 employed “eligible”“eligible” professionals, and another $5.7 million for the hospital itself.* professionals, and another $5.7 million for the hospital itself.*

““Eligible”Eligible” providers and hospitals must meet two requirements for providers and hospitals must meet two requirements for reimbursement under ARRAreimbursement under ARRA

1) must acquire a 1) must acquire a certifiedcertified EHR product or service EHR product or service2) must demonstrate 2) must demonstrate “meaningful”“meaningful” use * use *

““Meaningful”Meaningful” use implies use implies a host of new care processes for many providers such as “monitoring medication adherence, use of evidence-based order sets, clinical decision support tools at the point of care, patient outreach and reminders” with clinical data capture and sharing, enhanced with clinical data capture and sharing, enhanced clinical processes and “clinical processes and “ultimately linked to achieving measurable outcomes in patient engagement, care coordination, and population health.”

Meaningful use of EHR includes processes such as Meaningful use of EHR includes processes such as CPOE, ePrescribing CPOE, ePrescribing and and Barcode medication administrationBarcode medication administration. *. *

* ANIA- CARING 2010* ANIA- CARING 2010** ** “Meaningful Use: A Definition” Recommendations from the Meaningful Use Workgroup to the Health IT Policy

Committee June 16, 2009

CPOE: BasicsCPOE: Basics

Computerized Physician (Computerized Physician (PractitionerPractitioner) Order Entry) Order Entry

Electronic prescribing systems designed to improve patient outcomes by Electronic prescribing systems designed to improve patient outcomes by detecting and blocking medication errors at the time they most commonly detecting and blocking medication errors at the time they most commonly occur, when the medications are ordered. occur, when the medications are ordered.

Rather than being written on a paper order sheet that then needs to be Rather than being written on a paper order sheet that then needs to be transferred into a computer, medications are ordered directly into the transferred into a computer, medications are ordered directly into the computer by the practitioner, reducing the risk of medication errors.computer by the practitioner, reducing the risk of medication errors.

Computerized orders are more easily confirmed, compiled and integrated Computerized orders are more easily confirmed, compiled and integrated with other patient data and information such as medication allergies, with other patient data and information such as medication allergies, interactions and lab results.interactions and lab results.

CPOE: BenefitsCPOE: Benefits

Warns practitioner about possible drug allergies, interactions or Warns practitioner about possible drug allergies, interactions or possible dosing errorspossible dosing errors

May provide automatic updates regarding newly released and May provide automatic updates regarding newly released and approved medicationsapproved medications

Helps eliminate confusion errors resulting from “sound-alike” drugsHelps eliminate confusion errors resulting from “sound-alike” drugs

Improves communication between practitioner and pharmacy staffImproves communication between practitioner and pharmacy staff

Results in cost reduction secondary to improved efficiencyResults in cost reduction secondary to improved efficiency

Impact of the computerized provider order entry (CPOE) system on medication errors, by severity

Error severity

Total prescriptions pre-CPOE N=5016

Total prescriptions post-CPOE N=5153

Difference N (%); 95% CI for difference (unadjusted)

OR (99.5% CI) (adjusted)‡

Error severity, by categories

A (potential error; no ADE)  7 (0.1%) 1 (<0.1%)6 (<0.1%) (<0.1% to 0.2%)*

0.13 (0.02 to 1.07)

B–D (error, no harm; potential ADE) 

896 (17.8%) 417 (8.1%)479 (9.8%) (8.5% to 11.1%)***

0.43 (0.38 to 0.49)***

E and F (error, reached patient-contributed to harm;  preventable ADE)

8 (0.2%) 5 (0.1%)3 (<0.1%) (<−0.1% to 0.2%)

0.58 (0.19 to 1.77)

↵* p<0.05 ↵*** p<0.001. ‡ ↵ Generalized linear, latent and mixed effects model with adaptive quadrature; multinomial logit model; clustering at prescriber level; no weights applied; no additional variables. ADE, adverse drug event.

CPOE: EffectivenessCPOE: Effectiveness

Medication error rates decreased initially by 55%, and subsequently by 88% Medication error rates decreased initially by 55%, and subsequently by 88% at Brigham and Women’s Hospital in Boston, and were attributed to at Brigham and Women’s Hospital in Boston, and were attributed to implementation of CPOE. *implementation of CPOE. *

After implementation of decision support for antibiotics, similar decreases in After implementation of decision support for antibiotics, similar decreases in error rates (70%) were also demonstrated in antibiotic related ADRs at the error rates (70%) were also demonstrated in antibiotic related ADRs at the Latter Day Saints Hospital in Salt Lake City.Latter Day Saints Hospital in Salt Lake City.

Main Line Health, a five facility health care system with more than 1200 Main Line Health, a five facility health care system with more than 1200 beds, almost 2000 physicians and 70,000 annual admissions near beds, almost 2000 physicians and 70,000 annual admissions near Philadelphia noted dramatic reductions in possible patient ID errors and Philadelphia noted dramatic reductions in possible patient ID errors and medication errors within the first two years after implementation in 2004. medication errors within the first two years after implementation in 2004. Further reductions in 2006 and 2007 indicate that staff continue to utilize the Further reductions in 2006 and 2007 indicate that staff continue to utilize the data in a meaningful way.data in a meaningful way.

* * Koppel et al. JAMA 2005; 293: 1197-1203Koppel et al. JAMA 2005; 293: 1197-1203

“We are now able to track wrong-drug,wrong-patient types of occurrences. MAK

brings transparency to the whole medicationmanagement system that was never there

before.”

Rich CentafontSystem Vice President for Pharmacy and Radiology ServicesMain Line Health

CPOE: Why You Want ItCPOE: Why You Want It

Hospitals must be able to demonstrate CPOE use for at 10% of orders to Hospitals must be able to demonstrate CPOE use for at 10% of orders to comply with Stage 1 “comply with Stage 1 “meaningful use”meaningful use” criteria for 2011 criteria for 2011

One single medication ADR adds more than $2000 to the average cost of a One single medication ADR adds more than $2000 to the average cost of a hospitalization (1)hospitalization (1)

The total direct cost to hospitals nationwide of medication errors exceeds The total direct cost to hospitals nationwide of medication errors exceeds

$7.5 billion annually (2), not to mention the associated indirect costs in $7.5 billion annually (2), not to mention the associated indirect costs in increases in malpractice insurance premiums, lost productivity and not increases in malpractice insurance premiums, lost productivity and not necessarily least, hospital reputation and public imagenecessarily least, hospital reputation and public image

1) J Am Med Inform Assoc. 2004 Jul-Aug: 11(4):270-2771) J Am Med Inform Assoc. 2004 Jul-Aug: 11(4):270-277

2) Pediatrics. 2003 Sep; 112(3Pt 1): 506-509 2) Pediatrics. 2003 Sep; 112(3Pt 1): 506-509

““At many levels, CPOE is enhancing patient care at Holy Redeemer. At many levels, CPOE is enhancing patient care at Holy Redeemer. We are finding that communication among the care team is better We are finding that communication among the care team is better

coordinated and doctors’ orders are acted upon more quickly. coordinated and doctors’ orders are acted upon more quickly.

CPOE is an important component of Holy Redemeer’s strategy to CPOE is an important component of Holy Redemeer’s strategy to reduce errors, enhance patient safety, and improve the quality of reduce errors, enhance patient safety, and improve the quality of

care.”care.”

Jonathan Sternlieb, MD, FACG

Chief Medical Information Officer

Holy Redeemer Health System

An INVISION Customer for 16 years

currently migrating to Soarian Clinicals

Soarian Clinicals®: Your CPOE SolutionSoarian Clinicals®: Your CPOE Solution

Healthcare Process Management (HPM), the healthcare adaptation of business Healthcare Process Management (HPM), the healthcare adaptation of business process management is the principle behind the design of Soarian Clinicals® and process management is the principle behind the design of Soarian Clinicals® and plays a vital role in its CPOE capabilities, helping users reinvent operations, improve plays a vital role in its CPOE capabilities, helping users reinvent operations, improve workflow, refine patient safety and outcomes and revitalize staff satisfaction and workflow, refine patient safety and outcomes and revitalize staff satisfaction and moralemorale

Features of Soarian Clinicals® CPOE:Features of Soarian Clinicals® CPOE:Provides clinical staff with suggested actions to help streamline the medication Provides clinical staff with suggested actions to help streamline the medication ordering processordering process

Allows clinicians to enter orders while letting the pharmacy staff deal with the details of Allows clinicians to enter orders while letting the pharmacy staff deal with the details of dispensingdispensing

Gives access to order entry at different stages of the healthcare delivery cycleGives access to order entry at different stages of the healthcare delivery cycle

Uses embedded analytics for easy production of reports on all clinical and operational Uses embedded analytics for easy production of reports on all clinical and operational order processing dataorder processing data

Provides advanced medication order functions such as weight based dosing and IV Provides advanced medication order functions such as weight based dosing and IV dripsdrips

The end result is a more coordinated approach across many clinical disciplines The end result is a more coordinated approach across many clinical disciplines resulting in better communication and improved patient outcomesresulting in better communication and improved patient outcomes

Soarian Clinicals®: Your CPOE SolutionSoarian Clinicals®: Your CPOE Solution

Soarian Clinicals® Soarian Clinicals®

Helps redirect and simplify your workflow by reducing manual Helps redirect and simplify your workflow by reducing manual processes, so you van focus on what’s really important – patient processes, so you van focus on what’s really important – patient care and revenue productioncare and revenue production

Helps promote standardization to better measure and predict Helps promote standardization to better measure and predict improvement in clinical outcomesimprovement in clinical outcomes

Provides your practitioners with the information they need to make Provides your practitioners with the information they need to make better informed clinical decisions in today’s fast-paced healthcare better informed clinical decisions in today’s fast-paced healthcare environment environment

Allows your C-level management to more accurately measure Allows your C-level management to more accurately measure performance and implement necessary changes quicklyperformance and implement necessary changes quickly

My Two CentsMy Two Cents

CPOE made my life easierCPOE made my life easier

Reduced my paperwork burdenReduced my paperwork burden

Allowed me to spend more time dealing with clinical issues, rather Allowed me to spend more time dealing with clinical issues, rather than worrying if the pharmacy got it rightthan worrying if the pharmacy got it right

Gave me an easy way toGave me an easy way totrack medication changestrack medication changes

prevent potential drug interactions and ADRsprevent potential drug interactions and ADRs

help my documentation “paper trail”help my documentation “paper trail”

feel more confident about the safety of my patients and ultimately feel more confident about the safety of my patients and ultimately in the quality of care I deliveredin the quality of care I delivered