MISSION: IMPOSSIBLE The Use of Technology in Promoting Physician Adoption of CPOE

1. MISSION: IMPOSSIBLEThe Use of Technology in Promoting Physician Adoption of CPOE Massachusetts Hospital CPOE Initiative: Physician Involvement and Governance Mark Hulse, RN Chief Information Officer North Shore Medical Center

2. The Good News & The Bad News First:

3. Implementing CPOE is not as difficult as you think…

4. It’s Worse.

5. The Good News • You have plenty of company: CPOE adoption is growing nationally • As more community hospitals implement, a growing base of “on-the-ground” experience is available to draw from • With planning, persistence and agilitytheCPOE implementation mission is Possible.

6. Critical Elements of Success • Securing physician acceptance requires strong hospital and medical staff leadership • Recognition that CPOE is Not an “IT Project” • CPOE implementation throws a spotlight on many imperfect clinical practices • Keeping the implementation moving involves deciding which battles to take on

7. Establishing a Vision for CPOE

8. The Migration from Paper to Electronic • Don’t use CPOE as a first clinical application • Have results and other clinical data needed for decision making readily available on-line

9. RESULTS MED ADMIN RCD CURRENT ORDERS EXTERNAL REFERENCES

10. Rapid vs. Gradual Deployment • Deploying too quickly may not allow for changes in workflow adaptation, and result in implosion • Allowing voluntary adoption will result in stagnation beyond early adopters • The right balance is critical to achieve the “tipping point”

11. Choosing a Pilot Unit • Consistent patient and physician population (e.g. minimal “boarders”) • Willing physicians and nurses • Frequent team feedback sessions

12. Dealing with Integration Issues • Bidirectional pharmacy system integration is critical • Back-end integration also highly desirable for Lab and Radiology • Other ancillary areas: e.g. Dietary, Blood Bank

13. Workflow Analysis • The devil really is in the details • Over-analysis of workflow is impossible • Ask staff what their processes are, but then watch them to learn what they really do • Workflow analysis must be done for every nursing unit • No matter how uniform your care unit practices are, minor variations will exist and can cause major unanticipated issues with CPOE

14. Workflow Analysis • Map the current state out, then validate it • Use the “future state” map as an educational tool • Include ancillary departments in the workflow analysis as well

15. Order Notification • Going from paper to electronic is unsettling for nursing staff too • Orders may be received and acknowledged in Pharmacy before the nurse even knows about them • Paper printouts provide security, but can become a crutch you can’t take away later • “Heads-up” computer display of new orders is preferable

16. Order Notification Examples • Lab order “add-on’s” • Consults and other orders without an electronic back-end system

17. Training • Be flexible when offering options for physician training • Clinical Support Team available by page or phone for training • Reach out to physicians who don’t sign up: • Emails, memos from Chief, schedule time through practice manager • Access to CPOE provided after training is completed

18. “At The Elbow” Implementation Support

19. Clinical Support Team • Visible Clinical Support Team (CST) staff on unit 24x7 during initial 3 weeks • Offer help and assistance to MDs without being confrontational • Log issues and discuss with technical team during daily status meetings • Support is gradually “weaned” over 4-6 weeks

21. Ongoing Education • Adoption and skill level will vary widely across individual physicians • Multi-mode approach to ongoing training: • Department meetings to share information • Ready availability of ongoing support • Feedback button in CPOE • “Tip of the Week”

22. Tip of the Week • CPOM "Tip of the Week" • ISSUE: Chem-6 does not contain a creatinine; it will be replaced with Chem-7 • TIP: Our nephrologists have pointed out that there have been some clinical problems due to use of the Chem 6 (Na, K, Cl, bicarb, BUN, glu) because it does not contain a creatinine. Therefore, on 11/7, Chem 6 will be replaced in CPOM with Chem-7 (which is a Chem-6 plus creatinine). • ISSUE: Ordering heparin and warfarin • TIP: When heparin and warfarin are ordered, it is usually necessary to order lab tests (PT/INR or PTT) and instructions to nursing (e.g., "Notify doctor for INR above x") at the same time. In CPOM, heparin and warfarin have their own order sets, which make this easy. These order sets, currently called "Warfarin Anticoag Protocol", "Heparin Initiation" and "Heparin Maintenance" should be used when ordering these drugs. At present, these order sets are found on the Order Set tab in the "General" list -- see the attachment for a picture. Very soon, it will also be possible to find these order sets on the Med/IV tab main "common list". Please use the heparin and warfarin order sets when ordering these drugs -- it takes just a little bit of 'getting used to' but works much better than ordering the drugs "alone". • If you have questions about using CPOM, page the CPOM Clinical Support Team. To reach them, use pager # 72900 or search on "CPOM" in the Partners Paging Directory and select "Clinical Support Team".

23. Hardware: No Waiting for CPOE

24. Hardware – How Much is Enough? • Monitor # of physicians on each unit during peak ordering times (don’t guess!) • Account for other users (nursing, case management) • Space may be the biggest constraint • Enlist nurse managers to help prioritize use of workstations for CPOE during peak ordering times • Laptops, tablets, PDAs

25. Example Hardware Map D D D D D D D D D D D P P L D D D D D P P P P L L L D D D D D D D D P • Summary of Changes: • Completed renovations • Added 4 Desktops • Upgraded to CISCO wireless network & replaced 11 wireless network cards • Outstanding Work: • Adding monitor arms, keyboard trays and CPU Holders (Rich Kanter) • Moving 4 RN Laptops from Bays to carts • Adding 6 Desktops to Bays • Adding 1 laptop & cart for MD Rounds • Note: Unit will have a total of 6 laptops (4 RN, 1 MED ROOM, 1 MD) RN STATION RESIDENTS ROOM Non- HIS US BAY #1 BAY #2 Existing Desktop Existing Laptop Existing Laser Printer Add Desktop Add Laptop Add Laser Printer Deployed new Desktop Deployed new Laptop Deployed Laser Printer Reserved for Unit Secretary Reserved for Case Manager FILM AREA Non- HIS MD ROUNDS NEW MD WORKSTATIONS US CM

26. Addressing Usability Issues with Agility

27. Order Set Design & Development • Use pre-existing order sets (OS) where available as a template • Think “usability” and efficiency • Consistent organization across OS (e.g. “ADCVANDISL”) • Minimize clicks (e.g. pre-checked default values) • Monitor use of OS vs Ad Hoc orders • Does the volume of non-OS orders warrant adding these to existing OS’s? • Maximize use of “Quick Pick” or “Common Lists”

28. Drugs by Classification Example

31. Quick Orders Example

36. Clinical Decision Support • Achieving the right balance takes trial-and-error • Begin with a minimalist approach, and add DS incrementally • Avoid “Alert Fatigue”: • Physicians will click-through frequent alerts without reading them

37. Degrees of Decision Support

38. Change Control and Enhancements • Establish a multi-disciplinary group to manage CPOE content changes and enhancements • Stick to a defined process

40. Remote Ordering • Placing orders from the office or from home • Placing orders on patients who haven’t been admitted yet – “suspended orders” • Requires careful workflow analysis with nursing. They “activate” the orders.

41. Mobility • Wireless Computers On Wheels (COWs) useful for team rounding • Pen-based tablets • Utility will vary with CPOE vendor software • Most users find them still too heavy to carry around • PDAs: Screen real estate too small for most CPOE applications

42. Other Technology Enhancements • Rapid Sign-On and Access to CPOE • Single Sign-On • User logs in once, all applications are accessible without additional log-ins • Balancing HIPAA Privacy/Security and Clinician Workflow

43. Good Luck on Your CPOE Mission! …This presentation will self destruct in 10 seconds…