Committed to CPOE

According to findings published late 2008 by the Leapfrog Group, less than 10% of U.S. hospitals have fully implemented Computerized Physician Order Entry (CPOE) systems.

With the government mandating the use of CPOE by 2011 for hospitals wanting to take advantage of the ARRA HITECH incentives hospitals have to plan sooner than later. We’ve all heard the objections: “Only big teaching hospitals are using it” or “Our doctors will never!”

But what about the evidence supporting CPOE: the increased efficiency and decreased errors? According to a recent study published in the Archives of Internal Medicine, hospitals with higher scores for computerized order entry were associated with lower average costs per admission and 16% lower odds of developing complications across all reasons for admission.

The experiences of one HMS customer, Rockcastle Hospital and Respiratory Care Center in Mt. Vernon, Ky., have borne out that evidence. That this innovative CPOE project was successfully accomplished in a small, rural facility only increases its significance.

Case Study:
Rockcastle Hospital and Respiratory Care Center
Location: Mt. Vernon, Ky.
Type of care: 26-bed acute care
Number of sites: Medical Arts Building, 79-bed long-term respiratory care center, Home Health service

“Rockcastle Hospital is committed to creating and supporting a culture that focuses on excellence in delivery of service and an absolute obsession with patient safety and customer satisfaction,” says Steve Estes, president and chief executive officer of Rockcastle Hospital.

It was with that commitment in mind that Rockcastle Hospital set out to move their organization from a total paper system to a virtually paperless system. Rockcastle Hospital formed a multi-disciplinary team with representatives from all departments, and achieving 100% physician use of CPOE was a major component of their goals to improve patient safety, communication of patient information and access to information.

Rockcastle Hospital knew that with the government’s rapidly-approaching EHR mandate, this initiative would soon be a requirement. As a small, rural organization implementing a relatively new solution, they also knew they were taking up the banner of advancing technology in healthcare as a whole.

Focus on Physicians
When it came down to transitioning from a situation where physicians documented orders in the paper chart for processing by the nurses to physicians performing their own electronic order entry, Rockcastle Hospital knew that consistent reinforcement of the goal would be required.

“Even though our physicians had never worked with electronic records within our organization,, we knew CPOE was something we could accomplish,” says Cynthia Burton, RN, chief nursing officer of Rockcastle Hospital. “There was a core group of us dedicated to the success of CPOE, and we created a supportive and encouraging environment to ensure that success.”

“Once our organization decided to pursue an EHR, there really was no option but for physicians to get on board,” agrees Dr. Kimberly Cornelius, physician champion for Rockcastle Hospital’s CPOE initiative. “However, the physicians were excited about the technological advances an EHR provides and were willing participants in the process.”

To get physicians on board with CPOE, Rockcastle Hospital focused on three major areas: Training, Support and Physician input.

Training. Lots and lots of training was the first step to the successful implementation of CPOE – getting the physicians ready so they would be able to use the system from day one. Because some physicians were not very computer savvy, Rockcastle Hospital started with a more attainable goal of getting them to use the basics before concentrating on the more advanced functionality.

The organization began with lunch-and-learns to get physicians familiar with the system and what would be required of them. These initial learning sessions took place constantly to account for the variously time-crunched schedules of the doctors.

“We wanted to be as flexible as possible,” says Burton. “We wanted to accommodate the broad spectrum of needs.”

Next came individualized training customized to the needs of the physicians. For time-sensitive doctors wanting to gain the maximum amount of information in the shortest amount of time, that meant two-hour training sessions with no more than two physicians at a time.

HMS trainers and Rockcastle Hospital superusers both were involved in these sessions to further the efficiency. “I trained one-on-one with an HMS representative, which was helpful,” says Cornelius.

Support. After go-live, quick-reference guides to CPOE, including tips and tricks and ordering methods, were developed and placed at each physician station to serve as a reminder of basic usage. To further support the users, a core team of four superusers were available on-site 24/7 for two weeks to help with any problems while enabling the physicians to continue to care for their patients.

“We were dedicated to helping them, with the order entry specifically and computerization as a whole, to get them up and going with as little frustration as possible,” says Eric Smith, RN, Acute / ED Coordinator and CPOE superuser. “We have signs on the floor letting the users know that if they have an issue, they have someone to call on to come to them.”

Even now that the initial 24/7 on-site support phase has concluded and physicians are more accustomed to the system, they can still be assured that if they need help, all they have to do is pick up the phone and the help comes to wherever they are.

“The doctors have taken advantage of that support and appreciated that we didn’t just throw the program at them and say, ‘Here, use it!’” says Smith. “The encouragement and support have been key in their success.”

Physician input. Key physicians were part of the CPOE process from the beginning, even selecting HMS. They also had a hand in developing the solution, working with HMS to build files, order sets, pathways and more to create a user-friendly environment for physicians and staff.

“Our staff has worked with HMS to standardize and formulate orders that fit our particular circumstances,” says Cornelius. “It’s really more than a ‘canned’ program.”

For Rockcastle Hospital, being able to make CPOE specific to their needs has really encouraged use by physicians, especially when the result is significant time savings.

With physician-specific order sets, CPOE automatically pulls those preferences Rockcastle Hospital developed with clinical faculty so physicians can check from a list of tests standard for pneumonia, for instance, to streamline that time-consuming task. For one physician, they developed a list of her top 100 medications, and that order set comes up directly on her screen. Another doctor has an order set containing her routine diagnostic tests, and she just clicks what she wants without having to go through and find those tests. It’s all there at their fingertips.

“We have four physicians in particular who have really taken advantage of the advanced functionality and time savings that come with creating their own order sets,” says Smith. “Those physicians take care of the majority of our patient population, and their experiences – their successes – are ‘trickling down’ to the others.”

Adoption. Rockcastle Hospital has been pleased with how quickly the physicians have come to embrace CPOE.

“In only about 6 months, they had become comfortable enough with the system that they now want everything on the computer,” says Burton. “They’re now to the point where they’re saying, ‘Let’s make it do this, let’s make it do that.’”

Cornelius is also an advocate of CPOE and advises physicians to be patient when working with the new technology. “In the end, CPOE is definitely better than paper.”

Impact on Patient Care
Rockcastle Hospital’s consistent and encouraging approach is paying off: physician order entry is occurring and, moreover, core measures are being met. Less than a year after their implementation of CPOE, they were at 100% compliance.

“There were those at the facility that were concerned about a downturn in our core measures numbers because of the massive change in the system,” says Burton. “Our numbers are looking better, though. We haven’t seen any declines and even have seen improvements where we hadn’t seen any change in awhile.”

Some success can be attributed to the qualities of the HMS CPOE system itself. According to Cornelius, “I like the precision of HMS CPOE, the legibility, the records of timing of orders, and that the formulary is easily available.”

That patient information is now electronic, and therefore easily accessible, can lead to improvements in patient care.

“With the information right there on the screen, users are more in tune and more likely to catch near misses, medication discrepancies and more,” says Smith. “We’ve seen a decrease in medication errors associated with transcription”

From a quality research perspective, access to information results in more accurate reporting that shows whether orders and documentation are being performed correctly and also improves patient care.

“CPOE is excellent for us, and we have had excellent support in accomplishing our goals,” concludes Burton. “The EHR is a big step for patient safety.”

Other HMS Customer Testimonials for CPOE