How 26 hospitals deployed e-order systems in 28 months

The CPOE system means no more illegible notes from doctors

Concerned about patient care, Adventist Health System decided to deploy Computerized Physician Order Entry (CPOE) systems at all 26 of its hospitals in nine states. And it did so in only 28 months.

The result: an 11% decrease in how long patients stayed; a 16% drop in costs per case for heart failure patients; and a 95% reduction in call backs to doctors from pharmacists trying to clarify orders. It also reduced turnaround time for x-rays and lab tests.

CPOE systems enable electronic entry of healthcare instructions for the treatment of patients, including orders for x-rays, lab tests and prescriptions. The use of CPOE systems reduces errors that can occur because of poorly hand-written orders or through transcriptions of physician or nurse notes.

"Quite frankly, there's not a doctor in the world that disagrees with the fact that our handwriting creates problems for patients," said Dr. Phil Smith, chief medical information officer for Adventist. "We live in an environment where the Institute of Medicine says systems are causing the same number of people to die a preventable death each year as having a 747 crash every day in the United States."

Not easy, but worth it

Rolling out the multi-million dollar CPOE system across more than two-dozen hospitals was no small task. But, from January through September of this year, the system transmitted 13.2 million electronic orders and more than a million notes.

Perhaps more importantly, the CPOE system sent more than 400,000 clinical decision support alerts to physicians, which changed their prescribing behavior. That worked out to roughly 14 alerts for every 100 orders, and 10 of the 14 alerts resulted in order changes, Smith said. Adventist Health System uses clinical decision support system from Zynx Health.

Clinical decision support systems advise physicians and nurses on things such as adverse drug interactions based both on evidence-based medicine and patient information as well as problems that may result from other medical treatments.

Adventist Health System's success in quickly enabling CPOE in all of its hospitals was more about planning, commoditization and staying on task than technology execution, according to Smith.

Because Adventist was using a commoditized, standardized approach to CPOE, it spent the majority of its manpower on building out the first system, which was then used as the model for all others.

The pilot project took about 68,000 work hours before the CPOE systems were even implemented. "Sixty-eight thousand hours to make the order catalog, make it physician friendly, [offer] clinical decision support, [provide] order sets and make sure orders made sense to doctors," Smith said.

Once the foundation was in place, the CPOE team was relatively small, consisting of only a medical director, a clinical director, a part-time pharmacist, three clinical informatics leads and a part-time change-management lead. The team would work with sites to get them ready and then stay for 28 days after the CPOE system went live.

"We really wanted to leverage the local super users because our model is a centralized IT office in a nine-state hospital system," Smith said. "We had to make sure the hospital could fully support themselves [sic] after they went live because we were moving our team one month later."

Adventist Health System's IT division, called AHS Information Services (AHS-IS), is a centralized shop that supports 31 of the healthcare system's 43 campuses.

Less about IT than communication

Prior to rolling out its CPOE system from Cerner Corp., Adventist Health System deployed a basic electronic medical records system also from Cerner over a four-year period beginning in 2004. That enabled the electronic records interaction. In 2008, Smith and his team worked to get hospital board members and executives to champion the cause, which limited the amount of pushback from hospital CEOs and physicians.

"At some point, we have to admit to ourselves that this is about the patient and not about the doctor," Smith said. "We're mainly putting a system in to allow the doctor to clearly communicate his or her intent about what the care plan is for the patient.

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