Transcript Web Enterprise Viewing System

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
PreliminaryOutcomes
• 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
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
Medication-related
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
Evaluate order
Incident/adverse
event surveillance
and reporting
Select
medication
Prepare
medication
Dispense/
distribute
medication
14%
Administration Management
Monitor/Evaluate Response
Intervene as
indicated for
adverse
reaction/error
PBH 04/03
Assess and
document
patient response
to medication
according to
defined
parameters
Document
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
Medication-related
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
Evaluate order
Incident/adverse
event surveillance
and reporting
Select
medication
Prepare
medication
Dispense/
distribute
medication
14%
Administration Management
Monitor/Evaluate Response
Intervene as
indicated for
adverse
reaction/error
PBH 04/03
Assess and
document
patient response
to medication
according to
defined
parameters
Document
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
Medication-related
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/
Medication
Therapeutic
Ordered
Decisions Made •Physician
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
Intervene as
indicated for
adverse
reaction/error
PBH 04/03
Assess and
document
patient response
to medication
according to
defined
parameters
Document
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
PCX--”First Pass Stats”
PBH 04/03