Readers Write 6/11/08

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A Pharmacy Perspective About CPOE+CDS
By augurPharmacist

Here is a pharmacy perspective about CPOE+CDS. I have worked as a staff pharmacist with three different CPOE+CDS systems over many years.

In my role, I am “catching” the order output from these computerized order entry systems. Basically, I review incoming med orders for appropriateness (a pharmacists’ term that involves checks for safety, likely efficacy and concordance with established guidelines). I then seek modification of errant med orders as necessary. Finally, I oversee order fulfillment.

I suspect that the mixed messages in the medical informatics literature about how CPOE+CDS seemingly improves med safety (Kaushal, Bates) yet also facilitates new types of med errors (Koppel, Campbell) might be explained by a closer examination of three things: available functionality, deployed functionality, and scope of implementation.

CPOE+CDS systems have been engineered differently and therefore they offer dissimilar functionality. Some functionality differences are important and obvious to staff pharmacist users. For example, a CPOE function that can calculate, round, and automatically cap weight-based doses using predetermined, safe maxima is an important function from the pharmacists’ point of view. Not all CPOE systems can do that.

To be fair to our vendor colleagues, it is also true that certain CPOE functions may be available but underutilized. In this case, the client may not have implemented the most recent software version or they may have made strategic decisions not to enable particular functionality due to a variety of organizational, socio-technical constraints.

Finally, the scope of implementation is important to consider. For example, where chemotherapy is concerned, many CPOE+CDS systems are presently unable to provide the chemotherapy cycle and regimen management tools necessary to order and manage these high risk, multi-drug therapies. If CPOE+CDS is deployed in particular areas without functionality to support identifiable unique or rapidly changing medical practice requirements, one has to ask if the scope of implementation is appropriate. In such specialized areas, perhaps it would be advisable to remain with the status quo of written orders until CPOE+CDS systems are further developed.

In terms of medication safety, the availability and deployment of particular functions and the scope of use for CPOE+CDS may help explain divergent reports about the ROI and patient value of CPOE+CDS.

Never Underestimate the Determination of Your Customers
By Nick Khruschev

After an eight-year absence from any MUSE event, for reasons too political to articulate in less than 500 words, I finally attended a MUSE conference again last month in Dallas. Considering that I’d attended and participated in the 10 consecutive international conferences prior to Atlanta Y2K, I wasn’t exactly sure what kind of event I’d find in the post MEDITECH MUSE era. I’m happy to report that I found a first-class event run by an organization that is absolutely flourishing.

Aside from the opportunity to connect with many former acquaintances and colleagues, I felt free to explore the myriad of offerings from the many vendors who may overlap, but mostly fill a gap. There was no apparent threat to MEDITECH’s prominence as the centerpiece to all of these services and products which mainly serve to add value to that primary core system which all customers in attendance share.

It was evident to MEDITECH customers in attendance that they are or will be approaching a major technology cross-road. And they’re right, there will be a lot of change in the next few years, much more than most of MEDITECH’s customers have ever experienced during their time as a MEDITECH shop. Currently, information related to this significant change is trickling out into the consciousness of the customer base through inconsistent and sometimes inaccurate sources. It was clear from my personal observations that there was much confusion and mis-information circulating among the nearly 2,000 attendees at MUSE. Significant change can be a scary thing, particularly when it is not well managed or communicated. People know it’s coming, but excusing the "Clintonese" for a moment, many don’t know just what the definition of "it" is.

At this year’s conference, the vendor which best communicated MEDITECH’s new technology to MEDITECH’s customers was Iatric Systems. In my opinion, the vendor which should take that accolade in Vancouver next year should be MEDITECH. If there were ever a time to re-think the position on this eight-year cold war, it’s now.

The PACS Designer’s NPfIT Software Review
By The PACS Designer

The UK’s National Audit Office has released its 2008 progress report on the National Programme for IT. While some aspects of the program are performing well, other parts are lagging behind because of slow adoption by system users.

The NAO states "delivering the National Programme for IT in the NHS is proving to be an enormous challenge. All elements of the Programme are advancing and some are complete, but the original timescales for the electronic Care Records Service, one of the central elements of the Programme, turned out to be unachievable, raised unrealistic expectations and put confidence in the Programme at risk."

The progress report concludes that the original vision remains intact and still appears feasible. It now looks like one part of the program will take much longer to install at the various trusts and that is the Care Record System. They are now forecasting the CRS to be fully installed everywhere by 2015, four years later than originally planned.

The Picture Archiving and Communications System has fared much better than everything else with all the 127 trusts now using PACS. The PACS has reduced waiting times for diagnostic radiology and also increased the IT skill set of the PACS users. PACS up-times have generally met the 99.87% up-time goal but there has been some under performance in some of the trusts sectors. The Philips/Sectra team has had the best performance over the 18 month period that was measured starting in 2006. The Philips/Sectra team only had one month that did nor meet the 99.87% up-time goal. GE and Agfa fared much worse with GE missing the goal in six out of the 18 months and Agfa coming in last with seven months of misses out of eighteen months.

The Department’s latest survey, conducted in spring 2007, showed that 67 per cent of nurses and 62 per cent of doctors expected the new systems to improve patient care. As far as the electronic Care Records Service is concerned, it appears to be a lack of proper planning that has slowed adoption from TPD’s viewpoint. The blame can be shared by all, since a massive roll-out needs to be carefully planned in phases to insure the users get the proper training at the most convenient time. TPD’s not sure if it was used, but the use of a "Train the Trainer" program will make it more palatable for early adoption of new concepts in record keeping and could bring in the expected 2015 completion date for the Care Record System.

While much more needs to be done to complete the entire roll-out, it appears that the negative sentiment towards the implementation of IT solutions is dissipating. This change to a better attitude towards IT should be used to encourage all participants to put in a maximum effort to help each other to adapt to these new concepts for the betterment of the NPfIT,its patients, and providers.