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CPOE Is The Surest Route to Meaningful Use
By Linda Gleespen, RN, BSN
Few hospitals have complete EHRs, so demonstrating Meaningful Use to get government financial incentives looks like a pretty steep hill to climb. But if your institution’s strategy first begins with implementation of computerized physician order entry (CPOE) you will be on the road to success.
The 2011 Meaningful Use criteria for hospitals require the use of CPOE for at least 10 percent of orders, and many of the other requirements can be achieved with CPOE alone. For example, CPOE enables hospitals to collect data for many of the requisite quality measures because they’re related to test or medication orders. Examples include the use of high-risk medications in the elderly, the percentage of eligible surgical patients who received VTE prophylaxis, and the percentage of patients at high risk for cardiac events on aspirin prophylaxis.
Meaningful Use will also require medication reconciliation, which is much easier to do at discharge or during transfers if you have CPOE. And, each hospital will have to show it has implemented a clinical decision rule related to a high-priority hospital condition. My hospital system, Summa Health System in Akron, has created dozens of such decision support rules since we started using the Eclipsys Sunrise Clinical Manager application in 2006. For instance, for stroke care, we programmed a “hard stop” to prevent physicians from prescribing the clot-buster medication tPA if more than three hours have passed from initial onset of stroke symptoms. However, research has now defined clinical scenarios in which this three-hour window can be exceeded.
The beauty of clinical decision support rules is that the application can be altered to adhere to the most current standards of care.
I’m not minimizing the difficulty of successful CPOE adoption. At the two hospitals in my health system that have implemented CPOE, a couple of years of planning were required to prepare for CPOE, and early on, getting physician buy-in was a challenge. However, I’m proud to say that our latest statistics indicate that doctors are entering over 80 percent of their orders directly into the system. Only 8.8 percent of our orders are telephoned in, 7.3 percent are verbal, 2.3 percent are written, and under 1 percent are faxed.
Equally important, electronic order sets are used for 94 percent of hospital orders. These order sets incorporate evidence-based protocols that improve quality and safety, which is the paramount goal of Meaningful Use.
To add decision support features to the order sets, Eclipsys SCM enables us to create customized “medical logic modules” that automate key portions of orders. For example, when doctors enter orders for a patient with pneumonia, they are prompted to enter information about the type of pneumonia and other significant clinical information. The system then auto-selects the correct antibiotics. It functions like an electronic decision tree.
To measure how our order sets are affecting patient care, we compared how closely physicians were following the American Stroke Association and Joint Commission guidelines for stroke care with and without the use of order sets. We found that compliance with best practices was 40 percent higher with the order sets than without them. More important, the use of order sets in CPOE improved outcomes. When the order sets were used, 9.4 percent more patients went home directly from the hospital, and 21 percent fewer patients were readmitted.
By these demonstrations of Meaningful Use, the exceptional quality care and patient outcomes is truly what is meaningful.
Linda Gleespen, RN, BSN, is lead quality and clinical analyst for the Summa Health System of Akron, OH.
EMRs and Interoperability: HIT’s Oxymoron?
By Lynn Vogel, PhD, FHIMSS, FCHIME
ox·y·mo·ron; \äk-sē-‘mor-än\, noun, a combination of contradictory or incongruous words (as cruel kindness); broadly : something (as a concept) that is made up of contradictory or incongruous elements
How odd, you say, to propose as an oxymoron two terms that politicians, IT luminaries, healthcare experts, vendor product brochures, and academic journals typically assume simply and reasonably can and must go together. But do they really go together, or are we just trying to make them fit when maybe they don’t?
Consider the fact that every EMR product on the market today started with a single purpose: to automate the workflow of clinicians within a specific organizational setting, and in the process, seek to make it more efficient and more effective. Among other features, EMRs focus on making data from previous encounters or activities easier to access, assuring that orders for tests and x-rays have the right information, or that the next shift knows what went on previously. In general, in spite of visible successes and failures for all manner of products, EMR products do a pretty good job of automating a complex workflow — of automating intra-organizational clinical processes.
But interoperability, in the sense in which the term is used in today’s discussions about Health Information Exchanges (HIEs), is not about intra-organizational workflow, but about inter-organizational work flow. Recognizing that patients often receive care in a variety of organizational settings — hospitals, multiple physician offices, rehabilitation facilities, pharmacies, etc. — the challenge is to extend the internal workflow beyond the boundaries of individual organizations so that data is available across a continuum of care. Interoperability, then, is not so much about what happens within an organization, but about what happens across organizations.
A major assertion here is that the architectural requirements for automating intra-organizational clinical workflows are very different from the architectural requirements for facilitating inter-organizational interoperability. An intra-organizational architecture focuses on facilitating real-time communications among providers, optimizing the process of collecting data at the point of care, and ensuring that clinical tasks are carried out in an appropriate sequence.
An inter-organizational architecture needs to be designed to minimize the duplicate collection of data in different care settings, to facilitate quick searches of relevant data from a variety of organizational sources, and to rank data in terms of relevance to a particular clinical question.
If these assumptions are true, then one has to wonder whether we can ever achieve true inter-organizational operability using an architecture that has focused for more than a decade on optimizing intra-organizational processes.
An appropriate analogy might be taking a bunch of cars, which were designed to accommodate small numbers of people, and somehow string them together to make a bus in order to accommodate a large number of people with the same goal of moving them from one point to another. Yes, you could make a bus out of cars — no doubt with a lot of effort — but why would you? Requirements for tires, suspension, seats, luggage storage, and even bathrooms are very different for buses than for cars and require a different architecture if you want to build a bus that works. But isn’t that what we are trying to do with current proposals for using EMR architectures to build HIEs?
Maybe it’s time to rethink this approach. Interestingly we don’t have to look very far to find a set of experiences that would make more sense for an interoperability architecture than trying to extend our current EMRs. It’s the Internet. With millions of different data repositories around the world, an architecture that seems to work most of the time, and increasingly sophisticated search engines for locating data, it would seem that we should be looking more closely at the services-oriented architecture of this ubiquitous example of interoperability rather than trying to string EMRs together and replicate their architectures in an attempt to achieve objectives which were never in their initial designs.
So that’s why EMRs and Interoperability may be HIT’s oxymoron: the architectures may simply be too contradictory and too incongruous to fit together no matter how hard we try. If so, this would add a significant constraint to HIEs that are already being challenged by the sustainability of their business model. Bus manufacturers learned long ago that simply making cars bigger using the same underlying components wouldn’t result in a workable bus. Perhaps there is a lesson here for how we should be thinking about interoperability.
 Adapted from http://www.merriam-webster.com/dictionary/oxymoron, accessed on 9/19/2009.
Lynn Vogel, PhD, FHIMSS, FCHIME is vice president and chief information officer and associate professor of bioinformatics and computational biology at The University of Texas M.D. Anderson Cancer Center in Houston, TX.