A hospital that runs an electronic health record (EHR) platform without a computerized physician order entry (CPOE) system is only half-pregnant. It isn’t a truly electronic system until the thousands of paper order entries that flow around the hospital outside the EHR system
are incorporated into it.
In 2010, Prince Edward Island’s Health Ministry made it a priority to implement CPOE systems across the province’s seven hospitals after they’d implemented their Cerner Millennium EHR platform. The project was completed in 2014, and has eliminated almost all of the acute-care paper orders generated in the past. More importantly, diagnostics and medication orders have been speeded up considerably, and there is now an electronic mechanism for preventing and tracking medication errors and other potential problems.
“Implementing CPOE is the tipping point, because ordering is such a fundamental aspect of care delivery,” explains Liam Whitty, CIO at Health PEI. “Every decision a doctor makes triggers one or more orders. Without CPOE, an EHR is just a paper-based system supported with some electronic tools.”
But implementing CPOE is tricky business, precisely because orders are an integral part of the hospital’s workflow. “It’s like changing out the engine of a car while you’re driving it. When you’re switching over from paper to electronic, you don’t want to lose any orders. You have to maintain your care delivery,” says Whitty.
Some hospitals have made headlines because they had to revert back to paper orders after their CPOE implementations went very wrong, he adds.
To minimize risk, Health PEI devised a multi-pronged strategy to tackle several potential failure points.
Before they even touched the technology, the multi-disciplinary project team worked out paper versions of order sets for common conditions, like congestive heart failure, by collecting all the orders typically involved in treatment. Then they worked out how this data would flow through CPOE to catch bottlenecks and glitches. “We did a lot of testing ahead of time so it would be safer to go live,” says Whitty.
Once they were satisfied with the workflow, the team began what it calls its ‘rolling rollout’ implementations, switching on their Cerner Millennium CPOE modules one by one at each of the Island’s seven hospitals. CPOE is embedded in Millennium’s platform and requires licensing and configuration to switch on – but the change management challenges that ensue can be intense.
To ensure a smooth transition with knowledgeable staff, Health PEI created a provincial support team. “We don’t have the extra people or funds that larger jurisdictions have, so we pulled together a team from all seven hospitals. When we went live at hospital number one, people from hospitals two through seven helped with the planning and go-live support.”
Another prong of the strategy was going electronic with orders by type. “As there are so many different types of orders – diagnostic imaging (DI), laboratory orders, medication orders, and so on – we broke the project up into two parts to allow the different types to be done in phases. For example, in phase one we only had lab, DI and consult orders.”
Whitty says it’s best to tackle simpler orders before inputting the more complicated ones. “We got some of the easier ones like lab and DI out of the way first, then did the harder ones like medication orders once we were a bit more robust.”
Doing it by category makes managing paper orders and electronic orders concurrently during the transition easier, he adds. “Once you turn on lab orders, for example, the lab stops taking paper orders and that stream of paper disappears. However, the pharmacy would still be taking paper medication orders. So essentially you’ll have paper and electronic side-by-side – but it’s for completely different categories.”
In addition, Health PEI broke up order entering into two phases by staff category. “In the first phase, it was largely nursing staff entering orders into the system on behalf of doctors, who were still using paper orders. That allowed them to learn the system and work out the bugs.
“In phase two, the physicians started doing electronic orders themselves, but their trained colleagues could provide support. It’s really much less risky to have the nursing staff go first.”
Once CPOE is fully implemented in a hospital, order processing is speeded up considerably. “Orders are entered electronically right off the bat at the point of care, and they go instantly to wherever they’re supposed to go,” says Whitty. “The hospital workings become less about pushing paper around the system and much more about fulfilling needs. You get faster diagnoses and more responsive care.”
In addition, the CPOE now issues automated alerts that notify clinicians of important information, from supporting safer medication administration to highlighting overdue patient care activities.
Whitty says getting hard numbers about time savings is difficult, as there’s no accurate pre-CPOE baseline for processing paper orders at most hospitals. “Also, because we phased it in gradually, we didn’t have a particular go-live date to measure before and after. And there was no system to track medication errors before. ”
However, Health PEI has been able to measure some aspects. “We’ve been able to take an hour off the delivery time for non-stat antibiotic orders. We’ve also seen a 34 percent improvement in medication reconciliation at our largest hospital.”
Whitty says he would recommend PEI’s phased, gradual approach by order type and staff category to other hospitals planning their CPOE implementations, as there were virtually no glitches in PEI’s rollout. “PEI is a small place, so everything gets reported on in our newspapers. But our CPOE implementation didn’t make the news at all.”
The PEI CPOE project team won the 2014 Canadian Health Informatics Award for its efforts. “This is a tribute to the people behind the technology,” says Jim Shave, president of Cerner Canada. “Cerner’s partnership with Health PEI has helped establish a robust EHR system for the residents of PEI.”
There’s a positive trend afoot as more and more hospitals are going live with CPOE systems, adds Shave. “Over the past two years, we’ve gone live with CPOE at more than 30 sites, representing more than 13,000 clinical end-users across Cerner sites in Canada. When we get to this level of automation, then we can start to set our sights on more complex areas like population health management. I can’t wait for us to be in a position to use the data we’re collecting to advance healthcare in new ways.”