The landscape of computerized physician order entry changed forever with the recent signing of the American Recovery and Reinvestment of 2009. What used to be for many hospitals a question of “if” has now become “when” followed by “how soon.” That's because early adopters of certain IT solutions will be able to tap into millions in government funding, while those who do not may actually pay penalties.
With the stimulus, providers also will be required to demonstrate “meaningful use” of IT. While the qualifications for “meaningful use” have yet to be defined, the Healthcare Information and Management Systems Society recently issued their recommendations regarding the definition. The HIMSS statement indicated that “meaningful use” should be defined in stages, with the final phase requiring at least 85% of medical orders being electronically entered by physicians via CPOE.
In our drive to ensure quality care at Decatur Memorial Hospital, we built a comprehensive electronic infrastructure using bar-code medication administration and pharmacy automation tools. The next logical step was tapping the power of CPOE because it helps to speed the care process and eliminates medication errors that stem from illegible handwriting. CPOE also encourages physicians to manage patient care within evidence-based guidelines when clinical decision support is built into the system by the hospital.
The costs of implementing this technology include software and hardware (including adequate numbers of workstations and wireless connectivity), physician training and support, product development and enhancement, and upgrades. We have dedicated 1.5 full-time employees to CPOE continuing development. Our estimates of the original implementation costs are $1,443,973, with roughly $400,000 yearly annual expenses including labor. Despite the cost, this was never viewed as an optional project, but a necessary cost of delivering safe, effective healthcare for our patients.
In 2006, universal adoption of CPOE at Decatur was achieved in just nine months—three months ahead of the original 12-month goal. Paper order sheets were completely removed from all patient-care units. Today, 100% of routine rounding orders are placed electronically by physicians.
Decatur also achieved a number of measurable and sustained improvements in hospital performance. We experienced a 78% decrease in errors that had a direct impact on patients. One month after deployment, medication errors fell to four from a high of 16 before reaching a record low of zero errors. Transcription errors decreased by 60%; incomplete medication orders decreased by 94%; and incomplete radiology orders declined by 100%.
While we were pleased with our initial CPOE results, it was time to deliver on our promise to physicians and evolve the clinical capacities of the computer into guiding best practices. To realize the full potential of CPOE, we decided to revisit a project we conducted in 2006 to drive the appropriate utilization of blood.
McKesson's CPOE system was the keystone for our revamped blood project. Initially, we created simple transfusion order sets in the system. To help ensure that patients only received additional blood if needed, the order sets included the “option” to order one unit at a time and obtain new blood counts before ordering more.
Since physicians could still order blood without using the order sets, little change was achieved, so we created an interactive iForm. Designed to be more appealing to physicians, the iForm also captured critical information about the clinical reasons for transfusion. We set a threshold of 8 grams per deciliter to guide physician decisions regarding the need for transfusion.
Again, our results were mixed. Physicians used the standard order form sometimes and the iForm other times. We gained agreement from our Medical Executive Committee to require the use of the iForm for all blood transfusions. The iForm also ordered blood counts after transfusion, eliminated the automatic ordering of “two units,” and required explanations for blood use when the initial hemoglobin exceeded 8 units. Our iForm designer also made it possible to automatically import the most recent laboratory values, giving physicians the most current information at the time of ordering.
With these changes, we achieved universal use of the transfusion iForm—a tool that provides physicians with decision support and easily retrievable lab data for clinical reasoning. We have embedded logic, with branch chain division to justify ordering blood, and we have a feedback loop to determine if additional units are needed.
The number of inpatients transfused per month at Decatur Memorial Hospital has dramatically decreased. Over a two-year period, blood use dropped to 245 units from 290 units per month. In addition, the pre-transfusion mean hemoglobin value dropped to 7.9 gm/dl from 8.25 and post-transfusion value dropped to 9.7 gm/dl from 10.1. Decatur's data also show patterns of blood usage by patient type and physician, which enables continuous process improvement. And with our new process, we estimate that we are saving $126,000 to $270,000 per year in blood and associated costs.
With CPOE, we are now able to literally make every drop of blood count. And because we've effectively used CPOE to improve patient care and safety, we're well-positioned for the stimulus financial incentives as we continue to use IT to support a safer, more-effective care process.
Michael J. Zia
Chief medical officer
Decatur Memorial Hospital
Decatur, Ill.
