An information system without physician adoption is a bit like that treadmill tucked away in the corner of the basement. It's not going to do much good unless someone uses it.
In the healthcare industry, physician adoption marches on as one of the barriers blocking the inherent potential of information technology. Many physicians shy away from IT simply because they do not believe computerization can lead to improved patient care. Cost-cutting and process improvement arguments don't always resonate strongly with doctors. In addition, physicians don't want to live through the disruption that often accompanies IT implementations.
Not surprisingly, many providers hit an unforgiving wall when implementing computerized physician order-entry systems. According to the HIMSS Analytics EMR Adoption Model—a scale that ranks a hospital's progress toward a paperless environment from Stage 0 to Stage 7—the largest percentage of hospitals (about 40%) are stuck at Stage 3, as climbing to the next rung requires the implementation of CPOE.
Peninsula Regional Medical Center, a community hospital in Salisbury, Md., has overcome this hurdle by focusing on both the philosophical and practical barriers to CPOE adoption.
To encourage physicians to embrace CPOE, Peninsula Regional leaders fervently played the patient-safety card, frequently highlighting statistics such as the following: The Institute of Medicine estimates that medication errors account for about 7,000 deaths each year; the Agency for Healthcare Research and Quality attributes 770,000 patient injuries per year to medication errors; and the Food and Drug Administration says that at least one death occurs per day and 1.3 million people are injured each year as a result of medication errors.
The hospital's chief medical information officer punched up the discussion by pointing out that the healthcare industry's carnage is akin to a 747 jet crashing every other day for a full year.
Gaining philosophical buy-in was only part of the equation. Peninsula Regional leadership also strategically built momentum while ensuring that physicians were comfortable with the transition to automated processes.
To get the ball rolling, the hospital targeted the “easy wins,” commencing CPOE implementation in departments most amenable to adoption.
First up to the plate was the orthopedic department. These surgeons practice medicine in a very uniform manner, and, thus, it is much easier to transition from paper- and oral-based ordering to electronic ordering.
To keep the implementation rolling at a quick clip, leaders introduced CPOE in other departments within the same division—specifically neurosurgery and urology. After CPOE was successfully up and running in these areas, leaders rolled the system out department by department, in order of perceived ease of acceptance.
The same “start with the low hanging fruit” philosophy was used to prioritize safety issues. Teams consisting of pharmacists, physicians and nurses targeted high-risk medications first in an effort to prove the CPOE would improve safety and care outcomes.
For example, one team leveraged CPOE to improve patient safety associated with Coumadin, an anti-coagulant that is difficult to control and is associated with significant patient-safety risk. The team developed a Web-based interactive form with the CPOE application to encourage clinicians to adhere to current best practices related to Coumadin administration.
Hospital leaders also ensured that physicians were comfortable using the system as any struggles with the technology itself would cripple the initiative.
A peer-to-peer training program—where physicians train physicians, nurses train nurses and so on—met the educational needs of each clinician.
The hospital's CMIO took the approach one step further. The CMIO shadowed each specialist, standing at the orthopedic surgeon's side in the operating room, for example, to ensure that physicians were completely comfortable using the system in their unique roles.
Peninsula Regional's approach to IT implementation is moving the organization toward a paperless environment. The hospital already has reached Stage 6 on the HIMSS Adoption Model, a designation that has been achieved by a minute percentage of community hospitals.
The hospital also is positioning itself to receive its share of the incentive funds available through the American Recovery and Reinvestment Act of 2009. With 65% of orders processed electronically—directly by physicians at the point of care—Peninsula Regional is on course to meeting the CPOE stipulations that are part of the first wave of meaningful-use requirements.
Peninsula Regional has begun to experience care improvements tied directly to IT. For example, the hospital has reduced the number of patients with elevated international normalized ratio for blood clotting time from greater than 20% to about 10% in a one-year period. In addition, Peninsula Regional has eliminated concurrent orders of Heparin and Lovenox, a combination that results in potentially dangerous complications. The hospital also increased compliance with its Heparin protocol by 60%, greatly improving anti-coagulation management. And, the hospital has achieved a 19% reduction in adverse drug reactions with Dilaudid, a potentially dangerous narcotic medication.
Taken together, the costs to establish and maintain the underlying infrastructure of hardware and software that supports the clinical information systems, including CPOE used by physicians and clinicians, is in excess of several million dollars. The investment and effort have spanned multiple years and required the coordinated efforts of teams of physicians, clinicians and information technology specialist to provide a solution that delivers clinicians with the information they require where and when needed.
Because the hospital's medical executive committee issued a mandate requiring clinicians to use CPOE in July 2009, even greater results are expected to materialize in the future.
The ability to report these quality improvements will become increasingly important as the meaningful-use criteria evolves. In the final analysis, leaders at Peninsula Regional expect that their efforts will enable them to successfully report not only the IT utilization, but also the care improvement metrics that will be required to meet the government's meaningful-use criteria in the years ahead.
Chris Snyder is chief medical information officer and a hospitalist at Peninsula Regional Medical Center. Ray Adkins is chief information officer.
