Over the past several years, Cedars-Sinai Medical Center has invested considerable resources in technology to improve the clinical practice environment, including a Web-viewing system for clinical information (Web/VS) and a computerized physician order entry system (CPOE). Annually, the organization spends at least 25% of its capital budget on information technology.
Investing in technology to enhance the practice environment comes at a critical time for the healthcare community. Challenged by a growing work force shortage and increasing public awareness regarding patient safety and quality, many hospitals are looking to technology to provide improvements for both staff and patients.
The Agency for Healthcare Research and Quality estimates that organizations using CPOE can reduce medication errors and prevent 28% to 95% of adverse drug events. Increasingly, states and purchasers, including California and the Leapfrog Group, are calling on hospitals to adopt CPOE systems to reduce medical errors.
Despite the benefits and promise of such systems, less than 3% to 4% of U.S. hospitals have CPOE available for use by physicians. For many hospitals, developing and implementing such systems are prohibitive due to cost. Other hospitals, such as Cedars-Sinai, have faced other challenges to CPOE implementation, as will be discussed further in this article.
Cedars-Sinai's Patient Care Expert (PCX), which includes a CPOE component, is an innovation built upon several years of modernizing the computing infrastructure of the medical center. The institution specifically wanted to take advantage of modern Web technology and capabilities to improve patient care and enhance performance.
In preparing to adopt a CPOE system, the medical center identified key performance criteria, including the following:
- The system had to utilize browser-based technology, making it accessible through any browser-enabled computer, any time, anywhere.
- The system needed to be highly flexible, allowing for rapid modifications of content and functionality to meet the changing needs of a large medical staff and clinical work force.
- The system needed to be fully integrated with all ancillary services, patient registration and patient accounting.
- Finally, the system needed to be user-friendly for large groups of users with a diverse range of familiarity and experience with computers.
After rigorously examining available commercial products, including site visits to "flagship hospitals," we found no system that approached meeting the criteria we believed essential for long-term success. Following broad input from administration, clinicians and information technology experts, the Cedars-Sinai board of directors made the difficult decision of developing our own comprehensive system, in collaboration with Perot Systems.
The product of this investment is PCX, a comprehensive, integrated order entry/charge capture information system that incorporates core medical center operations into four modules.
- Patient management supports admission, discharge, and transfer of patients, as well as bed management and preregistration.
- Physician order entry automates physicians' entry of orders. They are checked automatically for drug interactions and forwarded to the appropriate personnel or service department for action.
- Patient accounting bills patients and their insurance providers with enhanced accuracy in capturing charges.
- Contract management oversees a database of provider contract terms used to verify payment ability during preregistration and proper billing of patient accounts.
In August 2002, after nearly three years of development and preparation, Cedars-Sinai launched a pilot program of the PCX system with great anticipation. The system was piloted for obstetrical patients over a two-week period, within which approximately 400 patients were entered into the system.
During the pilot, more than 140 physicians and 200 department staff members utilized the system to care for all obstetrical patients. Clinical staff entered more than 20,000 orders during the test run, which demonstrated the system's functionality.
We were extremely pleased with the results of the pilot since it provided valuable information about how the application and implementation processes could be improved during the hospitalwide rollout.
Once the improvements from the pilot program were incorporated, the CPOE component of PCX would be implemented floor by floor throughout the medical center, beginning Oct. 24, 2002, and running through February 2003. As designed, PCX Web-based technology would allow clinical staff to place and view orders from any workstation on the hospital network or via remote access from physician offices or homes.
By the Oct. 24 implementation date, more than 2,000 physicians were trained and certified to use PCX. While the medical privileges of approximately 150 physicians who did not certify to use the system were suspended, the majority of these physicians rarely admitted patients at Cedars-Sinai. (Editor's note: All physicians were required to be certified by Oct. 22.)
Some members of the medical staff argued that the 100% compliance requirement with CPOE certification and use by physicians was punitive and unfair. However, the medical executive committee, looking to the quality improvements PCX would bring, felt that a single level of patient care should be adhered to throughout the medical center.
Nevertheless, on Jan. 20, 2003, we made the difficult decision to temporarily suspend the implementation and use of the physician order entry of PCX.
By Jan. 23, 2003, (when the suspension went into effect) the system was operational for more than two-thirds of the medical center's inpatients. In aggregate, about 700,000 orders had been placed for more than 7,000 patients-more than 10,000 orders per day. The system performed as designed, and patients consistently received the care they needed in a manner that demonstrated the system's promise to improve quality and safety.
Though the system has met or exceeded our expectations for up-time performance and reliability, we found ourselves simultaneously managing four complex processes:
Physician change management: Four months into "go-live," physicians remained deeply concerned about the added time they reported in entering orders and their negative perception of the system's ease of use. Further, we believed that too many physicians at this stage in the implementation did not have an optimal working knowledge of the system's functionality.
Work flow change management: The procedures involved in hospital-based patient care are complex in any environment and need to be carefully and thoroughly understood in advance of automation. Additionally, CPOE will affect the workflow of all caregivers. We discovered there was far more operational workflow analysis and adjustment needed after "go-live" than was initially anticipated.
System enhancement: PCX is designed to allow rapid programming for improvements to user functionality. Literally hundreds of enhancements, based upon user suggestions after "go-live," have been placed in the system. Building on this strength, we intend to better capture and prioritize user suggestions for enhancing the system while "off-line."
The planned implementation itself: During this upcoming evaluation period, we will be aggregating input from all users to enhance PCX and improve the implementation and workflow procedures. By intensifying training and support resources, in addition to accelerating the system response time along with other changes, we expect to improve physicians' experiences. In addition, Cedars-Sinai is developing quantifiable indicators to measure how PCX will improve the quality of healthcare delivery and reduce the potential for medical and clerical errors.
One of the most important lessons learned to date is that the complexity of human change management may be easily underestimated.
It is well known that implementation of information systems may falter because of user-related vs. technological issues. For example, with nearly 2,000 physicians on our medical staff and close to 9,000 employees, there is a diverse range of familiarity and experience with computerized systems. At Cedars-Sinai, administrative and medical leadership, alongside individual physician users, will resolve the process, user and technical challenges identified.
Our medical center remains committed to CPOE implementation. Separate from the benefits reported in the literature, PCX is affording us a window on the processes of care, pointing to previously unknowable opportunities for quality improvement.
Michael L. Langberg, M.D., is the CMO at Cedars-Sinai Medical Center in Los Angeles.
Editor's note: During the CPOE hiatus, Cedars-Sinai officials say they will aggregate the input received from all sources to enhance PCX and improve its reintroduction. Once the input is analyzed, a timeline for reintroduction will be determined.