Hospital achieves 100% usage of CPOE system

All patient orders are entered electronically

Montefiore Medical Center, in Bronx, NY, has achieved a rare milestone: All inpatient orders — including medications, lab tests, diagnostic tests, and all other clinical care orders — are being entered electronically. In the process, Montefiore has achieved a 60% reduction in the time elapsed from writing a prescription to a patient receiving the medication, and a 50% reduction in the number of potential prescribing errors.

"We wanted to reduce the hand-offs you have when working in the paper world, and give the information to the physicians when they place their orders," explains Dorrie Napoleone, director of clinical information systems. "It’s much more effective if you tell them up front about patient allergies, potential drug interactions, or lab values that represent a contraindication."

Seeking to improve quality

"We had and we have excellent leadership," notes Napoleone, explaining the impetus behind this transformation. "They are pretty visionary, and they realized that the best way to improve quality of care is to get information into the hands of the decision-makers — in this case, mainly physicians."

The search for a system that could do this began in 1994, but the serious planning started in 1998. "There was a lot of preliminary work we had to do to set the foundation," explains Napoleone. "We needed to implement other systems first, such as automating the pharmacy, and patient registration in some areas [the Montefiore system includes about 1,100 beds in two hospitals]. A stand-alone CPOE [computerized physician order entry] system wouldn’t realize nearly the same quality benefits as an integrated one."

After integration, the following steps were required:

  • system selection;
  • securing funds and board approval;
  • contracting with the vendor.

The vendor was chosen by a group of 25 staffers — 14 physicians as well as representatives from nursing, pharmacy, and administration. "We educated them as to what their charter was: to go out and get a system that would work across the Montefiore integrated delivery system to support an on-line network that would be physician-friendly," says Napoleone. "Then, we took them out on site visits and vendor demos."

Vendors who did not provide the requisite technology were automatically eliminated. "We are a large-volume system, and response time is very important," says Napoleone, who points out that Montefiore staff write over 60,000 orders a week. "From a technology standpoint, we wanted a system that would have rapid response time and run 24-7. If you eliminate paper, you need a system that runs all the time."

The LastWord system from Seattle-based IDX Systems Corporation stood out. "It had the foundation of an on-line record across a delivery system," Napoleone explains. "It was designed to be a birth-to-death record, whether the patient was seen in the ED, in the doctor’s office, or in the hospital. Being created by physicians, it also has a strong clinical foundation." The IDX system is still in use by Montefiore, although LastWord has been replaced by a new generation called Carecast.

The system is activated when a physician places an order, which can be done from the office, from home, or from any one of 4,000 workstations around the medical center. "Some physicians have wireless units, so they can do it at the bedside, the nursing station, in the hallway — anywhere on campus where the Internet can be accessed," says Napoleone.

The order could be for medication, labs, or imaging. The physician opens the patient record on the computer, looks at the lab values and meds given, and writes the order. He or she selects options from a drop-down menu and fills in the required information, such as the dose. Then the physician hits the "process" button, and the order is electronically transferred to the next area — for example, to the pharmacy, and to the nurse with a "to do" list. "So, the nurse knows immediately that they have a dose to give, and the pharmacy knows they have a dose to deliver to the nurse’s station," says Napoleone. "This is an enormous streamlining in what has traditionally happened. The doc would have had to find the paper chart, get it, flag it, and someone would need to interpret his order."

In addition, as soon as the order is entered, a big pop-up window may come up that says the patient is allergic to a certain medication. "In almost all cases, the doc can override this if they want, but they get the alert box and have to respond to it," Napoleone explains. "We don’t necessarily want to stop the doc from doing what he thinks is right, especially if it’s an emergency."

Training the staff

To date, about 1,300 physicians and 1,800 house staff (residents), 2,000 nurses, and another 1,000 employees in ancillary areas such as registration and scheduling have been trained in use of the system.

The physicians were offered classroom training or given one-on-one classes in their offices. The training took one or two hours, "depending on how good they were with a PC," says Napoleone.

For nurses, the system was rolled out unit by unit via classroom training. However, that training was not entirely uniform. "We identified what was unique about each unit and worked with the physicians and nurses to make sure we accommodated those uniquenesses," says Napoleone.

While a computer can automate the care process of a patient, "What a day is like in the life of an oncology patient is very different than the one for a patient going for dialysis or being treated for a broken leg," she explains. "Different things need to happen and different kinds of orders are given." These can be customized in the IDX system so that pull-down menus offer the most appropriate options.

"There are also huge differences in dosages, for example, between adults, neonatal, and pediatric patients," adds Napoleone.

At a time when only about 5% of all hospitals nationwide have a functioning CPOE system, how is it that Montefiore was able to achieve 100% usage?

"A lot of it is attitude," says Napoleone. "Lots of people will give you lots of reasons why they can’t do it, but most of the reasons are not valid. If you actually sat a person down and said, We have a tool to improve your efficiency by 50%,’ they’ll probably say it’s great, but lots of places think that docs won’t like it, that they’ll rebel and go somewhere else."

That fact that Montefiore is a teaching hospital does make things easier, she concedes. "We do have residents who place orders, and this makes us a little more open to innovation and change," she says. "We are a very mission-driven organization; from the top we decided this was something we had to do. We would not have been successful without executive leadership fully supporting us; they are 1,000% behind the project. After that, it was a matter of teach, educate, and then activate." n