Core measure compliance gets better with CPOE

Don’t settle for plain vanilla’ system

There is a big difference between implementing computerized physician order entry (CPOE) and doing so with clinical decision support systems in place, emphasizes Margaret Quinn, MD, chief medical information officer at Neptune, NJ-based Meridian Health. "You can have just plain vanilla CPOE, but if the system is not intelligent, it only eliminates the handwriting issue and provides no additional benefits," she explains.

The organization implemented CPOE along with additional clinical decision support, which earned the organization the John M. Eisenberg Award for Patient Safety and Quality, a national award bestowed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Quality Forum.

"Most systems come with allergy checking and duplicate drug order checking, which can be very valuable in providing information for clinicians at the point of care. But we have taken it a lot farther and embedded evidence-based protocols into our system," Quinn reports. "We’ve seen a marked improvement in compliance as a result."

Clinical decision support

Clinical decision support "absolutely" needs to be part of any CPOE implementation, urges Quinn. "The more you include, the more value you will get and the better accepted it will be by physicians," she says.

However, the system won’t solve all your problems. "It’s not as though you put the system in place and you’re done," says Quinn.

A lot of discussion has to occur between clinicians and the information technology (IT) department to determine what the needs are, make sure the specifications for the system can meet those needs, and monitor the impact of the system to see if the alerts are well accepted and if they are really changing care, she explains.

Throughout the entire process, the outcomes nurse acted as a link between the clinical and IT side, says Quinn. "Then once things were live, the outcomes nurse was responsible for monitoring the use of protocols and improvement in core measures."

Before the system was implemented, quality professionals researched the literature and core measure requirements and brought it to the process improvement team, which is chaired by a physician.

"He then reviewed it with the chair of cardiology and agreed there was a need to address issues of aspirin and beta blocker use on admission for acute coronary syndrome and DVT [deep vein thrombolysis] risk on admission to the coronary care unit [CCU]. Together, they agreed on what the decision point should be, and the outcomes nurse then worked with IT to come up with what was needed."

Compliance improvement

Now, the system immediately alerts the physician about core measure requirements, such as prompting them for aspirin and beta blocker therapy, as well as DVT prophylaxis or full heparinization if the patient is being admitted for unstable angina.

For instance, if the physician is admitting the patient to the CCU, the system stops them, displays the patient’s cardiac test results, and asks, "Are you admitting the patient for acute myocardial infarction (AMI) or acute coronary syndrome?" If the doctor answers "yes," it prompts him or her to either order aspirin and beta blockers, or document the contraindications.

"It’s done right at the point of care, so we are using a process that already was in place; the doctors were going to a computer to say that a patient was being admitted. So we put in all the necessary alerts and prompts to give them the ability to immediately act on those as they went forward," says Quinn.

Previously, there was about 86% compliance with the AMI core measure requirements. About two months after the system was implemented, it was determined that certain areas didn’t show improvement due to inconsistent use by physicians.

"We went back and promoted use of the system and have been at 100% compliance since," says Quinn.

[For more information, contact:

Margaret Quinn, MD, Chief Medical Information Officer, Meridian Health, 1350 Campus Pkwy, Neptune, NJ 07753. Telephone: (732) 897-7846. E-mail:]