Healthcare Informatics, March 2, 2014 by Cynthia E. Keen
When evidence-based order sets of a computerized physician order entry system (CPOE), together with real-time clinical decision support (CDS), are used by clinicians within a fully integrated in an electronic medical record (EMR) system, miracles can happen. Specifically, the risk of dying while an inpatient in a hospital can be reduced, as was presented during a HIMSS14 virtual session the week of February 23, as the HIMSS Conference was taking place at the Orange County Convention Center in Orlando.
North York General Hospital (NYGH) discovered that its diligent, appropriate use of carefully implemented health information technology helped make it the top performing hospital in reducing inpatient mortality among all Toronto area hospitals and the second best performing hospital in Canada in 2012. While numerous factors can contribute to inpatient mortality reduction, a study presented at HIMSS 2014 directly linked the use of real-time CPOE/CDS to this positive outcome.
North York General may be perceived as a typical mid-sized healthcare enterprise. It consists of a 418-bed acute care community teaching hospital that is affiliated with the University of Toronto, an ambulatory care center, and a seniors health center. Its healthcare facilities and regional programs serve a population of about 400,000 living in the metropolitan Toronto area and south central Ontario. During the 2012-2013 calendar year, North York General Hospital had nearly 30,300 inpatient admissions and nearly 116,150 emergency department visits.
From a healthcare IT perspective, this community health system was light years ahead of the pack. In April 2011, it achieved stage 6 in the HIMSS Analytics EMR Adoption Model, one of only three hospitals in Canada to achieve this status. (No Canadian hospital had as yet attained stage 7.) In October 2010, NYGH had replaced its manual systems with CPOE and closed loop barcode medication administration systems. With these additions, the hospital's EMR had the ability to provide intelligent, evidence-based advice to physicians as they entered electronic orders for patients. This was phase 2 of eCare.
eCare was a multi-year, hospital-wide clinical transformation project utilizing health IT to improve patient outcomes. The primary goal of the project that began in 2007 was to improve quality and safety of patient care using advanced EMR technology to improve patient outcomes.
“Our hospital leadership was concerned about the fact that adverse events in Canadian hospitals represented 7.5% of acute care admissions and the potential of causing 9,250 to 23,750 preventable deaths per year. Inpatients are exposed to risks. Our leadership wanted to address this head on, and make our hospital a safer hospital,” said Jeremy Theal, M.D. a gastroenterologist and the organization's chief medical information officer. “We wanted to transition to a culture where our clinicians and staff embraced evidence-based care. We wanted them to take ownership of a project that would be the shared vision of its clinical staff and hospital administration.” As many hospital administrators know well, it's one thing to implement a CPOE/CDS system, but it's something else entirely to get physicians to use it.
Grassroots planning from the start
The project team began by evaluating inpatient discharge data for a 12 month period to identify patient conditions that the hospital treats. The objective was to cover at least 80% of diagnoses with standardized order sets. After a gap analysis had been performed, 350 order sets needed to be developed. The hospital opted to develop a “bespoke” rather than an off-the-shelf system, one developed by its clinical staff to fit the way the hospital worked. A centralized interdisciplinary order set build team consisting of four physicians, two pharmacists, and 15 clinical informatics applications analysts representing the equivalent of 3.5 FTEs reviewed sources of evidence. Evidence-based order sets were developed from existing local hospital order sets, protocols, and diretives as well as Canadian and International guidelines, peer-review journal articles, and vendor-provided information.
An additional 80 physicians and 150 clinical staff were recruited to review each order set and provide interdisciplinary and inter-professional input. Dr. Theal emphasized that physician/clinical staff hands-on involvement was essential to the project's success. Then it was necessary to see how each order set would fit into workflow. If problems were identified, new solutions were identified and tested. “The idea of putting a new solution onto an old broken process could have spelled disaster. We looked at this project as a key opportunity to integrate evidence into new workflows that would better fit the new system that was being implemented,” said Dr. Theal.
Each clinical process was scrutinized: how roles would change, what processes would continue/be terminated/start. A “loop” was defined for every orderable, a decision that resulted from visits to hospitals which had experienced orders languishing in cyberspace because all elements hadn't been addressed. The loop processes were then tested in a laboratory-type environment. Different physicians who would be using the order sets were given a clinical scenario, such as admitting a patient with a suspected hip fracture into the hospital, and asked to walk through the process. This process identified snafus that could then be addressed and retested before go-live.
Care practices were also reviewed. In situations where hospital staff and resources could not meet the precise evidence-based guidelines, the team got creative and found solutions that would best meet the order sets and ensure that patients would get the best care possible. Dr. Theal cited one example: to meet the guideline that stroke patients have a swallowing screening test within 24 hours of admission, which was not possible on weekends due to lack of availability of speech language pathologist, nurses on the stroke unit were trained to perform an interim test that would identify high risk from low risk patients on Saturday and Sunday
CDS alerts were created very sensibly, so that when they did appear, physicians would be motivated to react to them. The systems were integrated to complement and improve workflow, not to hamper it. One year after go-live, utilization statistics were dramatic. 100% of clinicans were using the system. Ninety-two percent of physician orders had been entered by physicians. Out of 1.7 milllion orders, 830,000 were entered through order sets. Two to three order sets had been used for each inpatient. And nearly half of the orders placed (49%) were made using evidence-based order sets.
Some other remarkable gains had been achieved:
Medication turnaround time improved by 83 percent
VTE prophylaxis rates increased from 50 percent to 96 percent with the help of CDS alerts
Medication reconciliation increased from 8 percent to 80 percent
Order set usage increased from 36 percent to over 97 percent
The hospital conducted a retrospective chart review and complex statistical analysis to determine if the use of CPOE with evidence-based order sets was associated with a reduction in mortality of patients diagnosed with either pneumonia or COPD and if the use of order sets that matched or nearly matched the inpatient admission diagnosis had a positive impact. Mortality rates decreased by 45 percent using the healthcare IT systems, and if order sets matched diagnosis at time of admission, the increase was 56%.
Such is the power of a customized, user “owned”, well designed and supported CPOE/CDS system fully integrated with an EMR.
(Sidebar): Keys to success
What were some critical success factors at North York General? Among them were these:
The goal is improving patient care
The organization needs to be culturally ready and trust that this is for clinical benefit
Engage front line clinicians who are respected clinical champions for peer driven change.
Don't deploy an out-of-box solution; a customized “bespoke” system will increase adoption success. Make clinicians a part of the process from the beginning.
Communicate – it's necessary to win the hearts and minds of users. This doesn't happen automatically.
Make sure that the infrastructure is robust and reliable.
Continuously measure, learn and make improvements.