Physician Order Entry with Meditech

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Physician Order Entry (POE)-General

Introduction
Physician order entry (POE) means computer order entry by physicians.

The purpose of this document is to educate readers on the state of the art of POE in general and with Meditech in particular. Information regarding successful and failed implementations is given so the decision can be made whether or not to proceed with POE at MDMC.

POE has received intense interest by physicians and hospital administrators over the last decade. It has been perceived as the gateway to decreasing costs, capturing charges and increasing quality through computerized interventions at the time of order-entry. For outpatients POE has different applications, physician incentives and history compared with inpatients. The findings reported in this paper, except for Meditech order entry, are for the hospital setting only, and are not applicable to outpatients.

The potential advantages of POE are so large that its widespread adoption seems inevitable. In fact, POE may be required by federal regulation, due to the recent national interest in reducing medical errors (ref. 1). Illegibility of physician handwriting is becoming less tolerated both by the public and by health care professionals. Also the potential financial advantages are appealing to administrators in the inpatient setting and to physicians for outpatient charge capture. Several Fortune 500 companies benefit plans are adopting standards for POE that are required for doing business with them (ref. 2).

Physician order entry is one progress point towards the electronic medical record, large database storage and retrieval of data from many patient electronic medical records (ref. 3). The data can be used to help clinicians associate key information in the database. Linking regional and local health databases are part of the National Health Initiative (ref. 3). Required national privacy requirements (HIPAA) for patient information are to be published soon and will likely speed the use of data in the databases.

The interest in POE locally and nationwide has focused on inpatient medication order entry, as it has been shown to decrease costs significantly and also improve quality (ref. 4, 5,6,7,8).

Characteristics of Optimal Computer Interventions for Medication Orders

Although all optimal interventions are rarely achieved simultaneously with hospital information system solutions, even minimal interventions produce dramatic improvements (ref. 6). Optimally, each medication order is checked by computer and informs the physician at the time of the order, of the following:

• Allergies, including by drug class
• Drug interactions
• Duplications
• Correct dosage based on patient-specific parameters
• Correct frequency
• Correct route of administration
• Correct drug based on sensitivities
• Correct drug/dosage based on lab parameters of organ function, CBC's, and drug blood levels

Benefits of POE

Over 50% of medication errors are due to MD orders and transcription errors. (ref 1). About 1 in 100 medication errors results in an ADE (ref. 5). Medication errors cause considerable extra work. The cost of an ADE has been estimated at more than $2,000 per event (ref. 1, 4, and 5). It has been shown that POE substantially decreases non-missed-dose medication errors (decreased by 81%) because POE structured orders, facilitated their checking and they are legible. Tierney et al (ref. 8) demonstrated that POE on a medical service decreased average length of stay by 0.89 days and produced a 12.7% decrease in charges.

Chin et al (ref. 6) embedded simple guidelines into POE. They showed a decrease in chest x-rays and the use of Zoloft, an expensive drug, as less costly alternatives were suggested at the time of POE.

POE with adequate drug safety screening will be required by many of the nations Fortune 500 companies (ref 2) for contracts for healthcare for their employees.

Disadvantages of POE

Lee, et al, and Weiner, et al, (ref 9,10) report physician satisfaction with inpatient POE correlates with effects on their productivity, ease of use, speed, and off-floor availability. Surgeons were less satisfied than internists. Nurses valued legibility and accuracy of orders with POE. The need for computer terminals increases with POE. The need for programmers may increase as the order entry and decision making tools change in response to physician input. Typing skills, which many MD's do not have, facilitate the use of POE.

POE Implementations-Successful

Successful implementation characteristics are outlined in ref 11. They are as follows: ". . . the system must be fast and easy to use, the user interface must behave consistently in all situations, the institution must have broad and committed involvement and direction by clinicians prior to implementation, the top leadership of the organization must be committed to the project, and a group of problem solvers and users must meet regularly to work out procedural issues.…"

The reference analyzing an unsuccessful implementation (ref. 12) stresses the following points for success:

• Keep under control everyone's expectations
• Study your current OE to modify and streamline problematic practice behaviors and operations before starting POE
• Anticipate problems
• Institution must be prepared to invest resources, both human and financial

POE Implementations-Unsuccessful

Massaro (ref 12) reports characteristics of unsuccessful implementation as follows:

• Alteration of established workflow patterns and practices
• Strict, literal interpretation of rules by the computer (or conversely, an inability of the IT system to identify intent)
• Ambiguity of governance policies
• Lack of clear understanding within the physician community of the long-term strategic value of POE
• Lack of understanding of the magnitude of cultural and behavioral changes and time required
• Lack of physician and administrative support
• Expectations oversold
• Did not anticipate problems
• "Technology issues used as surrogates for other agenda items related to the challenging of basic institutional assumptions and beliefs"

A possible solution to some of these problems is this. Speech recognition has the most promise for solving significant time and acceptance issues for inpatient POE. No stand-alone product is on the market yet to meet these needs. Speech recognition technology has recently improved on its recognition rate of male voices to the point of acceptance by physicians. Lernout & Hauspie has a "Prescription Writer" embedded in its ED Solution Product. If this product has an acceptable track record with physicians and if it can be used with the L & H recently acquired Dragon product "Naturally speaking Mobile", only one 600 megahertz Pentium processor will be needed per nursing station for downloading scripts voice-recorded by doctors.

Physician Order Entry-Meditech Specific

A few(4) hospitals using Meditech POE for several years have been located. They are in Greenwich, CON, Juneau, Oakland and San Diego. All information received from 3 of them is summarized in Current Status, below.

Current Status-Information from Current Users

	CHEB	Greenwich Hosp	Juneau Hosp
Meditech version	4.6		4.6
Who uses POE?	Interns, residents	Interns, residents, new attendings trained there	No housestaff; no employed MD's. 33% of attendings use POE
How enter orders?	OE directly	PCI	PCI
PHA interfaced?	No		No
How do nurses know when orders placed?	Automatic printout to patient location.		Automatic printout to patient location.
How done at night?	Same as daytime		Paper with written order to pharmacy.
Use order sets/guidelines?	Yes, many, by diagnosis, admission	Yes	Yes, by diagnosis, procedure, certain meds, physician.
POE used for what orders?	Meds, chemo, labs on admission or if on order sets	Lab, pharmacy	All MD orders
Verbal orders-how handled?	VO rarely done as Dr on-site at all times.  If done, nurse enters order in computer, prints out, and Dr. signs paper.		Paper only
Electronic signature-is it used?	Two levels of passwords used.  May go to PCI to require PIN in the future.		Yes-Two passwords plus doctor must put in a PIN to file the order in PCI.
What resources are needed for implementation?	Customer designed screens take lots of time to create. CHEB required approximately 6 more terminals for physician use.		Training time for physicians as it must be one on one.
Advice from experience?	Expect MD resistance. Must show the benefits. Doctors really like the order sets—requires a special committee to control this, as they want so many.		1.  Start small-2 or 3 physicians who can type and are facile, somewhat, with computers.  Get "kinks" worked out with them. 2.  Need key RN and key MD to set up the program initially and they work with the 2-3 physicians above. 3.  Initial physicians may be surgeon (ophthalmologist), OB, internist.  Order sets for ophthal, OB, heparin are used regularly. 4.  Need someone the doctors can call at anytime for help. 5.  Doctors need one-on-one training.  Nothing else works. 6.  Don't try to train doctors who don't have some typing skills. 7.  Set up ES in PCI for dictation before setting up POE, as it is simpler and docs get used to using it. 8.  Teach the doctors who volunteer.
Advantages of POE	Increases efficiency by MD orders being carried out sooner. Safety of correct calculations of dosages and alerts when maximum dosages exceeded. Chemotherapy dosages safer. Illegible handwriting problem solved. Cost savings example:  saved $18,000 per year by standardizing the dosage and administration of a certain drug		Patients get what is ordered faster--increase efficiency In ER > 50% of MD's use OE as charges through there and they can monitor their charges

Recommendations

Consider two questions: (1.) Does POE "work"? (2.) Does the potential for decreased costs and improved quality warrant further efforts on the part of MDMC?

(1.) POE does "work" in certain circumstances, as outlined in this paper.

The required use of POE by physicians with illegible handwriting who do not type will fail and their goodwill to try other solutions will probably be diminished. Current users advise that requiring POE increases the chances of failure of the whole implementation.

Implementing POE, even partially, is costly especially due the labor intensivity of designing the customer defined screens. Risk exists also in whether physicians will accept POE. The risk of lack of nursing acceptance and support of two separate order systems, paper and electronic, also is present. Risk of loss of the investment in labor costs is present if the hospital information system is changed.

Advantages of POE are the increased efficiency in orders being carried out, decreased adverse drug events, decreased inappropriate and costly drug usage, and decreased variation in orders from one physician to the next.

Given the current cost-reduction environment, the goal of POE implementation without addition of FTE's nor new work groups/committees is sought. Step-wise work on POE implementation assumes risk gradually and allows for abandonment or delay at any step. This approach allows the flexibility of taking advantage of the opportunities of POE, without ruling them out, while decreasing the associated risks.

(2.) The potential for decreased costs and improved quality warrants further efforts by MDMC.

The following sequential steps are recommended:

Steps	Opportunity	Risk
1. Obtain consensus to go to step 2, below.	Flexibility in deciding whether to implement gradual POE	Change to different hospital information system may require some labor-intensive work to be repeated
2.  Educate key nursing and pharmacy staff on POE.  Proceed to step 3?	Obtain informed input from informed nurses and pharmacists whether to continue with POE	Salary cost for education time
3.  Plan for successful first try at POE by working with 1-2 MD's.  Educate key medical staff and medical error work group.  Proceed to step 4?	Start to learn how much time is required for medication CDS's.  Learn about MD, nursing, and pharmacist acceptance. Make changes as needed.	Salary costs for step 3.
4.  Implement plans from step 3.	Learn how much time is required for medication CDs's.  Learn about MD, nursing, and pharmacist acceptance. Make changes as needed.	Salary costs for step 4.
5.  Evaluate success/failure of implementation.  Go to step 6?	Learn from step 4 what needs to be changed and whether to continue to step 6.	Salary costs for step 5.
6.  Plan for the future of POE at MDMC.	Multiple advantages of POE

Summary

Successful implementation of POE is highly culture dependent but promises numerous meaningful advantages. The characteristics of both failed and successful implementations are reviewed. Two current users were interviewed. One user similar to MDMC, Juneau, had success in partial implementation. With a gradual implementation plan to limit risks and keep open the opportunities to achieve the advantages, MDMC's chances for a successful partial implementation are enhanced.

References:

1. To err is human: building a safer health system. Kohn LT, Corrigan JM Donaldson MS, editors. National Academy Press, 2000.

2. ISMP Medication Safety Alert! Jan 12, 2000.

3. Interim report: Toward a national health information infrastructure. Prepared by the national committee on vital and health statistics and the workgroup on the National health information infrastructure. June, 2000.

4. Bates DS. Using information technology to reduce rates of medication errors in hospitals. BMJ. 2000; 320: 788-791.

5. Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma'Luf N, Boyle D, Leape L.The impact of computerized physician order entry on mediation error prevention. J. Am. Med. Inform. Assoc. 1999; 6:313-321.

6. Chin HL, Wallace P. Embedding guidelines into direct physician order entry: simple methods, powerful results. Proc AMIA Symp. 1999; 221-225.

7. Pestotnik SL, Classen DC, Evans RS, Burke JP. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Ann Intern Med. 1996; 124:884-890.

8. Tierney WM, Miller ME, Overhage JM, McDonald CJ. Physician inpatient order writing on microcomputer workstations: effects on resource utilization. JAMA. 1993; 269:379-383.

9. Lee F, Teich JM, Spurr DC, Bates DW. Implementation of physician order entry: user satisfaction and self-reported usage patterns. J. Am. Med. Inform. Assoc. 1996; 3: 42-55.

10. Weiner M, Gress T, Thiemann DR, Jenckes M Reel S, Mandell SF, Bass EB. Contrasting views of physicians and nurses about an inpatient computer-based provider order-entry system. 1999; 6: 234-244.

11. Sittig DF, Stead WW. Computer-based physician order entry: the state of the art. J. Am. Med. Inform. Assoc. 1994; 1:108-123.

12. Massaro TA.Introducing physician order entry at a major academic medical center: I. Impact on organization culture and behavior. Academic Medicine. 1993: 68; 20-25.

Dr. Able is in practice with John Muir Health in Walnut Creek, California. To contact Dr. Able, email ermadene.able@johnmuirhealth.com.

 

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