Closing Pandora`s Box on Free-Text CPOE Orders

Closing Pandora’s Box on
Free-Text CPOE Orders
Presenters:
Pua Cooper RN, MSN, CMUP
Mickey Miqueli, RN
Boca Raton Regional Hospital
• Boca Raton Regional Hospital is a not-for-profit, advanced
tertiary medical center with 400 beds, over 2,100
employees and more than 800 primary and specialty
physicians on staff.
• The Hospital is a recognized leader in Cardiovascular Care,
Oncology, Women’s Health, Orthopedics, Emergency
Medicine and the Neurosciences
• It most recently became an academic teaching hospital
welcoming it first medical residents from Florida Atlantic
University’s Charles E. Schmidt College of Medicine in July
2014.
• In July 2014, Boca Regional was one of McKesson’s first
hospitals to successfully attest to Stage 2/Year 1 of
Meaningful Use and is currently in its reporting window for
Stage 2/Year 2.
• Computerize Provider Order Entry (CPOE) was implemented
in October 2011
• Big-bang approach to go-live
• Rollout live to 750 privately practice medical staff on a single day
• The go-live included CPOE order entry for all hospitalized
patients in the acute care setting housewide
• Physician training
• Training was mandatory
• Online interactive course
• Instructor-led classroom sessions
• The Institute of Medicine estimates that hospitalized
patients are subject to at least one medication error per day
(Radley, et al., 2013)
• Ordering medications using CPOE decreases the likelihood
of an error by 48% (Radley, et al., 2013).
• CPOE reduces errors related to poor handwriting and/or incorrect
transcription.
• CPOE systems offer functionalities such as drug dosage support,
alerts about harmful interactions, and clinical decision support,
which may further reduce errors.
CPOE 101:
What’s different
about CPOE?
Physician
Unit Secretary
Laboratory
Pharmacy
Radiology
Nurse
• Allows the physician to manually type narrative instructions
into an order into CPOE
• Created as a means to enter an order not previously
conceptualized during the build stage of the project
• The order is only routed to the nurse
• At Boca Regional, this order is called a “Nursing
Communication”
• Requires physicians to understand how CPOE
orders are routed to departments
• Physicians often place pharmacy, lab and radiology
orders using nursing communication orders
• The computer can’t prevent it’s inappropriate use
. . . or can it?
• Physicians place med-related instructions in nursing
communications
Examples:
• Hold blood thinners before surgery
• Hold blood pressure meds for SBP<100
• Change IV Fluid to 100 ml/hour
• These orders do not get sent to the pharmacy; therefore, the
electronic medication record is not updated.
• If the nurse passes meds without seeing the order first, an error
occurs.
• This can result in harm to the patient and/or delays in care.
• The Office of the National Coordinator (ONC)
agrees that the excessive use of free-text CPOE is
creating a significant risk to patient safety
(HealthIT.gov, n.d.).
• In the ONC’s publication called “Computerized
Provider Order Entry with Decision Support SAFER
Guide”, they charge healthcare providers to
minimize free-text orderables by utilizing
standardized coded forms (HealthIT.gov, n.d.).
At Boca Raton Regional Hospital . .
The use of miscellaneous free text orders wreaked havoc
post CPOE implementation. Not only did these orders
pose a safety risk when abused, they negatively impacted
clinician efficiency by complicating the intended CPOE
workflow.
• A goal was established to reduce the inappropriate
utilization of these orders in order to prevent
medication errors.
• In the 2012 . . .
• 38,579 nursing communication orders were entered
• 4,365 contained medication related information
• The iterative redesign process spanned 17 months.
• The goal was to make ordering more intuitive for
users.
• Informatics led the project by identifying & engaging
the appropriate stakeholders throughout the
redesign process.
• This began with educating the senior leaders of the
existing safety issue and getting their support to make
significant changes to the existing physician workflow.
• Informatics worked collaboratively with clinicians
across the organization to understand and modify the
existing workflow. Proposed changes were vetted
proactively through the Physician Informatics Team
and the organization’s CPOE Clinical Content
Committee
• Users were educated of each change prior to
implementation. Less education was required as the
process was better refined.
Nursing
Informatics
Nursing
Leaders
Information
Services
Stakeholder
Engagement
Pharmacy
Informatics
Pharmacists
Physician
Informatics
Team
Senior
Leader
IT Steering
Demo
Screenshot
Demo
From April to July 2012, the number of free-text orders with medication-related information
averaged 70.3 per week. The redesign process resulted in a 43% decrease of its inappropriate
use. Comparing the equivalent time interval of April to July the subsequent year, the number of
free-text orders with medication-related information dropped to 30.1 per week.
120
# of Nursing Communication Orders Containing Med Information
100
60
0
NOV
OCT
20
SEPT
40
APR
MAY
Axis Title
80
Improved
Communication
Reduced use
of free-text
orders
Increased order
standardization
Increased
Education
Reduced
CPOE
corrections by
MD
A retrospective chart review was done to reveal how often
nurses failed to follow the medication-related instructions
embedded in a nursing communication order.
220
20
9%
Free-text
orders
reviewed
Number of
medication
errors found
Medication
error rate
Medication Errors Prevented
7000
1887 x 9% = 169 med
6000
1877
5000
4000
3000
654x 9% = 59 med errors
2000
654
397 x 9% = 35 med errors
397
1000
0
2012
2013
Number of nsg comms that would have occurred without intervention
2014
Number of nsg comms containing med information
• Hardwiring a culture of safety is difficult—if not
impossible—if stakeholders are not engaged or recognize
the need for change.
• For Boca Raton Regional Hospital, stakeholder engagement
was critical to the project’s success.
• Their feedback guided the iterative redesign process &
resulted in an ordering methodology that is now intuitive &
user-friendly.
• Nursing Informatics transitioned from weekly to biannual
data reviews to spot-check utilization and address any
unexpected trends.
• This solution can be easily be adopted by other McKesson
organizations using iforms in their CPOE application. HTML
& VGR language can be shared between IT departments and
adapted to meet an organization's specific CPOE build.
HealthIT.gov. (n.d.). SAFER Guides. Retrieved from
HealthIT.gov: http://www.healthit.gov/policy-researchersimplementers/safer/guide/sg007
Radley, D., Wasserman, M., Olsho, L., Shoemaker, S., Spranca,
M., & Bradshaw, B. (2013, February 13). Reduction in
medication errors in hospitals due to adoption of
computerized provider order entry systems. Journal of the
American Medical Informatics Association (JAMIA).
doi:doi:10.1136/amiajnl-2012-001241
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