PDF File: 

HCT3_wp_ondo.pdf

KLAS Enterprises

Product capability versus market penetration by product use suggests old habits are today’s principalroadblocks for EHR adoption and use.

Old habits, not technology, are today’s roadblocks for EHR adoption and use. Physicians traditionally handwrite orders or tell someone else what to order. Clerical personnel typically transcribe orders into the system and maybe a nurse validates the order.When physicians need a test result they ask a nurse or clerk to print it. Today everything can be done online but it is tough to train and move the professionals who are impacted by this new technology to adopt a new way of doing business. This, coupled with the fact that incentives and downstream benefits are not aligned to support this automation (costs, reimbursement, lack of standards, Stark Law), makes today’s environment one that has so far been defined by the early adopters.

As clinician awareness of the benefits of using an integrated medical record increases, there is an increasing belief that EHRs will soon become a standard of good practice for both ambulatory and hospital-based care. Computerized physician order entry (CPOE) plays a pivotal role in this discussion and many care delivery organizations are talking about CPOE as a component of a more comprehensive patient safety strategy. Medication-related activities are, in particular, receiving a lot of attention, including e-prescribing.

By way of introduction, KLAS, a market research and intelligence firm specializing in healthcare IT performance monitoring, gathers HIT vendor performance data from provider organizations, and offers research and consulting services based upon that data. They do this by first collecting product evaluations and then performing in-depth, confidential interviews with the IT executives and department directors who complete questionnaires. They gather valuable insight into specific strengths, weaknesses and future expectations for products.

CPOE

The 2005 CPOE Digest is the third successive annual report from KLAS regarding CPOE usage and its vendors and systems. The objective of each study was to survey every live North American CPOE site that was using a commercially available product, where there was a linkage and/or a relationship between the inpatient and ambulatory environment and a potential need to affect or be responsible for patient care treatment across these boundaries. The 2005 survey participants reported using the following products (listed alphabetically): American HealthNet, Cerner Millennium, CliniComp, Dairyland, Eclipsys (SCM, TDS and Emtek), Epic EpicCare, GE Centricity, IDX (LastWord, Carecast), McKesson Horizon Expert Orders, Meditech (C/S, Magic), Misys CPR, QuadraMed, Siemens (Invision, Soarian) and VisualMED.

The software objective of CPOE is for physicians to electronically enter virtually all clinical orders that they previously ordered via paper. In one user’s estimate, the focus on the software represents only about 15 percent of what the installation is about. Today users describe a CPOE project as a journey that never ends. CPOE is not a project; it is a paradigm shift in the delivery of care.

The challenge with CPOE is that while measurable progress is being made,much is left to be accomplished. CPOE is in use at less than 5 percent of U.S. hospitals and is in active use (physicians entering over 50 percent of patient orders) at 2.5 percent of hospitals measured. The really good news is that the progress this year has been primarily from non-teaching facilities. To the industry, this may be the most important finding of this year’s report. This is the first real evidence of CPOE adoption outside of the teaching environment. Non-teaching sites represent the hurdle that CPOE must overcome and usage in this environment provides an indication that adoption by privileged, non-employed physicians is possible.

The 2005 verifiable live sites totaled 245 versus last year’s total estimate of live sites at 199 (with 159 verifiable and 40 reported but not verified), an increase of 23 to 54 percent depending on which figure is used. Given CPOE’s small numbers, however, we are still at the early adopter stage and while progress is encouraging, critical mass has not yet been accomplished; but today’s results may very well represent the groundswell everyone is looking for. Sites that are live speak across the board to the benefits of efficiency, reducing errors and enhancing patient safety.

There are more “100 percent” users. CPOE usage is multidimensional and there is an indication of more “100 percent” use based on the three ways it is measured: (1) the percentage of physicians doing CPOE as compared to the number possible, (2) the percentage of orders a physician enters as it relates to all patients orders, and (3) the percentage of medication orders that are electronic.

CPOE Advice for Others

The commentary regarding benefits realized is more detailed in 2005 — providing greater insights into operational benefits spanning a wide range of activities, from clinical to financial. The benefit most often stated as being realized is efficiency and streamlines processes (46 percent), reduce transcription errors was second (40 percent) and reduce errors/enhance patient safety was third (38 percent).Workflow changes (36 percent) and physician acceptance (34 percent) top the list of surprises encountered or hurdles overcome.

At a macro level, users speak to CPOE being harder than envisioned and the general underestimating of the effect of CPOE on the whole order process, through the ancillaries and back to delivery of the results/medications. The advice for others spans a wide range of suggestions; at the top of the list were suggestions involving physician buy-in/involvement (38 percent) and the need for physician/nurse champions (22 percent). Mandating CPOE is at the bottom of the list (2 percent). Commentary at a more micro level with some not-so-obvious detail involves:

• Physicians: The fact is, CPOE does take longer than paper and our physicians all know that now. They are realizing they cannot have the exact same workflows they used to have. Training is a large component and the different doctors need specialized strategies to engage and properly train. The physicians themselves were surprised at the amount of training necessary for CPOE.We underestimated the hand-holding the physicians needed. Start with a control group such as orthopedics, anesthesia or OB/GYN, where standing order sets are well-accepted and controlled before moving to other departments. Physicians who do not use the system on a regular basis really struggle. The real value is in the mining of complex data for the physician. Rules help to push this data where the physician can use it most. The biggest surprise is good news: Now that it works the doctors want more usability.
• Nursing: In-depth and aggressive training of physicians, nurses and pharmacists is more important than you will think. While we knew from the beginning CPOE would be a challenge for the physicians, we underestimated the impact CPOE would have on nursing. Moving from paper processes to an electronic method is challenging. In the past, nurses were not required to be adept computer users. Nowadays, it is important for nurses to perform the key online clinical data documentation of vitals and other key daily data for the knowledge/rules CPOE needs to be effective.We have had difficulty implementing CPOE without having nursing online. Do everything else first: observations, nursing flow sheets, nursing documentation and ancillary system interfaces. The combination of CPOE and eMAR (electronic medication administration record) is a winner.
• Management: Make sure you understand what the organizational culture is willing to accept in terms of real clinical transformation and tailor the expectations accordingly. Be aware of how fast the organization can adopt change. After five years it is hard for the leadership not to be distracted. Obtain and maintain executive ownership, not just involvement. Get board, executive and medical leadership buy-in up front. The project must be a hospitalwide initiative, not an IT project. Keep patient safety as your focus. Prepare for wholesale organizational changes. Do not underestimate the culture change. It will cost twice as much as people think it will, and take twice as long to implement.
• Process: You cannot cookie cutter your approach in multiple organizations.We were surprised that over 7,000 abbreviations (some with multiple meanings) were used across our enterprise. Supporting workflow in high intensity areas and critical care units is more difficult. I was surprised at how inconsistent we were with processes across the organization. Every hospital has workarounds for processes that are broken and CPOE tends to uncover them. You cannot rely on the computer system to resolve all your procedural problems and changing a process is a much bigger deal. Procedural issues are often viewed as system issues.We underestimated how much the role of the unit secretary would be revamped. It has been a constant discovery process regarding how broken our old paper ordering process was before.
• Implementation: The secret in CPOE is setting the expectations. There is not a single formula to make this work. It takes a lot of time to build useful and effective order sets — this is the key to making it all work.We converted two years of detail clinical data and 10 years of visit history; we should have been more careful in making sure we expired the MD relationship on the converted data.We only occasionally make the fancy parts work well. Put your “A” team on the project. It is less than ideal to use resources that will not be around after implementation. It takes a lot more effort and attention than we ever guessed. Do not underestimate the importance and impact of workflow redesign.We provided elbow-to-elbow support and training. I recommend that all trainers be clinicians in order to add credibility to the understanding of the process. Many workflows are missed during implementation and then result in negative feedback during installs. The issue for us is preparing for all the contingencies downstream once the order is entered.We are wearing thin on having enough people to get this implementation done and keep the business running. Do not automate an existing bad process. Spend a lot of time up front getting the workflow right.
• Technology and Ongoing Support: The mix between keyboard and mouse is not clean. Some things can only be done by keyboard, some only by mouse and they often both exist when performing the same task, impacting both task efficiency and hardware choices/usability.We were not prepared for the large amount of click errors the staff made. We were shocked at the level of user dissatisfaction that can be caused related to system response time and uptime: We found we needed to deploy more equipment.We have not been able to develop a system for effective communication and notification of changes to CPOE users once it is live. The help desk for major clinical applications required restructuring. CPOE would not be possible without wireless carts or mobile devices.
• Interfacing/Integration: Interfaces are still a challenge. All vendors claimed that their CPOE solutions were fully integrated, while only three mentioned that in some cases there is interfacing to other relevant clinical systems. Although these integrated systems may exist, providers reported that much of the data getting into the CPOE system (laboratory, pharmacy, etc.) is interfaced. Integration of pharmacy and CPOE from same system vendor( s) was less than expected. The majority of vendors reported that their pharmacy system and CPOE system were integrated, however, all vendors had some sites that had to re-enter orders in the pharmacy system except for IDX and Epic. Thirty-one percent of all pharmacy orders entered with CPOE are re-entered in the pharmacy and this represents a 35 percent improvement overall (since 2003) and a 14 percent improvement from last year’s reported 36 percent re-entry. Additional challenges with CPOE and pharmacy are observed from state laws. A foreign ADT system creates challenges. Radiology tells us that 75 to 80 percent of the orders are wrong and that they do not have the ability to change or communicate back.

Alerting

Alerts are ignored if they occur too frequently. The results on alerting are mixed: 1) There are more complex active alerts (in the magnitude of thousands), 2) Those who are doing alerting are doing more (complex alerting), but 3) With the increase in CPOE sites reported there is an increase in the number of sites doing no alerting. Commentary does speak to alerting challenges, alert fatigue and alerts being turned off. Some users have established low- and high-level alerts. The low-level alerts are seen but can be ignored versus high-level alerts that “require action steps.” The challenge appears to be in the development of “high precision rules,” ones that eliminate the firing both of false positives and false negatives.

Medication Management

(Source: Medication Administration Study, September 2004) Systems and technology surrounding the area of medication management are a growing market due to the focus both of regulatory agencies and consumer groups calling for patient safety initiatives, specifically in the area of medication administration. In addition, bar code medication management (52 percent) was the No. 1-cited response by healthcare industry professionals as the most important computer application in the next two years (15th Annual HIMSS Leadership Survey sponsored by Superior Consulting).

The foundation elements to accomplish the goal of closed-loop medication ordering, alerting, administration and tracking are offered and put to use. The ability for physicians to enter all medication orders and to be notified of alerts from decision logic at the time of the medication order is generally, but not always, available. Making this environment more complex is the fact that nearly a third (31 percent) of all pharmacy orders are re-entered by the pharmacy. Access to medical or knowledge content during the ordering process, an online MAR (medication administration record) complete with all medications dispensed and positive patient ID at the time of medication administration is somewhat vendor/product-related.

Bar code technology is emerging as a solution in support of closed loop medication administration and the “Five Rights” (the right patient receiving the right medication at the right time by the right route in the right dose), laboratory specimen identification and blood verification — are based upon positive patient identification at the time the activity is conducted.

Today’s performance suggests the emergence of a strong product market as the three capable of being measured scored strongly (Bridge Medical MedPoint, Siemens Med Administration Check [MAC], and McKesson Admin-Rx) and 14 others are in various stages of development and deployment (AMTSystems PatientSafe, Baxter Patient Care System, Cardinal Health, Care Fusion wCareMed, Cerner Power POC Care Mobile, Eclipsys Knowledge-Based Medication Administration, GE Centricity Admin in Motion, IntelliDOT, MDG Medical Corporation, MEDITECH BMV,Mediware, Misys CPR, Omnicell SafetyMed and QuadraMed PC Affinity Med Charting).

With the industry looking for systems and technology to increase patient safety, reduce medical errors, improve communication between pharmacy and nursing, as well as meet intense pressure for these solutions from regulatory and consumer groups, the market share is expected to grow and seriously increase as seen with the 17 vendors cited in this report. Information at a more detailed level involves:

• ICU (31 percent) and Labor & Delivery (31 percent) were the two most common areas where survey participants indicated difficulty in implementing this technology (due to the immediacy of drugs needed in both of these medical specialty areas).
• Survey participants indicated that the barrier to the ease with which nurses use the medication administration system was related to the comfort level of the user regarding PC use, not the application itself.
• The average length of medication administration system implementation was seven months.
• An organization’s ADT and pharmacy vendors are chosen most often for medication administration products.
• Regarding quantifiable benefits, the majority of respondents (89 percent) indicated that increased patient safety is the “top” quantifiable benefit. Improved communication with pharmacy and nursing was a distant second at (18 percent) and better documentation was third (14 percent).

Ambulatory EMR

(Source: Ambulatory EMR Report,March 2005) As expected, there has been tremendous growth in the ambulatory EMR market with hundreds of EMR vendors currently offering products to physician practices.Moving forward, we expect to see continued growth in this sector with increased competition, vendor solutions or strategies that support a wide range of physician office practice sizes (solo practitioners to large group practices), mergers and acquisitions.

As clinician awareness of the benefits of using computers (as a tool to reduce medical errors) increases, more physician offices are looking at an e-prescribing/ambulatory EMR strategy. The ambulatory EMR marketplace offers many choices to physician offices. Each vendor offers unique benefits and challenges, but success in this space will require systems to be easy to use, adaptable both to physician workflow and specialty care areas. Ambulatory EMR systems do offer a wide variety of functionality and may include storage and retrieval of patient electronic charts, histories, schedules, claims and insurance records; capture of coding data at the point of care; workflow management to streamline and eliminate redundant data collection; prescription management, including contraindications; paper document scanning; referral management; electronic orders and results-reporting capabilities; health maintenance reminders and patient education; voice and handwriting recognition capabilities; standardized clinical vocabulary; and wireless point-of-care devices (PDAs or PC tablets).

Vendors in the ambulatory market are capable of meeting the high demands of clinicians and there is evidence of adoption that exceeds that seen in the inpatient environment. Today the ambulatory EMR vendors and products being measured are in relation to physician practice size:

• Over 25 physicians (A4 HealthMatics EMR, Allscripts TouchWorks, Cerner Millennium PowerChart Office, Epic EpicCare EMR, GE Centricity Physician Office EMR, InteGreat IC Chart, LSS [Meditech] EMR, McKesson Horizon Ambulatory Care, Misys EMR and NextGen EMR);
• 6-25 physicians (A4 HealthMatics EMR, Allscripts TouchWorks, Amicore Penchart, CHARTCARE EMR, GE Centricity Physician Office EMR, Greenway PrimeSuite Chart, Misys EMR, NextGen EMR, PMSI Practice Partner EMR and WebMD Intergy EHR & OmniChart);
• 1-5 physicians (A4 HealthMatics EMR, Companion EMR, eClinicalWorks EMR, GE Centricity Physician Office EMR, Greenway PrimeSuite Chart, JMJ EncounterPRO,MediNotes Charting Plus, Misys EMR, NextGen EMR, PMSI Practice Partner EMR, VitalWorks Intuition EMR and WebMD Intergy EHR).

E-Prescribing

Studies indicate that physician offices are not interested in standalone e-prescribing systems, but are seeking an integrated EMR solution that includes one integrated database and e-prescribing functionality, including drug-to-drug and drug-to-allergy interaction checking (Source: E-Prescribing/Ambulatory EMR Perception Study, March 2005). In a recent study, 60 percent of survey respondents have already chosen an e-prescribing/ ambulatory EMR strategy and decision points of feature/function and sole source were the key drivers in choosing the system. Of the 40 percent of respondents who had no e-prescribing/ ambulatory EMR strategy, 43 percent indicated that 2005 will be the year to determine their strategy. The top eight e-prescribing vendors most often considered by survey respondents were: A4, Epic, GE, IDX,McKesson, Misys, NextGen and WebMD. Large physician practices are more likely to have an e-prescribing/ ambulatory EMR strategy than smaller practices. Based upon survey results, the e-prescribing/ambulatory EMR market is healthy, is growing and vendors are ready to provide systems to meet physicians’ needs.