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Patient safety improves with new program

by George Spain
Information Services
A new clinical information system project will help close the loop in protecting patients from medication errors.
The Cardiology Service and 3W Ashley River Tower (ART) nursing unit recently launched a computerized program called Computerized Physician’s Order Entry (CPOE). The program, acting in concert with other modules in the extensive patient-focused eCareNet project, will check patient medications from initial orders to delivery.
“This is what we’ve been working toward for years, a patient-focused, computerized checks and balances system to reduce adverse drug events,” said Frank Clark, Ph.D., chief information officer and vice president for information technology.
“CPOE closes the loop that begins with a physician’s orders, moves through to pharmacy assembly on to floor delivery, then finally to a health care worker administering the medicine,” said Melissa Forinash, director of support services in the Office of the CIO (OCIO), and one of the projects leaders. “A number of information services (IS) personnel have been involved in rolling out various eCareNet modules, including Clinical Documentation, AdminRx, and now CPOE.”
With CPOE, a physician enters initial orders into the computer, which are then sent to a Central Data Repository (CDR) and on to the departments, which will fulfill the orders or request for service. Orders to connected departments, such as radiology, pharmacy, and laboratory services, flow immediately to those systems. Non-automated departments receive printed requisitions.

For example, a physician may order medications, lab work or X-rays which are then sent electronically to the appropriate provider.
Many parts of the eCareNet system have been around for years. CPOE also closes the loop by adding a physician’s direct orders in a
concise manner. This helps overcome some of the biggest causes of medication errors due to inaccurate translation of handwriting or confusion in verbal orders. 
Orders entered in CPOE go to the pharmacy’s eMeds system (completed in 2006). The pharmacy then fills and barcodes the order (by law each is visually checked by pharmacist) and sends the medication to the patient’s floor. A health care provider then checks the medication’s barcode against the patient’s wristband barcode where another part of the eCareNet system called AdminRX (completed in October 2007) checks meds against the initial order and the nurse is able to document the medication as administered. The information is then forwarded to the data repository.
Using eCareNet Viewer, the entire process can be accessed by the physician or other health care workers to check on the progress of the patient.
Currently, CPOE is fully established in 3W ART unit. Plans call for the system to be rolled out to the remaining non-critical care units in ART by the end of this fiscal year. CPOE helps reduce medication errors by ensuring that the five rights of patients are met: right patient, right medication, right time, right dose, and right route.
Getting it wrong is costly in terms of human suffering and a hospital’s bottom line. Studies have concluded that medication errors occur frequently and represent a  significant portion of increased hospital costs. The authors estimate hospital costs increased by $2 billion nationally due to preventable adverse drug events for inpatients. As a result of increased attention to medical errors, many institutions are contemplating increased use of information technology and clinical decision support, according to the American Medical Informatics Association in 2002.
CPOE is MUSC’s approach to solving this problem.
Medication orders are processed and new medications are delivered to the patient faster. CPOE results in savings by reducing paper and ink consumption, which also contributes to a reduced environmental impact.

The people
Along with a good plan, it takes good people to rollout a major information system like CPOE.
The IS teams included Lucy Arnold, Amy Charles, Vicki Dibble, Jim Early, Melissa Forinash, Angela Locke, and David Strange. Chris Alexander and Krista Moloney helped develop computer-based training programs and classroom sessions.
In addition, Jennie Holt from pharmacy and Timothy Hartzog, M.D., from the Department of Pediatrics worked on the project nearly full time.
Nurse managers Jennifer Minick, R.N., and Melissa Meara, R.N., for 3W were important contributors to the workflow discussions and planning as were members of Bonnie Foulois’s nursing informatics team. Eric Powers, M.D., physician service line leader for heart and vascular services, was a supportive advisor to the project.
A small physician advisory group consisting of John Waller, Larry Afrin, Hartzog, Jim Madory, and Ken Spicer provided design and workflow input and helped make recommendations to the overall CPOE steering committee, chaired by Pat Cawley.

The project
A project the size of CPOE requires a planning, management, and cooperation between the clinical workers who will  use the system, and the information services staff and field engineers who assemble the necessary computer technology.
Mark Daniels, the Information Services Patient Care Systems manager and one of the leaders in the project, attributes the initial success of the rollout to a change in the way IS approaches computerized clinical systems.
“It used to be that a department would come to us with a plan or with some hardware and we [IS] would begin programming to meet the original specifications. Things would never seem to work out right, because specs would always change,” Daniels said. “We really didn’t know what they wanted when we started, we only knew what they asked for.

“From the beginning, CPOE was different. IS and clinicians formed parallel teams to analyze the needs, draft the reports, and monitor progress milestones,” Daniels added. “There would be no finger pointing if the project got stuck, we were all in it at every step of the way.”
Daniels attributes part of the on-track success to formalized project management (PM).
PM is a structured method of approaching large undertaking by formalizing the approach to resources, time, money, and scope in a way that each member of the teams knows where the team is at any point.
Dan Furlong is the PM officer for OCIO and the main instructor in MUSC’s Project Management 101 course. Furlong was an important advisor to the CPOE project, overseeing progress and helping out team managers, Daniels said.
“I served alongside the eCareNet program manager with enough distance from the project that I could provide a different vantage point regarding issues and risks. But the real work was being done by our project teams,” said Furlong. “CPOE’s success is a testament to what properly focused teams can accomplish.
“Our office serves as a consultant to help MUSC project teams prepare plans, review project performance, and facilitate meetings. We also provided training to the team members, sometimes formally, and sometimes on the job.” said Furlong.
In the PM 101 course, Furlong, a state certified PM, combines multimedia presentations with hands-on exercises and group activities. The course includes PM terms: framework, fundamentals, project life cycle, roles, responsibilities, expectations of stakeholders and team members, risk assessment, and software development lifecycle.

CPOE Nursing Informatics Department
by Faye Wimberly
Nursing Informatic's Team works 24/7 to prepare and teach classes for all new Information System program implementations, including Computerized Physician’s Order Entry (CPOE). Team members are always on call to help users work through any problems with the new system.

RN Application Trainers include, Beth Ansel, Wanda Brown, Sharon Harris, Janice Hazy, and Andy Roche. The trainers recently wrapped up shooting an educational film on proper patient armband and medication scanning techniques and clean up procedures.

RN Applications Support is provided by, Dan Gracie, Nancy Hilburn, Jo Evans, Shawn Lanham, and Terri Roberson.


Nov. 14, 2008

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