Computerized provider order entry improves workflow and outcomes

Automation of prescribing practices reduces medication errors. Cincinnati Children’s Hospital Medical Center (CCHMC) is a 370-bed tertiary care hospital serving approximately 550,000 children in southern Ohio, northern Kentucky, eastern Indiana, and western West Virginia. Children at CCHMC benefit from multiple centers of excellence that offer advanced services, such as heart care, organ transplant, blood and marrow transplant, newborn intensive care, and aerodigestive treatment. In 1998, CCHMC participated in the Child Health Accountability Initiative on Medication Errors, in which a pediatric multisite consortium collected data and identified significant opportunities for improvement and reduction in medication errors related to prescribing practices. Based in part on this study, CCHMC determined that automating and integrating computerized provider order entry (CPOE) and clinical documentation applications would greatly enhance patient care and the clinical workflow of all care providers. CCHMC’s clinical documentation team chose the INVISION® system from Siemens Medical Solutions Health Services Corporation as its Integrating Clinical Information System (ICIS). The components of this electronic platform include a Web-based portal, CPOE, clinical documentation, medication/I.V. charting, rules engine, and a longitudinal clinical repository. A picture archiving communications system, additional homegrown Web portals, and a data warehouse system work in conjunction with ICIS to provide a comprehensive electronic healthcare record (EHR). CCHMC achieved successful ICIS implementation through analysis and improvement in its underlying processes, combined with a sound technical and project-management approach. In recognition of its efforts, CCHMC received the 2003 Nicholas E. Davies Award for advances in EHR implementation. Implementation The functional design of ICIS is comprised of two major applications: CPOE and clinical documentation. CPOE includes all inpatient care orders and uses approved procedure and diagnosis-based pediatric order sets. With patient safety as the driving force behind the project, the clinical order entry team employed pediatric-driven standard decision-support tools such as drug allergy, duplicate orders, therapeutic drug duplicate, and drug/drug interaction checking. Clinical documentation applications include medication/I.V. charting; vital signs; heights/weights; allergy, physical, and admission histories; intake/output records; I.V./central venous catheter assessments; pain assessments/reassessments; online charging for I.V. and enteral pumps; and nutrition, speech, and physical therapy/occupational therapy screenings. To enhance patient care and staff communication, the clinical documentation team developed age-specific nurse-to-nurse orders, which allowed nurses to select orders based on a patient’s developmental age. The system, which guides care delivery, generates a nursing worklist that contains patient demographic information and all care orders. CPOE and clinical documentation integration resulted in the medication/I.V. charting directly linking medication ordering, dispensing, and administration—reducing CCHMC’s transcription errors. Previous internal and published data indicated that these errors represented 15% of all CCHMC medication errors, which have since been eliminated. One safety feature particularly worth highlighting is dose-range checking. Due to the lack of commercial dose-reference data for children, CCHMC spent years researching and compiling an internal reference database that includes the most often ordered and high-risk inpatient drugs from birth to 18 years. These efforts paved the way for the development of a dose-range checker that includes 11 different checks for appropriate pediatric dosing. To date, ICIS hosts 285 order sets—including 27 best-practice guidelines; 28 blood and marrow transplant (BMT), 39 oncology, and 19 hematology active sets; with approximately 200 sets in development. Order sets are organized by department and subgrouped by division. Individual provider order sets aren’t used, as CCHMC focuses exclusively on evidence/consensus-based approaches to care. (See “Categories of knowledge-based prompting within the ICIS system.”)TABLE: Categories of knowledge-based prompting within the ICIS systemClinical documentation supports the initiation of pain management education and assessment upon admission. In the comfort category of the admission history, the screen lists questions that prompt the nurse to select a pain scale tool appropriate for the patient’s developmental age. The comfort screen links to the online pain management policy as a decision-support tool. To ensure completion of the initial pain assessment on admission, the physical assessment pathway includes a link to the pain assessment function. Using the rules engine application, nurses are prompted on patient selection when pain assessment documentation standards related to initial assessment or postintervention aren’t met. The admission history also offers nutritional and functional screenings, with various alerts that display if entered selections result in a failed screen. The results of these screenings appear on the nursing worklist and health care provider displays. The admission history information carries from case to case for a 180-day period, providing heightened documentation efficiency and user satisfaction, since system users don’t have to enter data multiple times. Results A multidisciplinary clinical informatics outcomes research group examined the impact of ICIS through targeted hypothesis-driven research projects. ICIS has been instrumental in helping CCHMC demonstrate improved clinical outcomes, including: ♦ 100% compliance with pain assessment documentation requirements ♦ 52% improvement in medication turnaround times ♦ 50% reduction in all medication errors ♦ 24% reduction in verbal orders for controlled substances ♦ 20% improvement in care consistency for those diseases/diagnoses for which order sets are available ♦ reduced clinician/service provider pages/phone calls to clarify orders ♦ eliminated medication transcription errors. Since implementation, 100% of inpatient orders—except BMT/oncology/hematology orders (approximately 3,000 orders a day)—are placed in ICIS by attendings, resident staff, and advanced practice nurses, with verbal orders placed by other licensed professionals. Care providers enter documentation into ICIS in all departments except BMT/oncology/hematology. Future projections The second phase of ICIS included system expansion to the hematology/oncology departments and clinic in December 2003. This rollout included the first CPOE and clinical documentation implementation in the outpatient arena. The clinical documentation team recently implemented shift-to-shift assessments, discharge planning, a multidisciplinary plan of care, progress notes, and education record. The multidisciplinary approach taken for phase two significantly changed documentation practices across disciplines, including occupational therapy/physical therapy, speech, audiology, social services, child life, respiratory therapy, and nutritional support. Anticipating the outcomes of this initiative, the team is confident that merging process and technology will result in enhanced patient care and increased patient and family satisfaction.