Will the ED open doors for order entry?

A hospital’s emergency department is frequently the initial point of entry for patients. It may also be the first place a computerized provider order entry (CPOE) system arrives in a medical facility.

Hospitals face pressure to adopt CPOE technology, which is notoriously tricky to deploy. Stage one of the government’s “meaningful-use” criteria calls for hospitals to handle at least one medication order electronically for 30 percent of its patients. Reaching that threshold determines whether hospitals qualify for incentive dollars under the meaningful use initiative.

Yet CPOE could prove a stumbling block on the path to the stimulus funding. Late last year, a College of Healthcare Information Management Executives (CHIME) survey of healthcare CIOs cited CPOE as “one of the more difficult objectives to achieve.”

Against that backdrop, some healthcare providers and consultants point to the ED as a gateway for introducing CPOE.

“We have found that the ED is a great place to start with CPOE,” said Dr. Reid Conant, an emergency medicine physician who practices at Tri-City Medical Center in Oceanside, Calif.

Tri-City is something of a CPOE veteran. The hospital went live with Cerner Corp.’s Millennium healthcare information system in 2004, beginning its deployment in the ED. But Conant said other hospitals are also subscribing to the ED-first approach. In addition to his ED duties, he runs a health IT consulting firm and has worked on a dozen CPOE projects over the past three years.

“A number of hospitals have directed their focus to the ED,” he said.

A boost from the ED certainly wouldn’t hurt the CPOE field. The Leapfrog Group, a coalition that advocates for healthcare safety, reports that 13.2 percent of hospitals have fully met the organization’s standard for CPOE implementation. A decade ago, that figure stood at 2.3 percent, according to Leapfrog. It’s an improvement, but one that still leaves plenty of room for greater adoption.

Indeed, hospital associations and other healthcare groups have expressed concern that the majority of hospitals are not quite ready to meet the CPOE requirement, noted Jennifer Covich Bordenick, chief executive officer of the eHealth Initiative, a non-profit organization that seeks improvements in healthcare quality, safety and efficiency through the application of IT.

“We’ve seen hospitals in all different stages of adoption across the country,” she said. “Some are ready for it and others are farther behind.”

The Case for the ED

Why incubate CPOE in the ED? For one, healthcare executives say ED physicians are accustomed to change and, therefore, more accepting of new ways of doing things. Cultural issues loom large in CPOE implementation. More than half the CIOs who described CPOE as a challenge cited “getting clinical staff to use the system” as their biggest concern, according to the CHIME study.

“By nature of our practice, we are dealing with unplanned challenges—we don’t know what is coming in the door,” Conant explained. “ED physicians tend to be fairly adaptable when it comes to new technology and new practice patterns.”

“The good news is the ED is run by younger people who are very computer savvy,” added Erica Drazen, managing director of the Emerging Practices Group at CSC, a technology solutions provider.

In addition, Drazen said the ED, as a unit distinct from the rest of the hospital, provides a stable setting for CPOE. “It’s a nice, isolated environment—a great place to start a CPOE rollout.”

Conant agreed that the ED is a more manageable environment. Departments, he noted, typically operate a handful of physician workstations, and those are typically stationary as opposed to moving throughout an entire hospital. Tri- City has 12 workstations, while six to eight devices are typical of other EDs, Conant said. The low device population reduces hardware and workflow issues associated with a CPOE project.

Government policy provides another reason to lead with the ED: Deployment in this one department can go a long way toward satisfying meaningful-use requirements for CPOE. Conant said Tri-City’s ED sees more than 70,000 patients a year, which is more than 30 percent of the patients that come through the hospital annually.

For many facilities, the ED “is a large chunk of the 30 percent, if not all of it,” Conant said. CPOE deployments aimed at hospitalists (internal medicine specialists who coordinate patient care with a primary care physician) or pulmonary critical-care groups can also contribute to meaningful use objectives, he noted.

The inclusion of the ED in the meaningful- use calculus is a relatively recent development. The government’s proposed rules for meaningful use didn’t include incentives to deploy health IT in the ED. The final rule, however, included the ED, and further clarification late last year from the Centers for Medicare and Medicaid Services confirmed that hospitals can count all ED visits toward meaningful use or just those involving observation services.

“The average emergency department sees twice as many patients as a hospital,” said Dr. James McClay, associate professor at the University of Nebraska Medical Center and chair of the American College of Emergency Physicians’ emergency medicine informatics section. “If you issue an electronic order on each of those, you could be covering a significant amount of patients.”

Ways to deploy

In the past, hospitals that automated ED order entry purchased specialized, department-specific packages that included CPOE. A purchasing decision was based on a product’s ability to satisfy ED workflow needs “without regard for its interaction with the hospital side,” noted Dr. Rick Mansour, chief medical information officer at Allscripts.

The same thinking held true for other hospital departments as well. Mansour said pharmacy and nursing documentation systems were also standalone affairs a decade ago. “It was the rise of best-ofbreed, niche systems,” he said.

Today, some inpatient electronic health record (EHR) vendors offer enterprise- wide CPOE solutions that include the ED. Drazen said most if not all hospitals want to migrate toward one integrated solution. But the timing of such a move, she added, depends on a handful of factors: the availability of a robust solution from a hospital’s primary EHR vendor, the level of satisfaction with the current ED system, and budget.

Lutheran Medical Center in Brooklyn, N.Y., went through that type of analysis. The hospital planned to install Medsphere Systems Corp.’s OpenVista EHR system, which includes CPOE. But it was already running the EmpowER ED system. So the decision came down to using OpenVista house-wide or interfacing EmpowER to OpenVista, which is the open-source version of the Department of Veterans Affairs’ VistA EHR.

Claudia Caine, the hospital’s chief operating officer, said the facility opted to scrap EmpowER, even though it was happy with the product, and deploy a single, integrated solution.

“We wanted interoperability and wanted the connectivity of one seamless medical record,” Caine said. “Having to interface EmpowER…posed a lot of challenges we didn’t want to face.” OpenVista also appealed to the hospital as open-source software, she added. Lutheran Medical Center went live with the solution in November.

Tweaking for the ED

The integrated approach, however, may call for some tweaking on the ED side. Lutheran Medical Center found it needed to re-create ED functionality in its new system that it previously had with EmpowER.

“We couldn’t strip the emergency room of EmpowER without replacing all of its lost functionality,” Caine said. “The VistA system in the VA didn’t really have a full ER system and we had to do a lot of work…before we went live.”

The hospital collaborated with Medsphere to develop features, including a tracking board, which Caine described as the ED’s air traffic control system. The board keeps tabs on patients in the ED, using a large flat panel display. Clinicians also consult the board on terminals in the ED. Medsphere will share the tracking board feature with other customers via the Medsphere-sponsored Healthcare Open Source Ecosystem, according to the company.

Hospitals may also have to create order sets to use with a new ED system. Liberty Hospital in Liberty, Mo., switched from paper-based order entry to a CPOE system from Eclipsys Corp. in 2008. As part of the transition, the hospital’s ED and clinical analytics department developed order sets, keeping the workflow similar to what physicians were accustomed to doing with the manual system, said Dr. Brent Carlson, an emergency medicine physician at Liberty Hospital. The hospital also incorporated orders sets from Zynx Health, a clinical decision support vendor.

EHR vendors, meanwhile, have been working on CPOE-in-the-ED functionality. Mansour said IT vendors need to address ED-specific workflows to accommodate the needs of emergency medicine. Typically, orders in a CPOE workflow go from physician to pharmacy to medicine administration. But the ED workflow, he said, skips the pharmacy step, so the order goes straight from the physician to an automated medicine dispensing machine.

Mansour said systems developed by Allscripts and Eclipsys have made such ED adjustments over a period of years, working with its hospital customers. Allscripts acquired Eclipsys in 2010.

“Clients help you in the design and development of those workflows,” he said. Better systems should make it easier for hospitals to deploy CPOE in the ED—and that could better their prospects for meeting meaningful use targets.

Those targets will become harder to hit in the coming years. Bordenick said the automated order threshold will increase to 60 percent of hospital patients in stage two of meaningful use and is projected to reach 80 percent in stage three. “It’s going to get tougher and tougher,” she said.

And the contribution of the ED will become increasingly important.

No ED is an island

A large proportion of hospital admissions comes through the emergency department—more than half in some facilities—and that drives interest in unified EHR/CPOE solutions. In some inner-city hospitals, elective surgeries represent the exception rather than the norm. At Brooklyn’s Lutheran Medical Center, 60 to 65 percent of the hospital’s admissions arrive via the ED, said Claudia Caine, the center’s chief operating officer. That situation contributed to the hospital’s decision to pursue a single EHR and CPOE solution, rather than treat the ED as an island of automation. “Having the emergency room…seamless with the rest of the hospital’s medical records was essential,” Caine said. Having clinical information flow through the same system affords consistent access to information. Dr. Reid Conant, emergency medicine physician at Tri-City Medical Center in Oceanside, Calif., cited that as a benefit of the hospital’s enterprise-wide Cerner Corp. system. “The data is available in a structured format,” he said. “It is in the same system, so providers have immediate access.” One alternative to the single solution is creating an interface between the ED system and the hospital’s clinical information system. But that scenario could compel physicians to retrieve data in a format they are less able to manipulate, Conant said.

Click on ED and CPOE to access the original article.