A Post-Live CPOE Implementation Debriefing
By Rich Mach
In an effort to assist you in a smoother CPOE implementation, I have outlined some
observations and tips that helped me in a recent Siemens Physicians View Starter Set
implementation.
A) Challenges to the implementation process:
1. Upgrade:TIF interface to Siemens Pharmacy.
Prior to really beginning the Pharmacy portion of the install,
we took the extra time to upgrade to the newest version of the Pharmacy application
and interface. I believe that this work up front paid off in the long run
because this allowed the hospital to utilize the full benefits of the expanded Siemens
Allergy functionality. In addition, the Pharmacy upgrade made loading of the
CVE much cleaner since the Service Master and PDM was already reconciled as part of
the upgrade process.
2. Build in enough time for order set completion.
Even after receiving Order Sets from the departments, there must be a review and
spec process prior to the build phase. It is ideal to engage core team
clinicians to devote some time to this task. Set a date after which only
minimal changes can be made to the Order Sets. Without a “freeze
date” those continual revisions can bring the specification portion of the
build to a halt.
3. Optimize system performance and time out issues with OAS Gold &
Net Access. Make sure that the “Physician Design
Team” agrees on a time out level and subsequently communicates their acceptance
of this to other physicians. Do a system performance assessment. If you
do it in Test, place a load on the Test System that accurately reflects what
happens in Production. At my facility there were system response issues on the
hour several times a day. We worked with Siemens to find and eliminate the
cause of these slowdowns. We would have been better served to find and resolve
the issue in Test.
4. Re-engineer clinical workflow. Changes
to clinical workflow are bound to happen. Unit Clerks and Nursing will be
affected as much as, if not more than, Physicians. Take the time to do a
current workflow analysis at the start of the project. Document the process.
Once the building has begun, make sure that Nursing Administration is
involved in design meetings. Help them plan ahead for the inevitable fall out
of the changes.
5. Eliminate "moving target" of desired results (screens,
reports, procedures, etc...). At some point in time,
the code needs to be locked down. That seems to be a difficult concept for
clinicians to grasp. Make sure that they understand, up front, that there is
a hard and fast deadline for changes prior to integrated testing. Otherwise you
run the risk of a system in flux in the critical training and testing stages.
Helping them to see the ramifications of repeated training of their staff will
make dollars and sense.
6. Location, Location, Location. Being physically located apart
(different buildings) from the clinicians and teams is pretty much standard in any
healthcare setting. This location issue makes it difficult
for meetings and smooth communication. It is a good idea to make sure that a PC
and projector are available for every meeting. This helps to provide
illustrations of concepts as you discuss them. Assigning someone to take notes
will eliminate later frustrations and help make everyone more comfortable with the
results of those meetings.
7. Choose realistic timeframes. Be careful of arbitrary deadlines and Live dates. If the final product is rejected by physicians because of system / application issues, it will take longer to get them back on board. Better to take the time up front necessary to gain consensus and increase your chances of a successful outcome.
8. Reduce Internal politics (department vs. department). This is always a problem in any project. CPOE tends to be a high profile project and so the players are higher in status and will demand more. Increasing communications, cross functional core teams and support from the highest ranking officials will surely mitigate the pettiness of internal politics.
9. Work diligently to get clinicians accustomed to using browse functionality. If a particular test is not on the common list displayed when a clinician selects a department or sub-department, the question is asked, “Where is ………. Test?” Teaching a clinician to use the whole department browse function is a challenge. The tendency is to want everything on the common list, which defeats the purpose. When they see the results of the limited common list and the ease of the browse function, you can be sure they will use it again.
10. Pay “special” attention to specialty function building, IVIG, Antibiotic ordering, TPN, pain service orders, protocols. Review and verify specialty items needed for any unit you are bringing Live. If you don’t need them for that unit, hold off on building them. Take extra time to make sure that all of the complexities have been discussed and taken into account. At my facility, we decided to leave TPN out of our pilot unit and add it as other units went Live. The complexities of ordering and administering TPN were thought to be a better phase 2 item. Sometimes getting a more vanilla system up and stable then adding more complex protocols leads to successful results.
11. Keep up with the demand for order set revisions once initially created. Lack of sufficient detail (from a lay perspective) on some order set forms requiring need for repeated phone calls to clinicians while coding forms. Again, this goes back to making sure that everyone understands and knows the deadlines and is communicating properly. Having a good clinical liaison is very important for exactly these kinds of issues. Make sure that the clinical teams understand the time commitment needed to bring an application like this on line. Clinical staff will need to be involved with the design and building of the pathways, the set-up of the CPOE profiles, the design and implementation of the order sets, and the testing and training of the application. This is a major time commitment, for two or more clinicians, for an extended time period.
12. Remember differences in types of clinical access (IE: MED Students) and access in general. In my situation, we were lucky that the residents and PA’s were licensed to order the same as staff physicians. But Med Students would need to be treated in a different manner. The other factor to consider when going Live, unit by unit, is how to restrict access to only those clinicians treating patients on those floors Live with the application. The plus with a web based system is that clinicians can sign on from anywhere and place orders, so you can’t restrict to terminal ids. All of the solutions, different views, different sign-on TCLs or logic based on sign-on id, present their own maintenance issues. Security and access can make or break a successful CPOE live.
B) Keys to our successful implementation:
1. Hold validation sessions - interactive programming changes.
Hold weekly meetings with the physician and nursing design teams to
show them the progress of what is being built and get their assessment of the
functionality. If you can incorporate an “approval” process in
these meetings, so much the better. This process was designed to include the
clinical area department heads and clinicians specializing in the design of the
pathway. When we had a rough pathway put together for respiratory orders, we
brought in a Pulmonologist and the head of the Respiratory Department to review the
pathway and make suggestions on how the pathway could be improved. After a
couple of short meetings, the Respiratory Department head as well and the physician
design team, signed off on the pathway. We didn’t have to work as hard on
the back end due to the involvement during the process.
2. Anticipate nursing order entry using
Browser Technology. Based on feedback from Nursing
Administration, we added a Nursing View and created Nursing functions specifically
for the implementation of CPOE. Nursing procedures and policies will change
with the implementation of CPOE. It is important to include this up front in
your project planning.
3. Establish a clinical support team.
Have a “physician design team” in place and utilize that team as much as
possible. It not only gives you the clinical expertise to fall back on, but
helps to add legitimacy, in the eyes of the clinical staff, to the pathways and
order sets you build.
4. Create a variety of educational/training
materials and number of training sessions. Try to find a number of different
ways to reach your target audience. We employed demonstrations during weekly practice
meetings, did demonstrations during Grand Rounds, and had an all-day demonstration /
informational fair. All of these methods allowed us to solicit feedback and introduce the
product. To train clinicians, we had formal training classes, set up training days in the
clinician lounges, and had all day sessions on the pilot floor prior to going Live. During
training they were supplied with a training book, and a small “cheat sheet” book of
simple hints and “how to’s/job aide” that could be stored in their coat
pocket. It is crucial to go where the clinicians are and meet with them as their schedule
allows.
5. Provide a plethora of devices. Avoid the
situation where clinicians need to wait to write orders. Count up the estimated maximum
number of clinicians who could be placing orders at any one time and make sure that you provide
enough devices for everyone. We installed 15 new wall units with PC’s just outside
patients rooms and added 5 wireless COWs (Computer on wheels) for clinician order entry use.
This was in addition to the computers at the nursing station. Reducing a
clinician’s ability to use his/her computer is a sure path towards alienation.
6. Dedicate a Pharmacy tester / builder. Many clinicians
indicate that placing medication orders on line is the best thing about the CPOE application.
Thus, it is very important to make sure that this part of the system is flawless.
A pharmacy resource (pharmacist) is very important to that success of this project. Make
sure that you have a resource that will be available at least 50% of the time.
7. Use a pilot approach. It’s hard to imagine
anyone using a “big bang” method to bring CPOE live. By using a pilot unit
you can get real time feedback on the system and make changes so that succeeding units will have
an increasingly smooth experience. Make sure that your pilot unit is sophisticated enough
to help you cover the myriad of the challenges you will face as you bring up other units.
That said, try to estimate the number of order sets you will need to create and take that into
consideration prior to selecting your pilot unit. Try to keep the number of order sets you
need to build down to about 20.
8. Create effective communication between IT, Physicians, Nursing.
Start this early and work hard to include everyone you think will be impacted by
this project. You will be surprised at the breadth of the staff and the resulting impact.
No one will dispute that you can not over communicate on a project of this magnitude.
9. Create documentation and opportunity for training.
We refrained from assigning CPOE Net Access view for a clinician’s ID
until they had been through training. This may seem harsh but sometimes just getting people to
the training table is the hardest part. Once they felt that they had accomplished the base
training and were given their logon’s, they could then us the documentation to complete
their just in time training.
C) Things that were a surprise concerning the implementation / pre-implementation that
we did not anticipate prior to the project.
1. The impact on the Medical Records. The physicians are now
electronically signing their orders, so the physicians felt there was no need to go to Medical
Records to sign the paper record at post discharge. This was a matter of explaining that
this was not a true electronic medical record, so they did indeed need to still sign the paper
record. Also, the Medical Records department needed to create a process for the printing
of orders on a regular basis in order to be placed in the paper chart.
2. The impact on the Ancillary systems, i.e. Lab
(accession #s, canceled orders, etc) This centered around making sure that
orders were interfaced correctly and the correct action was taken. In some instances, where
there was no electronic interface, a manual process of identifying orders and the correct action
steps needed to be worked out with the ancillary department. Dietary and the ordering of
nutritional supplements was another hurdle that needed to be overcome. Diet orders were
not treated as separate orders all the time, so it was necessary to make sure all the data was
interfaced to the Dietary system correctly.
3. Level of resistance from various areas (even some IT ones).
Change is difficult to introduce and embrace. We encountered individuals who wanted to
have the system, but did not want to change any of the business processes involved. We
also had people who wanted to develop more than the scope of the project dictated. This
not only included departments outside of IS, but there was some resistance within IS as well.
For more information, please contact
rmach@getvitalized.com