The Good, The Bad And The Ugly of HIT August 2008 David C Classen, MD, MS University Of Utah and CSC

2 Leapfrog CPOE/EMR Flight Simulator “Anyone here know how to play Microsoft’s Flight Simulator?”

3 Leapfrog CPOE/EMR Flight Simulator: Published Articles

4 Acknowledgments Funding in Phase 1 – California Healthcare Foundation – Robert Wood Johnson Foundation Funding in Phase 2 – Agency for Healthcare Research and Quality Project Staff – Core FCG Team: David Classen, Jane Metzger, Emily Welebob, Fran Turisco, and Peter Kilbridge – Primary Advisors: David Bates, Mark Overhage, Allen Vaida, Stuart Levine, Andy Spooner, Mark Frisse, and Paul Nichol Supporting Organizations

5 Why is a Tool Like This Needed? More than one million serious medication errors occur in US hospitals; many are life threatening CPOE systems with proactive use of decision support tools are recognized as one important investment to help avoid preventable medication-related adverse events Implementing decision support is a multi-year project in any hospital using CPOE Until now, hospitals have not had the ability to test how well their CPOE systems are catching common, serious prescribing errors New Studies Suggest CPOE/EMR Implementations can cause harm

6 Can CPOE Cause Errors? (2005)

7 Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System Scott Watson, Trung C. Nguyen, Hülya Bayir and Richard A. Orr Yong Y. Han, Joseph A. Carcillo, Shekhar T. Venkataraman, Robert S.B. Clark, Richard A Orr. Pediatrics 2005;116;

8 Leapfrog is an initiative driven by organizations that purchase healthcare to improve safety, quality, and affordability. The Leapfrog Group Focus has been on hospital-based care to date –Intensivist coverage in ICUs –Computerized physician order entry (CPOE) to reduce serious medication ordering errors –Evidence-based hospital referrals –NQF Safe Practices Leapfrog’s Call for Ambulatory Healthcare IT Safety Features: –An electronic health record (EHR) –Prescription checking to avoid preventable medication- related adverse events –Basic disease and wellness management prompting

9 What is the Leapfrog CPOE Standard? Physicians enter at least 75 percent of medication orders via a computer system that includes prescriber-error prevention software. Demonstrate that their inpatient CPOE System can alert physicians to at least 50 percent of the common, serious prescribing errors using the Leapfrog CPOE Evaluation Tool.

10 Leapfrog CPOE Testing Standard Complements Other Initiatives CCHIT (“on the shelf”) –Certification of vendor EHR products Ambulatory, Inpatient, + new areas of Child Health, Foundation, ED Pay-for-Performance Initiatives (“outcomes of IT and QI”) –IHA, BTE, Others –Ambulatory clinic site-specific reporting of select EHR functionality National Quality Forum (“after implementation”) –Hospital safe practices survey Voluntary hospital site-specific certification Includes several aspects of EHR including Safe Practice #12 CPOE Now directly linked to Leapfrog CPOE Standard Leapfrog Group (“how implemented software is contributing”) –Voluntary reporting with site-specific scoring Hospital evaluation Physician practice evaluation

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12 What is the CPOE/EMR Evaluation Tool? The Computerized Physician Order Entry (CPOE) Evaluation Tool is embedded in the Leapfrog Hospital Survey A remote simulation test of a hospital's CPOE system Provides hospitals feedback on how well their CPOE system alerts users to common, serious prescribing errors

13 Purposes of the Evaluation Purchasers The Public How far along is this organization in using CPOE or ambulatory EHR to help improve medication safety and quality? Hospital and Medical Practice Leadership Now that we have implemented CPOE or ambulatory EHR, how well are we doing in using it to help avoid harm and improve quality? The Leapfrog Group needed a way to evaluate how software is actually being used from two perspectives. How will we know if we are meeting these standards?

14 Principles Behind the Evaluation Methodology Principle #1: Target the Harm –Common sources of ADEs (not errors) –Sources of severe harm (existing literature and expert consensus) Principle #2: Encourage Quality Improvement –Categorize test set by type of error –Provide feedback to the provider organization for each category –Provide advice about nuisance alerting Principle #3: Accentuate the positive –Encourage quality, as well as harm reduction (ADEs) Address errors of commission and omission Include corollary orders and duplicate interventions

15 Development of the Tool Tool developed by First Consulting Group with assistance from patient safety experts and the Institute for Safe Medication Practices Developed and then tested in numerous hospitals and ambulatory clinics in Ambulatory Tool also developed to be released in 2009 Pilot tested with seven hospitals in Spring 2008 (5 adult/general hospitals; 2 children’s hospitals) –Tested the tool with systems from all of the common CPOE vendors

16 How Does the Tool Work? Hospitals download a series of test patients and test orders –Sample test –Actual evaluation The test orders are entered into the hospital’s CPOE system (usually test system) for the test patients Hospitals record system responses on an answer sheet and report those responses on the tool website The evaluation tool compares responses and calculates how many times the implemented decision support helped to avert a potential adverse event

17 How Does the Tool Work? [cont’d] Timed test –Four (4) hours to download patients and enter patients and their characteristics into hospital CPOE system –Two (2) hours to enter medication orders, record system responses, and enter responses into the scoring sheet on the tool website –Hospital generally find these time limits to be generous Hospitals receive back a report with: –Score for each test category (see scoring details for descriptions) –Overall score on test –List of missed orders that could cause severe patient harm Deception analysis & nuisance orders have been incorporated into test

18 What types of test orders? Order CategoryDescription Therapeutic duplicationMedication with therapeutic overlap with another new or active order Single and cumulative dose limits Medication with a specified dose that exceeds recommended dose ranges or cumulative dose AllergiesMedication (or medication class) for which patient allergy has been documented Contraindicated route of administration Order specifying an inappropriate route of administration Drug-drug interactionMedication that results in known, dangerous interaction when used in combination with a a new or existing ordered medication Contraindication based on patient diagnosis Medication either contraindicated based on patient diagnosis or diagnosis affects appropriate dosing Contraindication based on age and weight Medication either contraindicated for this patient based on age or weight or for which age and weight must be considered in appropriate dosing Contraindication based on laboratory studies Medication either contraindicated for this patient based on laboratory studies or for which relevant laboratory results must be considered in appropriate dosing CorollaryIntervention that requires an associated or secondary order to meet the standard of care (e.g., monitoring) Cost of careTest that duplicates a service within a timeframe in which there is typically minimal benefit from repeating the test

19 Web-Based Evaluation Tool Testing Flow Score Generated Against Weighted Scheme Program Patient Criteria Enter Orders into CPOE Application & Record Results Download and Print Test Orders Hospital Self Reports Results on Website Report Generated Obtain Patient Criteria (Adult or Pediatric) Aggregate Score to Leapfrog Category Scores Viewed by Hospital Score Generated Against Weighted Scheme Program Patient Criteria Enter Orders into CPOE Application & Record Results Download and Print Test Orders (HM if AMB) Hospital Self Reports Results on Website Report Generated Obtain Patient Criteria (Adult or Pediatric) Hospital Logs-On (Password Access) Hospital Logs-On (Password Access) Aggregate Score to Leapfrog Order Category Scores Viewed by Hospital Review Orders and Categories Review Patient Descriptions Review Scoring Hospital Logs-On (Password Access) Complete Sample Test -

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28 CPOE Evaluation Tool – Scored Results, Sample

29 CPOE Evaluation Tool – Scored Results, Sample (cont’d)

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Logistics of the Tool

32 Which Hospitals Can Access the Tool? Hospitals must first indicate in the Leapfrog Hospital Survey they have a CPOE system in place in at least one unit of the hospital (CPOE Q#1 = YES) Tool is not accessible or usable to hospitals that have not implemented CPOE in at least one unit (it just doesn’t work!) – or to US hospitals who do not participate in the Leapfrog Hospital Survey

33 Accessing the Tool Hospitals access the tool from the Leapfrog survey homepage On the left-hand side of survey homepage (“Go to CPOE Evaluation Tool”) Hospitals use same security code for CPOE tool as Leapfrog Survey If hospitals do no have a security code, the website has instructions on how to get one

34 Before you Start Very detailed instructions have been provided - read them completely through and very carefully before you start Hospitals will need a small team of individuals to conduct the test (suggested areas of expertise listed in instructions) Sample test is provided – TAKE ADVANTAGE (has smaller number of patients and pharmacy orders, but same 4 hr/2 hr time limits and will help you understand who needs to do what) For credit, adult/general hospitals need to complete the adult test; children’s hospitals complete the Peds test Reminder: Timed test!!! Advanced planning is crucial!

35 Help Desk Support If need assistance during test, click on “Leapfrog Helpdesk” on left-hand side of CPOE tool homepage: Includes an ability to indicate “test underway/immediate help needed” Help desk response time may be hours, not minutes. So advanced planning and taking sample test is critical. Please do not wait until the end of June to complete the test! Can not guarantee that your questions will get answered in time to complete test by deadline.

36 CPOE Tool Website Resources Instructions Scoring Description CPOE Evaluation Tool FAQs

37 Scoring for 2008 Hospitals must complete the test to achieve either Fully Meets or Good Progress on the CPOE Leap in 2008 In the 2008 survey, scored results will not be used, only the fact that the hospital tested its system. In 2009, scores from the test will be used.

38 CPOE Evaluation – Impact on Overall CPOE Score 2008 survey cycle: successful completion of test is the only requirement for credit in CPOE overall score 2008 survey scoring algorithm: –Fully implemented: CPOE implemented, 75%+ IP orders, and appropriate* test completed –Good progress (3/4): CPOE implemented, <75% IP orders, and appropriate* test completed –Good early stage effort (1/2): CPOE implemented OR Selecting/implementing, written strategy, budgeted, champion –Willing to report publicly (1/4): Completed CPOE section of survey 2009: Leapfrog will release results of test, scoring criteria TBD * Adult inpatient test for adult/general hospital (pediatric test optional); pediatric test for children’s hospital

39 Clarifications Hospitals must wait six months to repeat the test Hospitals can use a mirror or “test” CPOE system, but the system has to match exactly Hospitals in multi-hospital health systems all need to take test, even if all have a “common” CPOE system

Questions?