If Implementing CPOE Were Easy… Every Hospital Would Have One! Greg Kall, CPHIMS Regional Vice President/CIO Cleveland Clinic Health System Cleveland, Ohio

“Despite the considerable benefits, fewer than 2% of U.S. hospitals have CPOE completely or partially available and require its use by physicians.” Why… - The Leapfrog Group CPOE Fact Sheet 4/18/04

Because it’s hard to do!

Today’s Agenda  About CCHS Eastern Region  Acquisition  Planning/Organizing  Application Build  Physician Adoption

About CCHS Eastern Region: Statistics  4 community hospitals near Cleveland  Total registered beds: 1,400  4 separate voluntary community medical staffs with a total of 1,000 active staff members  2004 volumes 466,580 Outpatient registrations 466,580 Outpatient registrations 145,400 ED registrations 145,400 ED registrations 43,900 I/P acute discharges 43,900 I/P acute discharges

About CCHS: Core Technology  Single consolidated IT infrastructure and management  McKesson STAR v 9.0 ADT, Radiology, Pharmacy ADT, Radiology, Pharmacy Single MPI with corporate number Single MPI with corporate number  Cerner “Classic” Lab  eGate interface engine  Softmed Transcription and 3M Encoder in HIS

About CCHS: Our Plan COMMON PLATFORM FOR 4 COMMUNITY HOSPITALS  Clinical Database  Computerized Clinician Order Entry  Results review  Rules and Alerts/MLMs  Documentation MAR, vital signs MAR, vital signs Clinician charting Clinician charting  Pharmacy and medication administration

About CCHS: Deployment Status  Live at 2 hospitals Huron Hospital 7/13/04 Huron Hospital 7/13/04 Euclid Hospital 10/26/04 Euclid Hospital 10/26/04  Functions live: Clinical database Clinical database Orders Orders Results Results Rules & Alerts, MLMs Rules & Alerts, MLMs  400,000 + orders placed electronically to date

What we discovered …  There is no roadmap – not many of us have done this before! Those that have are always….different  Systems analysis and workflow redesign are the biggest challenges In our case we had to reach In our case we had to reach commonality between 4 hospitals  The technology is the easy part

What I hope to accomplish today…  Provide you with as many ideas as I possibly can in 25 minutes  For those who are just starting To give you hope To give you hope  For those who are underway To give you new ideas To give you new ideas Something for everyone!

Acquisition

Acquisition  Build Clinical Support  Provide Leadership  Sell the Finance Folks

Acquisition: Build Clinical Support  Search and Selection Team Doctors, Nurses, Ancillaries, IT, Finance (all sites) Doctors, Nurses, Ancillaries, IT, Finance (all sites)  Vision Statement “ To create a user friendly computer-based patient health information environment encompassing all contacts that a person has with the Eastern Region of the Cleveland Clinic Health System”  Define: What it is and what it is not  Define: What will be accomplished This became the basis for the cost/benefit This became the basis for the cost/benefit

Acquisition: Provide Leadership  Become a Focal Point  Become an Expert  Provide Information Medical Staff presentations, Executive Staff retreats, Expert Q & A sessions Medical Staff presentations, Executive Staff retreats, Expert Q & A sessions  Manage Expectations Long project Long project Emphasize the organizational commitment Emphasize the organizational commitment

Acquisition: Sell the Finance Folks  Speak the language  Create a justification (cost/benefit) HINT: Use the justification throughout the contract negotiation HINT: Use the justification throughout the contract negotiation  Integrate the project into the organization and department budgets

Planning and Organizing

 Implementation Organization  Project Tracking

Planning and Organizing: Implementation Organization  Purpose (More than a Steering Committee) Guide the design and implementation of the system Guide the design and implementation of the system Make sure that it gets done Make sure that it gets done Remove barriers Remove barriers Prevent “you didn’t ask me!” Prevent “you didn’t ask me!” Facilitate consistency Facilitate consistency  Composition – All hospitals were represented Clinical Decision Making (RPAC, PCAC) Clinical Decision Making (RPAC, PCAC) Administration (COOs, CNOs, Finance, HR) Administration (COOs, CNOs, Finance, HR)

Planning and Organizing: Project Tracking  Timeline  Dashboard  Cashflow

Timeline

Dashboard

Cashflow

Application Build

 Implementation Team  Workflow Redesign/Adaptation  Design Endorsement Sessions

Application Build: Implementation Team  4 Physician Advisors – PAID Part Time  1 Pharmacist  3 Nurses  1 HR Trainer  3 Information Technology 1 Dedicated Interface Engine Analyst 1 Dedicated Interface Engine Analyst 1 Report Person 1 Report Person 1 ADT/Charge Master Expert 1 ADT/Charge Master Expert  1 Project Manager BUILT INTO COSTJUSTIFICATION

Application Build: Workflow Redesign  Most intense part of the project  Dedicated team (Process Redesign Task Force) Nurses, Physicians, Unit Secretaries, Ancillaries Nurses, Physicians, Unit Secretaries, Ancillaries  Reported to Patient Care Advisory Team  Big impact on hospital policies and procedures

Application Build: Design Endorsement  Designed to transfer ownership to user community Nursing, Physicians, Ancillaries Nursing, Physicians, Ancillaries  Held 4 Design Endorsement Sessions Session 1: Reviewed designs – paper walk-through Session 1: Reviewed designs – paper walk-through Session 2: Preliminary software build review Session 2: Preliminary software build review Session 3: Users walk through with the application – a situational demo Session 3: Users walk through with the application – a situational demo Session 4: Downtime walk through Session 4: Downtime walk through  Required sign-off and acceptance from participants

Technology: End User  Created Public Clinical Workstations (PCWs)  Placement of PCWs determined by hospital walkthroughs with Physician Advisors, Nursing and IT (Network, Applications, WSA)  Ratio:.75 PCWs for every 2 hospital beds  PCWs were pre-imaged by supplier  Placed PCW well ahead of go-live to “burn in”  Optical Mice are better

Physician Adoption

 Guiding Principles  Physician Involvement  Physician Connectors

Physician Adoption: Guiding Principles “The AMA supports the concept of early involvement and participation by the hospital medical staff in decisions as to installation of a hospital information system and in the development of policies governing the use of such a system in the institution.” AMA Policy: H Computer-Based Hospital and Order System (CMS Rep. F, I-79; Reaffirmed: CLRPD Rep. B, I-89; Reaffirmed: BOT Rep. R, A-93)

Physician Adoption: Guiding Principles “Research has shown that involving users in the implementation process and providing features of benefit to them, such as time-saving measures like specialty specific order sets, widespread implementation across the organization, and engaging the clinical leadership are the most important keys to success” Medical Informatics, Improving Health Care Through Information JAMA, October 23/30, 2002-Vol 288, No 16

Physician Adoption: Physician Involvement  From the Start EMR Task Force EMR Task Force  During Implementation Regional Physician Advisory Committee Regional Physician Advisory Committee Hospital Physician Advisory Committee Hospital Physician Advisory Committee  Post Live Hospital Physician Advisory Committee Hospital Physician Advisory Committee Clinical Informatics Committee Clinical Informatics Committee

Physician Adoption: Connectors  Key physicians had a dedicated resource  Someone they knew and trusted  Monthly interaction – 12 months before live Information Information Solicited concerns Solicited concerns FAQs FAQs

In Conclusion  We are the pioneers!  Keep sharing what you know!

Questions?