1. Order Comms: Is the tale wagging the dog? Dr Rick Jones Yorkshire Centre for Health Informatics University of Leeds Leeds Teaching Hospitals Trust http://www.ychi.leeds.ac.uk

2. Theme Whose tale (tail)? Which dog? What does the literature tell us about order communications? Myths & Reality

3. Local MORI poll Please take 2 minutes to write down your answers to the questions on the next slide. All will become clear as the presentation progresses Before we start….

4. Survey questions 1.In what percentage of US hospitals is CPOE installed and working? 2.Write down your assessment of the cost of installation of CPOE in a typical 500 bed DGH. 3.How much per year would you expect to save per year by installing CPOE? –In the laboratory –Outside the laboratory in the clinical services Survey results are at the end of the slide pack

5. Literature Drivers for order comms Benefits Costs Implementation Issues Based on a literature review conducted at YCHI – Dr Susan Clamp, Prof Justin Keen Additional papers from numerous sources

6. Drivers “Computerized physician order entry (CPOE) is touted as a major improvement in patient safety, primarily as a result of the Institute of Medicine’s 2000 Report – ‘To err is human’ - Berger, JAMIA 11:100, 2004 44,000 US deaths – 7,000 due to drug errors ‘Leapfrog Group’ of 170 Fortune 500 companies – preferentially direct employees health benefits to health institutions with CPOE

7. Claimed Benefits Reduced medication error rates Reduced preventable adverse drug events Standardisation of care Improved efficiency Improved quality of care Cost savings

8. Intelligence from the US

9. Question How widespread is the use of CPOE in the United States?

10. CPOE in US Hospitals 2002 Hospital Survey 650 US hospitals – mail and telephone survey on use of physician order entry –Availability –Inducement /coercion –Participation - % of physicians using CPOE –Saturation - % of orders processed

11. Availability

12. Inducement / Coercion

13. Participation

14. Saturation

15. Costs 200 bed hospital with CIS –$0.5m installation - $1.74k pa running 1000 bed hospital with new CIS –$15m installation – $1.5m running Bates et al, 1997 500 beds with partial CIS –$7.9m installation – $1.35m running costs First Consulting, 2003

16. Why so expensive? Puget Sound Veterans Administration Experience Pilot for roll-out of CPOE –2 hospitals – 347 beds / 485 residents –20 months preparation –Project manager and Program assistant –10 full time clinical application coordinators –Full time programmer –Extra IT staff for hardware & network support –2000 Windows workstations - >5 per bed! No costs capital costs published

17. Issues in implementation Puget Sound Increased clinical time spent on orders – 5% increase Problems due to patient transfers Discharge medications more difficult Redefined roles for doctors, nurse & clerks Lower nursing awareness of new orders Alerts & order checks inadequate Poor screen design Locking of orders during pharmacy processing Location and accessibility of workstations – even with 5 per bed! System availability – unscheduled downtime

18. An instructive read Overall, house staff were dissatisfied with the commercial system, giving it an overall mean score of 3.67 (95 percent confidence interval [95%CI], 3.37–3.97). In contrast, the CPRS had a mean score of 7.21 (95% CI, 7.00–7.43), indicating that house staff were satisfied with the system. Overall satisfaction was most strongly correlated with the ability to perform tasks in a “straightforward” manner. Physician Satisfaction with Two Order Entry Systems Harvey J. Murff, MD and Joseph Kannry, MD J Am Med Inform Assoc. 2001 Sep–Oct; 8(5): 499–511.

19. And another….. The implementation process should be understood as a thoroughly social process in which both technology and practice are transformed. Following Orlikowski's concept of “emergent change,” they suggest that implementing a system is, by its very nature, unpredictable. Success and failure are not dichotomous and static categories, but socially negotiated judgments. Understanding Implementation: The Case of a Computerized Physician Order Entry System in a Large Dutch University Medical Center Jos Aarts, MSc, Hans Doorewaard, PhD, and Marc Berg, MA, MD, PhD J Am Med Inform Assoc. 2004 May–Jun; 11(3): 207–216.

20. Benefits “Installation of such systems could actually increase the number of adverse drug events and result in higher overall medical costs, particularly in the first few years of their adoption.” Leapfrog group data –520,000 averted potential ADEs saving $2 billion Harvard experience –200% increase in actual ADEs during implementation –equivalent to $6 billion increased costs Computerized Physician Order Entry: Helpful or Harmful? Robert G. Berger, MD and J.P. Kichak, BA J Am Med Inform Assoc. 2004 Mar–Apr; 11(2): 100–103.

21. Conclusions CPOE – not the cut and dried case that many assume Need for rigorous business appraisal before commitment Serious investment of time and effort essential Culture change and not technology is the challenge

22. Survey questions 1.In what percentage of US hospitals is CPOE installed and working? 2. Write down your assessment of the cost of installation of CPOE in a typical 500 bed DGH. 3.How much per year would you expect to save per year by installing CPOE? –In the laboratory –Outside the laboratory in the clinical services

23. Use of CPOE

24. Costs

25. Business sense? – cost/savings pa 14 - £0 payback on £25k – £1.5m investment – i.e. infinite payback

26. Thank you