1. FOCUSFOCUS

2. CPOE at Cedars-Sinai What Worked, What Didn’t Cedars-Sinai Medical Center Los Angeles, California C S Paul Hackmeyer, M.D. Chief of Staff 2000-2001

3. PBH 04/03 Patient Care Expert (PCX) System Physician Order Entry: Automated physician’s entry of orders. Med orders automatically checked for allergies, drug interactions & dose range (October 2002) Patient Management: Admission, discharge, transfer, bed management & preregistration (May 2003) Patient Accounting: Bills patients & insurance providers with enhanced accuracy for capturing charges (July 2003) Contract Management: Database of contract terms to verify payment ability during preregistration & proper billing of patient accounts

4. PBH 04/03 Patient Care Expert (PCX) System Physician Order Entry: Automated physician’s entry of orders. Med orders automatically checked for allergies, drug interactions & dose range (October 2002) Patient Management: Admission, discharge, transfer, bed management & preregistration (March 2003) Patient Accounting: Bills patients & insurance providers with enhanced accuracy for capturing charges (July 2003) Contract Management: Database of contract terms to verify payment ability during preregistration & proper billing of patient accounts Temporarily suspended January 23, 2003

5. PBH 04/03 PCX In the News

6. PBH 04/03 PCX in the News

7. PBH 04/03 What Worked CPOE

8. PBH 04/03 The system itself What Worked No crashes or unscheduled downtime No lost or mistransmitted orders

9. PBH 04/03 Oct 24, 2002 – Jan 23, 2003 What Worked 700,000 orders placed & transmitted 8,000+ patients 10,000 orders per day

10. PBH 04/03 Medical Records Components (still running) What Worked Coding & abstraction Charge entry

11. PBH 04/03 Education about value of CPOE re: Medication Errors What Worked

12. PBH 04/03 Medication Alerts What Worked

13. PBH 04/03 PCX CPOE Alert Statistics Oct 24, 2002 – Jan 23, 2003

14. PBH 04/03 Live Interface to ICU System MAR What Worked

15. PBH 04/03 PreliminaryOutcomes What Worked Decreased length of stay Decreased mortality rate Decreased SAEs

16. PBH 04/03 What Didn’t Work CPOE

17. PBH 04/03 What Didn’t Work Physician Issues & Change Management Very difficult to get physicians to test system during development After go-live, much angst over added time for order entry Negative perception for ease of use Insufficient education for optimal use

18. PBH 04/03 What Didn’t Work Work Flow Change Management CPOE affects all caregivers Incompletely understood complex hospital procedures that affected order management Much more operational workflow analysis required

19. PBH 04/03 What Didn’t Work Need for System Enhancement Hundreds of suggestions post “go- live” to be prioritized for action By its nature, CPOE is difficult to bring down even transiently Difficult to significantly enhance system while it is running

20. PBH 04/03 CPOE Complexity of human change management may be easily underestimated For physicians, speed, ease of use and intuitiveness of the system are critical Complex workflow issues affecting orders must be completely understood and incorporated in the system. Example: Patient transfers to and from procedure areas. Lessons Learned

21. PBH 04/03 CPOE Reimplementation Plan Other parts of the PCX system will go-live as scheduled: Patient Management (March), Patient Accounting (July) Workflow issues will be carefully analyzed CPOE portion of the system will be enhanced to improve speed & ease of use Significant medical staff input will be obtained to test enhancements Reimplementation schedule not yet set

22. PBH 04/03 CPOE Reimplementation Plan PCX Advisory Task Force to the MEC Safety Council evaluation and monitoring Advisory Task Force and the Safety Council will advise the MEC on a monthly basis. Reimplementation schedule not yet set, but will be fully vetted and approved by the MEC

23. Questions?

26. PBH 04/03 Formulary, purchasing decisions Inventory management Dispense/ distribute medication Medication Management Process Where the Adverse Drug Events originate Obtain Medication-related History Document Medication History Diagnostic/ Therapeutic Decisions Made Medication Ordered Evaluate order Select medication Educate patient regarding medication Order verified and submitted Prepare medication Educate staff regarding medications History-Taking Ordering Pharmacy Management Education Select the correct drug for the correct patient Administer according to order and standards for drug Document administration and associated information Assess and document patient response to medication according to defined parameters Intervene as indicated for adverse reaction/error Administer MedicationMonitor/Evaluate Response Document Medication Inventory Management Administration Management Incident/adverse event surveillance and reporting Surveillance 49% 11% 14% 26% (Mostly IV) Bates et al.; JAMA 1995;274:29-34

27. PBH 04/03 Formulary, purchasing decisions Inventory management Dispense/ distribute medication Medication Management Process Where the Adverse Drug Events originate Obtain Medication-related History Document Medication History Diagnostic/ Therapeutic Decisions Made Medication Ordered Evaluate order Select medication Educate patient regarding medication Order verified and submitted Prepare medication Educate staff regarding medications History-Taking Ordering Pharmacy Management Education Select the correct drug for the correct patient Administer according to order and standards for drug Document administration and associated information Assess and document patient response to medication according to defined parameters Intervene as indicated for adverse reaction/error Administer MedicationMonitor/Evaluate Response Document Medication Inventory Management Administration Management Incident/adverse event surveillance and reporting Surveillance 49% 11% 14% 26% (Mostly IV) Bates et al.; JAMA 1995;274:29-34

28. PBH 04/03 Formulary, purchasing decisions Inventory management Dispense/ distribute medication Medication Management Process with specific technologies to reduce errors Obtain Medication-related History Document Medication History Diagnostic/ Therapeutic Decisions Made Medication Ordered Evaluate order Select medication Educate patient regarding medication Order verified and submitted Prepare medication Educate staff regarding medications History-Taking Ordering Pharmacy Management Education Select the correct drug for the correct patient Administer according to order and standards for drug Document administration and associated information Assess and document patient response to medication according to defined parameters Intervene as indicated for adverse reaction/error Administer MedicationMonitor/Evaluate Response Document Medication Inventory Management Administration Management Incident/adverse event surveillance and reporting Surveillance Wireless devices for medication history capture, etc. Physician Order Entry (PCX) Pharmacy Information Systems Robotic dispensing systems Bar coding administration, smart infusion pumps Automated Surveillanc e Electronic Order Transfer (PCX)

29. PBH 04/03