Practice Insights – CPOE and eRX Deadlines Fast Approaching

Critical access hospital clients use REACH services and expertise to help them along the path to achieving meaningful use.

With deadlines fast approaching, hospitals and clinics are furiously working to implement effective systems for computerized physician order entry (CPOE) and e-prescribing (eRX).

Chippewa County Montevideo Hospital and Medical Clinic—25 bed hospital and its primary care clinic, and Northfield Hospital and Clinics—37 bed hospital, with an attached long term care center, four primary care clinics, a woman's health clinic, orthopedic and fracture and other specialty clinics, have had very different paths for their EHR journeys. When Chippewa County Montevideo learned of the meaningful use requirements, it decided to get in on the incentives. CPOE is the first meaningful use measure it worked on, going live on June 1. "E-prescribing is on the top of the list of next things to tackle," said Mary Kostad, RN, clinical applications analyst, at Chippewa County Montevideo Hospital and Medical Clinic. "For e-prescribing, we plan to start with a standalone module that's straightforward, and then move to an integrated module when we are not under the pressure of deadlines."

The administration at Northfield wanted a full medical record and hired staff in 2003 to start its EHR journey. "ARRA put us on the fast track—we would rather have done it slower," said Cindy Grolla, RN, clinical informatics director, Northfield Hospital and Clinics. Meaningful use falls under the American Recovery and Reinvestment Act (ARRA). "It's been a long, busy journey. We're pretty well positioned to meet AARA. We were well on our way when it was released. We mainly needed to implement CPOE." Northfield has been live with e-prescribing since February in the clinics and May 1 in the hospital. It went live with CPOE on May 24 and expects to meet the CPOE requirements because of its use in the emergency room (ER), which is 30 to 40 percent of its orders.

CPOE

CPOE is complex to implement. Almost every department does ordering, the process is different between physicians, and it's a whole new language and workflow. Because of how extensive the change is, it's not a popular meaningful use measure. Planning for CPOE takes a team effort to flow chart all of the processes and to develop new ones.

"CPOE definitely is one of the most extensive components that we have implemented. It has included nearly every department," said Grolla. "In the past we tried to implement CPOE, in one unit with two doctors, and it didn't work."The health care organizations shared these insights:

• A full-time person is needed to implement CPOE.
• Make sure that order entry is physician friendly. Develop order sets with physicians in mind, not nurses. Physicians are less willing to answer questions that lack clear immediate value (e.g. "why didn't you give the patient an anticoagulant?"). They want to click once to order a protocol.
• Build all pre-printed orders into your systems.
• Don’t set a go-live date until you are confident that the order system you are using can be converted into an order entry system that providers will accept. 
• Test CPOE in a full simulation. Some software can take live patient data and remove all identifying information for testing; others can't. Physicians do not want to do CPOE in test mode, they want to do it with a real situation.
• Some departments or specialty clinics may have to be included later. Their order sets may be very different and vendors may not yet have created the programming needed to make orders flow (e.g. pre-op orders).
• EHR vendors can't keep up with the changes and the demands for implementation and assistance, so be prepared to do much of this on your own.
• If an EHR product was certified to meet quality measures with a certain workflow, your vendor may not be willing to modify its system to meet your specific process needs. You may be told, "No, that's the way we have to do it—it's our best practice—that's how we are certified."
• For questions about the specific state guidelines regarding prescribing rights, contact your state boards and implement your own facility policies using this information as a resource.

One of the concerns with entering medication orders into the system, is that the drug interaction/drug allergy alerts pop up at the time the order is initiated. "At CCMHMC, we have made the decision to have nursing staff enter medications as recorded only and any medications ordered need to be initiated by the ordering provider," said Kolstad. "It is up to each facility to determine the right process for themselves and their patients' care."

Many physicians like to dictate notes, which cannot be captured as discreet data in an EHR. Although Northfield has CPOE in its clinics, it will not try for meaningful use in 2011 because of physician preference for dictation. "They do not like the template notes that they receive from other clinics. ED doctors feel the same way. They want to be able to tell the patient's story; they don't think template notes do that," said Grolla.

Only certain elements need to be discrete, said Dr. Paul Kleeberg, REACH clinical director. Physicians can still dictate the majority of their notes and qualify as meaningful users, especially if they leverage their staff to assist with entering the key elements.

For physicians at Chippewa County Montevideo their biggest concern is that CPOE will take time away from patients or it will add time to the end of the day. "It may only take about one to two minutes per patient, but by the end of the day that's 30 to 40 minutes," said Kostad. "We're looking to see if there's more that nurses can do before the doctor goes into the room, such as entering additional documentation that would not need to be entered by the provider. We're trying to make this more give-and-take, not just adding more tasks onto a physician's pile. This process, including all meaningful use requirements is definitely still a work in progress."

Attend the REACH Webinar "Workflow Details: Best Practices Around Implementing CPOE" on July 26 to learn more about CPOE.