Published in the January 2013 issue of Today’s Hospitalist
Your hospital is preparing to implement an EMR with CPOE, and there is simmering disagreement about what’s most important. While the physicians want to be able to use the technology to communicate more efficiently with primary care physicians and consultants, hospital administrators are more concerned about meeting meaningful use regulations.
According to Russ Cucina, MD, a hospitalist at the University of California, San Francisco (UCSF), who is medical director for information technology, competing expectations of CPOE systems are not only frustrating, but common. But at last fall’s UCSF hospital medicine conference, Dr. Cucina urged hospitalists to use the rollout of an EMR and CPOE as an opportunity to accomplish goals that may all too often seem out of reach.
“What leverage do you have?” Dr. Cucina asked. “What can you do while your hospital is making this major investment to make sure that this is not something that happens to you but happens for you and your patients?”
At a session on the dos and don’ts of CPOE implementation, most hospitalists in the audience said that they’re already working in hospitals that are rolling out an EMR with CPOE. Dr. Cucina said the good news is that hospitalists’ broad participation in hospitals gives them an inside track on redesigning systems of care. But the challenge is that they have to step up to the plate to take advantage of that opportunity.
The first move to make, he explained, is to think broadly about how you’d like to change your practice. Would you like, as many audience members indicated, to be able to communicate more effectively with referring physicians, or would you like to use information to spot drug-seekers? Or do you want to use an EMR to eliminate wasted work or longstanding problems?
“The point is to set your own goals within your group and to pursue those in partnership with your hospital,” Dr. Cucina said. Realize that meeting those goals will likely require you to map out your present workflow, so you’ll probably want to give a member of your group time (and some compensation) for IT design and implementation. And make sure your goals are not only measureable and attainable, but can be put on a timeline.
Also expect that the goals that physicians set may only partially overlap with the hospital’s priorities for EMR technology. According to Dr. Cucina, the big goal of many hospitals is making sure that their EMR system comes in on budget and meets the criteria for different stages of meaningful use requirements.
“Don’t pave the cowpath”
One key goal for doctors to bring to the table when implementing EMR systems is building order sets. That’s often necessary, Dr. Cucina pointed out, because vendors are doing such an “abysmal” job of developing clinical content for physicians.
“Good order sets are absolutely key to surviving CPOE,” said Dr. Cucina, “and physicians must write them.” And while he admitted that devising order sets for common diagnoses is time-consuming, he noted that the end result is not only better clinical content, but better buy-in from physicians.
There’s another benefit of physicians developing their own order sets: It allows hospitalist groups to standardize their practice. Dr. Cucina explained that IT professionals have a saying: “Don’t pave the cowpath.” In other words, don’t set in stone “or in an EMR “the crooked, narrow and meandering ways of doing things that many physician groups have developed over the years.
“Do not leave order sets up to individual doctors,” he added, despite the pressure you’ll face from physicians who insist they have their own way of doing things. “You have a tremendous lever to change practice with these designs, so don’t allow for individual practice variation without reason. The notion that there is a stylistic way to treat pneumonia or most of what we’d do is, I’d argue, an outdated notion.”
One advantage of investing time and money in standardized order sets goes beyond just standardized practice. It allows physicians to more easily update the system once standards change or new drugs are introduced.
Standardized order sets also help improve nursing practices. “Nurses get better because they’re getting the same message and making fewer mistakes,” said Dr. Cucina.
Audience members pointed out, however, that they were frustrated at having to reinvent the wheel by not being able to access order sets designed by Kaiser Permanente or large academic centers. Dr. Cucina noted that most EMR vendors have a library of order sets that have been designed by their other clients. He suggested trying to draw on those efforts when designing order sets.
“But things are always different within each individual hospital,” he warned. Even if you can borrow order sets from other facilities, plan to spend time adjusting them for your facility.
Be prepared for resistance from your colleagues. There will always be “cowboys” who will reject order sets and want to enter their own orders. But meaningful use stage 2 criteria, which take effect next year, mandate that 80% of the doctors in the hospital use order sets.
And the ordering process itself helps promote the use of order sets. “It is significantly harder and takes longer to electronically enter individual orders than it ever was to handwrite them,” Dr. Cucina pointed out. “That carrot should help steer physicians toward using order sets.”
As for training before the go-live, said Dr. Cucina, it should be fairly extensive and mandatory.
“Just like a sharp needle, CPOE is a clinical instrument,” he said. “Physicians should not be able to use CPOE in the hospital unless they’ve completed training and passed a competency exam.” At some point, he said, he suspects that CPOE training will become regulated, although there are currently no guidelines.
All of the 4,000 physicians affiliated with the UCSF system, he noted, last year underwent between six and eight hours of interactive Web-based training, as well as four hours of classroom training. They then had to pass a competency exam. The physicians, who are all salaried, trained on their own time and were not paid for it.
The good news is that the Web-based training that UCSF developed was “very well-received, scales well and has the benefit of standardization.”
An audience member noted that in her health care system, the 1,000 physicians underwent a mandatory 16 hours of training each before they’d be allowed near the system. The 300 doctors among them who chose not to do the training lost their hospital privileges.
Dr. Cucina said he agreed with that policy. He noted that at UCSF, physicians who thought they could forgo training were told that their practices would be suspended.
And in the end, the fact of CPOE training persuaded some physicians to retire, although very few. “We thought that was fine,” said Dr. Cucina, “and so did they.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
WHAT’S THE BEST WAY to train physicians to use EMR systems and CPOE?
While advance training needs to be mandatory, “most learning happens after go-live,” according to Russ Cucina, MD, a hospitalist at the University of California, San Francisco (UCSF) who is medical director for information technology. Support personnel “need to be out on the floor with their yellow jacket or their blue armband, not at the other end of a phone, 24/7.”
For the first two weeks, Dr. Cucina told a group of hospitalists at last fall’s UCSF hospital medicine conference, he recommends a ratio of no more than four physicians to one support person. “It really needs to be that intensive.” An audience member noted that the support personnel at her hospital during the go-live were super-user physicians, who were paid for their time providing support.
According to Dr. Cucina, the No. 1 mistake hospitals make during go-lives is tailing off support too soon and too steeply. It simply doesn’t work to cancel support after only two or even four weeks.
“You may not admit that complicated ICU patient who needs TPN in the first two weeks,” he said. “If there is no one around to help you, that won’t go well.” Even weeks after go-live, he said, “graduate” training can be very effective, particularly in “lunch and learn” sessions that concentrate on perennial problem areas.
But how do physicians get the juice to make all this happen? One audience member noted that in his facility over the previous four months, physicians were barely trained ahead of the go-live and support was close to nonexistent. “The administration just says, ‘This is what’s going to happen,’ ” he noted.
The only recourse physicians have, Dr. Cucina responded, is to educate hospitals “perhaps by hiring consultants “to get them to understand how much can go wrong.
“EMRs have both positive and negative momentum,” he explained. “When people start realizing that data can be accurate, electronic records become much more important than paper ones, so clinician behavior tends to get better.” If, however, EMRs and CPOE are allowed to be just “junk depositories,” they become “more and more disrespected, and that’s self-sustaining as well.”
How to avoid alert fatigue
DOCTORS AND NURSES are on a collision course with their administration when it comes to one aspect of EMRs. Should the alerts that the system comes with be turned off?
“Administrators and risk managers are going to think that this is a part of what they paid a lot of money for,” explained Russ Cucina, MD, a hospitalist at the University of California, San Francisco (UCSF), who is medical director for information technology. “But alert fatigue develops very quickly and is very long-lasting.”
A big part of the problem is that the two companies that produce databases used in EMRs “MediSpan and First Databank (FDB) “both take much too conservative an approach to interactions, so using their databases is fraught with alerts. At UCSF, however, drug allergy alerts are activated only if patients have a documented allergy.
“If an alert comes up every time you order a drug,” Dr. Cucina said, “that’s not an alert.”
He also noted that the IT team at UCSF selectively turned off many of the level 4 alerts. A class-reaction alert between furosemide and sulfa drugs was turned off, for example, as well as an interaction alert for ordering both lactated Ringer’s solution and oral potassium.
“There are other level 4 alerts that you’d like to have,” Dr. Cucina explained, so his group spent time picking and choosing which alerts to leave turned on. The only drug alerts that categorically remain on in the system are ones for high doses and for absolute contraindications.
Is there information you shouldn’t document?
WITH PHYSICIANS now electronically capturing (forever) every scrap of patient information, are there times when sensitive information should be kept out of the system and away from potentially prying eyes?
At a recent presentation on CPOE held by the University of California, San Francisco (UCSF), a hospitalist in the audience who works in a practice with 50 employees explained that she provides care to many of her coworkers. At least half of those people, she said, may have gender preferences or drug issues that they don’t want made public. “I’m not going to document that a patient mixes Haldol with alcohol to lose weight,” the doctor said.
“Why not?” asked Russ Cucina, MD, a hospitalist who is UCSF’s medical director for information technology and was giving the presentation. “Because I’m a good doctor,” she replied.
Her worry wasn’t that her records could be anonymously hacked, but that other employees, who constantly navigate through the electronic system, might access “even inadvertently “each other’s charts.
Dr. Cucina offered two reasons why patient information, even when it may be sensitive, should be entered into an EMR. For one, electronic records have a huge advantage over paper records: They can be firewalled behind passwords. Anyone who accesses any portion of them leaves his or her own electronic fingerprint.
He noted that UCLA Medical Center in 2008 learned that the hard way when it was fined and had to fire employees for snooping in celebrities’ computerized charts. To safeguard patient information, said Dr. Cucina, health care workers need to know that any inappropriate access to records can be traced and will be penalized.
His second argument was that leaving key information out of the medical record “even if it would be embarrassing if discovered “puts the patient at risk. “When that patient shows up in the ER with torsades from the Haldol, the ED doc doesn’t know that,” Dr. Cucina said. “That patient has been disserved.”