Any Hospital Doing Full CPOE

rninformatics, DNP, RN · Aug 12, 2009

Greetings Mydesyn,

I've been involved in a few CPOE implementations.

I've seen scenarios where:

1) the doc enters the order electronically and a paper requisition prints to both the performing department and the unit (if the pt is an inpt) where the pt is located.

or

and this is not CPOE

2) the doc writes the order and a unit clerk or RN enters the order - the order may or may not print to the performing department and or to the unit - depends on how the facility wants it set up.

Too often the orginal work group intructs us to "yes" set it up so the req prints then 2 days in to all that paper they go" "On second thought can we get a report that just tells us what has been ordered"

Depending on the system there is a "report" or a work sheet for the technologists, performing dept and or nurses which replaces the paper req printing out.

In the first scenario above the docs entered all orders but we also had nurses entering their own "nursing orders" you know like turn Q 2 or foley cath care Q shift, etc. Plus we had other "Providers - Nurse practioners and PAs entering orders.

The printing of a req or the appearance of the order on a report or worklist is both as a double check that the order really did get entered and is used in work flow to alter staff that this or that needs to be done/performed.

If you need reference sites that are currently using CPOE - Rush University Medical Center in Chicago, IL and Evanston Hospital in Evanston IL. both utilize CPOE. Oh and several of the Advocate hospitals in IL utilize CPOE.

Hope that helps.

We are in the process of implementing CPOE - what I have noticed is that most facilities are doing some sort of partial implementation
1) The physicians enter orders into the computer but they print to the floor OR
2) The physicians only enter medication orders but not all orders OR
3) The physician writes the order but a pharmacist or clerk enters the order into the computer
Is anyone at a facility where the physician enters all orders into the computer and nursing verifies / performs care based on the computer order only - no printout.

mydesygn · Aug 15, 2009

I guess I find it really discouraging, we are doing full CPOE. Our hospitalists are entering all orders electronically - labs going to lab dept, nursing orders, xrays, meds.. As we ran into issues, our hospitalists ask "what are other hospitals doing" and I have to reply - nothing - they resolved the issue by printing the order or having a clerk enter the order electronically.

We are using Meditech and many of our current issues will be resolved when we update to the next version but in the meantime, we are working around issues.

I find that many of the many hospital systems vendors define CPOE by the Leapfrog standard of physicians entering medication orders electronically which is really misleading-once you define full CPOE as all orders suddenly the number of CPOE implementations that they advertise drop dramatically.

rninformatics, DNP, RN · Aug 15, 2009

Greetings Mydesygn,

Don't be discouraged. You should be patting yourself on the back that "all" your hospitalist are compliant in using CPOE. That in itself is an accomplishment!!!

I hear your frustration but I'm not understanding. You wrote that " As we ran into issues, our hospitalists ask "what are other hospitals doing" and I have to reply - nothing - they resolved the issue by printing the order or having a clerk enter the order electronically. " What exactly is your "issues"? You dont want a req to print out after the docs enter an order?

Are you trying to find a way to notify other staff that an order has been entered without a req printing? You may have to look at mobile devices such as handhelds and PDAs.

You can set up Meditech to send e-mail alerts.

The inclusion of a req printing out in the flow of your CPOE process does not mean you are not following Leapfrog's definition of CPOE. What are your issues specifically related to CPOE? I've worked with MT Magic and Client Server versions and now with CS 5.6. Are you saying you can't do full CPOE until 6.0? What are the issues you are using "work arounds" for?

Come on keep your perspective. I'm currently working with modules I never had any original training in..... answering questions from ICU nurses about PCS and I've never built or trained in PCS and won't get PCS app or Dx training until Oct!!

I'm about to be Lead Project Manager on PCM, currently support PCS, BMV and ORM and again I've never trained or built in those modules!! I miss OE, ITS and EMR! But currently those are not the modules I'm supporting. I'm being asked to do PC tech stuff related to evaluating a dept. for needed drop installation, filling out departments' app request forms and other nit pickie crap that I have not had to do since I entered the specialty 10 years ago! :cry:

So if I can keep my perspective so can you!

Angela

I guess I find it really discouraging, we are doing full CPOE. Our hospitalists are entering all orders electronically - labs going to lab dept, nursing orders, xrays, meds.. As we ran into issues, our hospitalists ask "what are other hospitals doing" and I have to reply - nothing - they resolved the issue by printing the order or having a clerk enter the order electronically.
We are using Meditech and many of our current issues will be resolved when we update to the next version but in the meantime, we are working around issues.
I find that many of the many hospital systems vendors define CPOE by the Leapfrog standard of physicians entering medication orders electronically which is really misleading-once you define full CPOE as all orders suddenly the number of CPOE implementations that they advertise drop dramatically.

mydesygn · Aug 15, 2009

One of our issues, for instance is that physicians don't want to answer the Collected By Nurse query when entering labs - whether a lab is collected by the nurse or the lab phlebotomist can only reliably determined by the unit. At this point, we will likely have the doc enter an instruction to a clerk who actually enters the lab order. Our ultimate goal is to have orders entered by the physician go directly to the performing department and not print to a clerk who then enters the order for the performing dept.

When I hear that all the physician orders print to the nursing unit - it usually means that someone on the nursing unit is then entering the order for the performing dept and thus you lose the efficency gained from the xray order going directly to xray and not having to wait for a clerk to enter order. The main benefit that the physicians have noticed is how much faster their xrays and labs are done after they enter the order.

When the physicians ask what other hospitals, they are looking for a creative solution that avoids the obvius workaround of simply having an order print to the unit and then have someone on the unit enter the order for the performing dept. In addition, many areas are printing the nursing orders to the nursing unit thus avoiding having the nursing staff not rely on the PCS status board for notification of orders.

mydesygn · Aug 15, 2009

We are 5.54 with a planned update to CS 5.64 next year so in the meantime we work around the fact that continuous labs are not clearly identifiable from the PCS status board, the text of nursing interventions do not display when viewing orders in the orderset view.

Fortunately, we have a fairly large IS department. Up until last year, we had one analyst to one module. I supported EDM, however now we have split our department between application support and project teams. My project team consists of 4 analysts and CPOE is our only project. We are fortunate that our inpatient nursing has be fully documenting in PCS and EMAR for the last 7 years so they are already actively using the PCS status board. Our physicians dictate in ITS as well as document H&P on paper. The challenge is been helping the docs understand that you can't simply convert paper orders to electronic - they are slowly realizing how much time the nursing and performing dept spent clarifying/looking for information because the paper order was not sufficient.

For instance, our docs never realized that our GI Lab would go search the patient's chart to find a reason for performing the ph probe because the doc only wrote ph probe on the paper order and had never written a reason - we are now asking the physician to enter a reason when entering the electronic ph probe order.

rninformatics, DNP, RN · Aug 15, 2009

"One of our issues, for instance is that physicians don't want to answer the Collected By Nurse query when entering labs"

If we are to truly utilize CPOE we also need to support one of its foundational principles:

Decreased medical errors due to having the prescribing physician enter the order. Less steps between prescribing and dispensing or carrying out the order decreases the chance for error. Having the actual clinician who has ordered the care enter the order decreases medical errors.

Are we doing the process justice by exempting the physician from Best Practice? If the physician is ordering the lab he/she should know whether or not his/her pt has a central line that requires a nurse to draw the blood as opposed to a phlebotomist.. Just as the doctor should also know if the urine specimen has to be collected via a catheter or voided. CPOE is not just a technological process it is also a culture change

"Our ultimate goal is to have orders entered by the physician go directly to the performing department" I've set up system where the req print printed out to both the performing department and to the pt floor/unit/dept location to ensure all involved in the process are aware of procedures/tests,interventions/care ordered is administered........ printing of req or the presence of the orders on a on-line work que or work list report are seen as double checks.

"When I hear that all the physician orders print to the nursing unit - it usually means that someone on the nursing unit is then entering the order for the performing dept" I've implemented several different vendors' order entry products and have never seen that and wouldnt make that assumption.

Perhaps the problem is in our use of verbiage. "Physician orders" can print out on a nursing unit to a Kardex type report, they can print out in the form of a med rec report, and they can print out as individual requisitions.

A "req/requisition" printing out could be as a result of a "physician order" having been entered or as a result of a nursing order/intervention having been entered. Requisitions unlike physician orders are utilized to continue the OE process.

PROCESS: Lab order entered for a UA, requisition prints to lab so they know there is an order for a UA, requisition prints to unit so the staff knows they need to collect UA specimen, once UA collected req goes to lab with specimen.

"When the physicians ask what other hospitals, they are looking for a creative solution that avoids the obvious workaround of simply having an order print to the unit and then have someone on the unit enter the order for the performing dept. In addition, many areas are printing the nursing orders to the nursing unit thus avoiding having the nursing staff not rely on the PCS status board for notification of orders."

I agree whole heartily that this should be avoided. Did you post to Meditech L, NursingL, CARING and your local area NI group?