Computerized Physician Order Entry & Medication Management Analysis and Planning

Shreveport, Louisiana

February 2003

Siemens Medical Solutions Health Services Corporation

Confidential

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Siemens does not warrant that the material contained in its documentation is error-free. Documentation supplied to Siemens by third parties and included with this documentation is not warranted for accuracy or completeness.

The information contained in this document is subject to change.

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Siemens Medical Solutions Health Services Corporation

51 Valley Stream Parkway

Malvern, PA 19355

Telephone: (610) 219-6300

Prepared by Siemens Medical Solutions Health Services Corporation

51 Valley Stream Parkway

Malvern, Pennsylvania 19355

(610) 219-6300

Cecilia Backman, MBA, RHIA, Clinician Engagement Leader

Mary Schwind, RN, MS, Principal Consultant II

Carol Mensch, RN, MSN, Principal Consultant

Cathleen Omodio, MMSc, Principal Consultant

Frank Kapronica, RPh, Principal Consultant

Cathy Burdett, RN, Clinical Implementation Consultant

Billie Jean Strader, Clinical Implementation Consultant

Table of Contents

Key Findings and Potential Opportunities. 2

Next Steps. 5

Summary of Findings, Opportunities, and Potential Benefits. 9

Detailed Findings, Opportunities, Potential Benefits, and Impact Rating. 16

Patient Identification. 16

Inpatient Order Processing. 18

Patient Safety. 46

Security. 47

Professional Practice and Standards of Care. 48

Education and Training. 50

Outpatient Processing. 52

Technology. 57

Attachment A: Interview List 58

Attachment B: Reference List 62

Attachment C: Medication Errors as Causes of Adverse Drug Events. 65

Attachment D: Percentage of U.S. Adults Who Have Experienced Medical or Prescription Errors. 66

Attachment E: Criteria for Pilot Unit Selection. 67

Attachment F: Med Administration Check Process. 68

Attachment G: Frequently Asked Questions Regarding Med Administration Check. 69

Attachment H: Sample of a Pharmacist Intervention Log. 71

Attachment I: Sample Tally Sheet for Medication Orders Errors or Problems. 72

Attachment J: Trigger Events for Rules Engine. 73

Attachment K: High-alert Medications. 74

Attachment L: Physician Opinion Survey. 75

Attachment M: Workflow Example – Respiratory Therapy. 76

Attachment N: Timelines. 77

Siemens Medical Solutions Health Services Corporation (Siemens) and The Louisiana State University Health Sciences Center-Shreveport (LSUHSC-S) are undertaking an initiative to implement Computerized Physician Order Entry (CPOE) and Med Administration Check (MAK). By implementing these solutions with guidance from Siemens’ Clinical Performance Improvement Planning Services, LSUHSC-S is taking a proactive, clinician-led approach to supporting workflow change and technology implementation.

LSUHSC-S is a highly regarded medical school and healthcare university with average admissions of 19,000 per year and approximately 5,559 surgical procedures performed annually. The facility has a Level I Trauma Center and registers an average of 56,000 patients in the Emergency department. The medical staff comprises 450 members. Approximately 250 are active staff physicians and there are approximately 350 residents. The facility has 450 licensed beds with an average daily census of 329, which represents an overall occupancy rate of 75 percent. The average length of stay is 6.2 days, including newborns. Several primary care outpatient clinics service the patient population.

Implementation of advanced clinical solutions involves automation of clinical processes, which are some of the most complex and people-centric work processes in existence. The success of the implementation will depend not only on LSUHSC-S organizational readiness for implementing a technology, but also on its ability to redesign workflow, manage change, and ensure the cooperation and support of physicians, nurses, and other clinicians.

This report presents the findings and opportunities identified during the Clinical Performance Improvement (CPI) Planning phase of the implementation. The LSUHSC-S project steering committee will use this information to prioritize critical implementation and workflow redesign activities. This prioritization will be used in the next steps for the project.

This deliverable will:

1. Present and prioritize findings and opportunities in a concise format.

2. Define a structure whereby these opportunities can become actionable.

3. Become a living document to support efficient transition from thought to action.

LSUHSC-S is experiencing continuous growth, which along with technology is adding a new degree of complexity to the organization. Clinical automation is in place for automated dispensing devices (Diebold MedSelect), physician electronic signature, and Internet use. LSUHSC-S now plans to implement CPOE and Med Administration Check in early 2004.

Scope

Siemens’ Clinical Performance Improvement Planning service was developed to link strategic understanding of the customer’s objectives to the tactical deployment of the CPOE and Med Administration Check solutions. The purpose was to assist the customer to be fully ready when the implementation begins in order to realize a successful project.

Key objectives for this assessment included the following:

· Conduct a high-level review of key clinical operational processes, standards, and practices including:

– Patient identification

– Access to supportive clinical data

– Access to drug information

– Order entry and clinical checking

– Drug dispensing and distribution

– Medication administration and resultant documentation

– Charge capture and supply chain management

– Medication error and outcomes analysis

– Information system technology, security, and network support

– Quality and risk management practices

– Automated policy and procedure access

– Specialty area specific requirements

– Best practice and standards of care

– Patient safety

– Medical Staff and executive level practices

· Conduct inpatient and outpatient workflow assessments:

– Physician workflow

– Nurse workflow

– Ancillary service workflow

– Admission and Registration workflow

– Supportive administrative workflow

· Define a series of next steps to support the successful introduction of software and begin consideration of other key information system and process changes that will further support an improvement in clinical care.

Approach

For the purpose of this implementation assessment, Siemens’ approach focused on validating existing order entry and medication management processes through a combination of group and individual interviews, observations, document reviews, and consideration of specific clinical systems currently deployed within the LSUHSC-S organization.

Siemens’ CPI consultants conducted discovery over the course of approximately 10 weeks using the Siemens CPI Methodology and four distinct discovery tools. The scope of each discovery tool is as follows:

CPI Observation & Discovery Part 1 – Defines the project expectations and sponsorship of the executive level.

CPI Observation & Discovery Part 2 – Identifies critical issues and strengths in project organization; defines project committee structures along with decision-making and change management processes.

CPI Observation & Discovery Part 3 – Evaluates specific technology and integration needs and opportunities; determines customer readiness.

CPI Observation & Discovery Part 4 – Analyzes clinical workflow; compares to future automated workflow to determine gaps and variances. Aligns customer’s business and clinical needs to system functionality.

Key findings and potential opportunities from this CPI discovery process are summarized in the next section.

Key Findings and Potential Opportunities

Siemens identified the following key findings and potential opportunities for improvement during the assessment.

Allergy information collected in the inpatient and outpatient setting is not consistently entered into INVISION®. This information will be necessary for optimal implementation of CPOE.

· Capture and communication of allergy information is not standardized within LSUHSC-S.

· Entry of allergy information varies among units and practice settings.

· Allergies are recorded on a variety of forms or are placed in different computer systems.

· Recording of factors such as type and severity of allergies is not consistent and requires follow-up phone calls from the Pharmacy department.

· Updating of newly discovered allergies or allergic reactions and reporting these to other areas of the hospital may not occur after the initial assessment.

· Some physicians report clinical decision-making is impeded by the lack of a comprehensive list of allergies.

Key clinical documentation is not accessible on INVISION. This will need to be addressed in advance of the CPOE implementation.

· Determining a patient’s treatment plan is impeded by lack of clinical documentation in a readily accessible format.

· Searches for test results, medication lists, vital signs, consultation reports, medical transcription, etc. is time consuming and this information is not always available.

Physicians interviewed overwhelmingly expressed a desire for a computerized patient record. This would serve as a solution to missing clinical data. Although this is well beyond the scope of the identified projects, LSUHSC-S will have to make provision for automation of some clinical data in order for physicians to adopt a CPOE environment.

· Vital signs are manual in the current environment.

· Allergy information is incomplete within INVISION.

· Medication data are incomplete and manual.

· Patient history may be incomplete within INVISION.

Medication administration and documentation practices are not standardized. Standardization of processes is a pre-requisite to the implementation of Med Administration Check.

· Documentation of medication administration varies across medical and surgical units.

· Medication administered is documented on multiple forms, such as anesthesia records and respiratory flow sheets, making it difficult to obtain an accurate understanding of all medications the patient is receiving.

· Changes Nursing staff make to the Medication Administration Record (MAR) such as time and/or frequency are not always communicated to the Pharmacy department.

Integral components of a comprehensive Med Administration solution are not in place today. These components will need to be addressed as a prerequisite to the implementation.

· Not all necessary components are in place. These components include:

– Bar-coded patient identification bands

– Bar-coded medication packages

– Bar-coded scanner and point-of-care devices

– Medication distribution system to the bedside

– Wireless networking

– Process issues to support the five rights of patient safety

· An overall bar-coding standard has not been developed for the organization.

There is no standardized process for order generation and transmission and for medication orders. A standardized process will need to be developed as a prerequisite to CPOE.

· Variation exists across floors and units concerning the order generation process.

· Various healthcare providers have authority to create orders manually on carbon-copy physician order forms.

· Faxing of carbons presents illegibility problems in order generation.

· Nursing personnel or unit secretaries transmit new orders. Responsibility for this function is dependent upon the time of day, floor, or unit.

· Most nonmedication orders are entered via the INVISION system.

· Order clarification is usually accomplished by telephone. A nonphysician then manually generates subsequent verbal orders.

· Some orders, primarily consults, require generation of additional forms and additional telephone calls, pages, or fax communications.

· Staff noted discrepancies regarding written orders versus system-generated orders.

· The respective departments change ancillary orders without making corresponding changes in the INVISION system.

· Notifications regarding the existence of new orders vary across units and floors. Methods range from creasing physician order forms, turning the chart wheel to red, or placing charts in specific areas on the unit.

There are minimal order sets at LSUHSC-S. The use of order sets will facilitate physician acceptance of the system.

· Use of order sets (physician, unit, or ancillary specific) appears to be minimal.

· For order sets that are in use, there does not appear to be a formalized process for order set approval.

Handwritten, colored note cards are used as a means of communication between the providers of care. An alternative means of communication will need to be developed prior to implementation of CPOE and Med Administration Check.

· Communication about pending procedures, new orders, and other relevant clinical information is generated on handwritten, colored note cards by Nursing.

· Attachment of these colored cards to a patient’s chart prompts nurses in carrying out daily activities.

LSUHSC-S has several standalone software systems that may need to be interfaced to INVISION to send or receive orders. LSUHSC-S should immediately develop an integration plan for CPOE and Med Administration Check.

· There is redundant data entry and duplication of effort as a result of standalone systems.

· Systems identified as used within LSUHSC-S include Doctor’s Choice (ER), Sunrise (Hematology/Oncology), and IMPAC (Radiation Oncology). There may be other systems that are heavily used.

Admission and registration processes are not isolated to the Admissions department. This will have an impact on Med Administration Check. All inpatient areas performing the registration process will need to be equipped to produce bar-coded wristbands. This may be true in the outpatient environment as well if Med Administration Check is implemented in this environment.

· Multiple areas perform the admission and registration process.

· The process for registration is not standardized in these areas.

· Some patients receive care on a unit before a registration is complete.

Pharmacy staffing issues will have to be addressed to support effective implementation and maintenance of CPOE and Med Administration Check.

· The Pharmacy department is understaffed, especially with Pharmacy technicians.

· Potential elimination of a staffing arrangement with the College of Pharmacy in Monroe could impact the availability of pharmacists.

Nurses expressed concern and apprehension in regard to the CPOE and Med Administration Check projects. The Nursing staff’s perception of these projects, and their willingness to cooperate, will contribute to success or failure.

· Concerns regarding implementation of new computerized applications include:

– Receptivity

– Notification about new orders

– Software failure and system integrity

– Downtime processes

– Physical space in nursing units

– Initial and ongoing training

– Pharmacy department accuracy

· Nursing personnel are skeptical about physician willingness to use computerized systems.

· Nurses fear that physicians will still ask them to access the system for order placement, test results, etc.

Ongoing physician education is an issue. Physician training and system support will be required. The patient safety benefits of CPOE will be maximized only with high physician utilization.

· The resident staff turn over on an annual basis.

· The INVISION training program for residents is only 45 minutes in length.

· It was estimated that only 50 percent of the Medical Staff is computer literate.

· There is no formal mechanism to perform just-in-time training for physicians. The Clinical Analysts help in this regard, but they would not be able to handle the volume of requests that would accompany a complete CPOE rollout.

Investments will have to be made in education for Nursing, case managers, Pharmacy, and staff of other relevant ancillary departments. This will prove invaluable for smooth transition and long-term overall acceptance of CPOE and Med Administration Check.

· Although no issues were noted here, Siemens believes this is important to document to prevent education being overlooked and to reiterate its role as a key component of success.

No metrics have been established for this project. It will be important to establish, collect, and review metrics to ensure that LSUHSC-S is benefiting from its investment in CPOE and Med Administration Check.

· Although there were no issues identified here, Siemens believes this factor is important to document. A list of recommended metrics is included in the next section.

Next Steps

At a high level, Siemens proposes the following next steps for LSUHSC-S. More detailed steps are included in the body of this report.

Organizational Steps

· Review the opportunities and recommendations contained within this report.

· Prioritize these opportunities based on the Impact Rating Scale.

· Translate these prioritized opportunities into tactical plans that identify specific adaptations to the project scope, timeline, workplan, and resources.

· Assign personnel to appropriate committees and teams. A suggested organization is outlined in the Discovery 2 section of this document (see page 12). Make all committees and teams interdisciplinary in nature and include all levels of staff. Each body should comprise individuals who perform these functions on a daily basis as well as those who have the authority to implement agreed-upon ideas.

· Focus on completing application training offered through Siemens Education Services and assign internal “super users.”

· Begin formation of the Training & Education Team to address a strategic plan for rolling out housewide education.

· Design a physician education strategy that is user friendly (that keeps training time to a minimum, makes resident training mandatory, and provides provisions for physician one-on-one training as needed). Consider developing a pocket-size reference for physician use.

· Implement the following clinical metrics as part of this project.

– Illegible physician orders

– Improper modifications to orders

– Use of U for units

– Physician compliance with medication order safety guidelines (use of abbreviations, no “trailing zeroes” such as .50, and consistent use of “leading zeroes” such as 0.5)

– Number of clarifications by type for ambiguous orders

– Incomplete orders

– Apothecary symbols used

– Use of ampoules or vials

– Improper abbreviations

– Point at which medication errors occur and benchmarks (ordering, transcribing, dispensing, or administering)

– Physician ordering errors by type (wrong dose, wrong choice, wrong frequency, drug-drug interactions, wrong drug)

– Number of modifications of orders

– Potential errors identified

· Implement the following organizational metrics as part of this project.

– Length of stay

– Denial rates

– Physicians accessing the system

– Verbal orders

– Duplicate orders

– Number of order sets in use

– Allergy entry within 24 hours of admission

– Turnaround time for ancillary tests – Radiology

– Turnaround time for ancillary tests – Laboratory

– Reduction in medication cycle time

– Cost per discharge (CMI adjusted)

– Lost charges

– Medication errors – adverse drug reactions

– Medication errors – adverse drug events (ADEs) – ordering and prescribing

– Medication errors – ADE – transcription

– Medication errors – ADE – medication administration

– Medication order interaction – duplicate ingredient

– Medical record delays – percent of discharged A/R

– Reduced forms costs

· Keep in mind the physicians’ stated desire for a computerized patient record. Ensure that decisions made today will lead toward that eventual goal.

· Develop device plans and implement these plans as a prerequisite to system implementation.

· Choose a vendor for the wireless network and initiate plans for installation.

· Install prerequisite software INVISION v24, Siemens Pharmacy v 23.4, Lifetime Clinical Record® v24 upgrade, INVISION Med IV charting (completed), OAS Gold (completed), Net Access, DS25/TS Upgrade, DB2 V7 upgrade, Super SUT Apply Services, and OPENLink® v23 upgrade.

Allergy Management Steps

· Begin system and operational design.

· Design, publish, and implement policies and procedures that address the following:

– Roles and responsibilities of all individuals involved in the allergy management process.

– Role of each skill level during downtime, both planned and unplanned.

·Develop and implement a strategy that provides consistent collection and entry of allergy data into INVISION.

·~~Develop device plans and implement these plans as a prerequisite to system implementation.~~

·~~Choose a vendor for the wireless network and initiate plans for installation.~~

Med Administration Check Steps

· Begin system and operational design.

· Design, publish, and implement policies and procedures that address the following:

– Roles and responsibilities of all individuals involved in the medication administration process.

– Role of each skill level during downtime, both planned and unplanned.

· Evaluate all standalone software systems that will be required to interface with INVISION and develop an integration plan for Med Administration Check.

· Develop standardized medication administration and documentation practices as a prerequisite to the Med Administration Check implementation.

· Develop an overall bar-coding standard as an integral component of Administration Check as well as for other applications that may benefit from bar coding.

· Identify a medication repackaging strategy.

· Identify wireless versus tethered wand scanner.

· Identify a positive patient identification solution using bar codes.

–· Develop and implement policies and procedures regarding bar-coded wristbands for all patient access areas.

–· Evaluate Pharmacy department staffing issues to ensure supportive, effective implementation and maintenance of Med Administration Check.

–· Develop and use metrics related to medication management and adverse drug events.

–· Establish protocols for the automated capture of patient information (such as weight and age) for appropriate drug therapy.

· Seek all available means to standardize prescribing practices due to the volume and rotation of residents in the facility.

· Determine a strategy for launching Med Administration Check on a pilot unit. Include an assessment of resource needs and the order of implementation for the application (concurrent versus tandem).

CPOE Steps

· Begin system and operational design.

· Design, publish, and implement policies and procedures that address the following:

– Roles and responsibilities of all individuals involved in the order entry process.

– Role of each skill level during downtime, both planned and unplanned.

– Assignment of personnel that are to enter orders into the system when the system is back up and running.

· Evaluate all standalone software systems that will be required to interface with INVISION and develop an integration plan for CPOE.

· Establish standards for entry of all key clinical documentation into INVISION for ease of access by physicians and other clinicians, thereby eliminating alternate forms of communication and prompts regarding daily patient care.

· Develop a standardized process for order generation and transmission across all departments and Nursing units as a prerequisite to CPOE. Develop policies and procedures for any revised process so that staff clearly understand implemented changes.

· Use an interdisciplinary approach for the development of order sets. Have physicians lead this effort through their departmental structure.

· Evaluate Pharmacy department staffing issues to ensure supportive, effective implementation and maintenance of CPOE.

· Establish protocols for the automated capture of patient information for order placement, e.g., patient history, vital signs, allergies, medications.

· Determine a strategy for launching CPOE on a pilot unit. Include an assessment of resource needs and the order of implementation for the application (concurrent versus tandem).

· Give strong consideration to acquiring the Siemens CPOE Model Starter Set provided by Siemens. Industry experts reveal that the average time for development and full implementation of physician-developed standard order sets is six months per order set. The starter set will speed implementation time, provide greater flexibility and functionality than the INVISION Order Entry application, and allow physicians to create order sets using terminology that is familiar to physicians.

· Consider promotion and approval of order sets at the Medical Staff department level to prevent duplicity and/or individual physicians developing their own order sets.

In summary, LSUHSC-S would like to have CPOE and Med Administration Check implemented in a pilot unit by February 2004. In order to make that happen, the above items as well as other recommendations listed in this report will have to be addressed. Although implementation will occur in pilot areas, it will be important for LSUHSC-S to consider the entire organization when planning rollout. This will mitigate rework as LSUHSC-S rolls out these applications to other areas.

The Siemens CPI consultants and clinical solutions team extends appreciation to LSUHSC-S’s executive team, physician staff leadership, and clinical staff of pharmacists, nurses, and other personnel who were actively engaged throughout this process. All are to be commended for their interest and cooperation. Their input enabled Siemens to produce this report summarizing key findings in detail and outlining potential opportunities to further reduce errors, decrease cost, and improve quality at LSUHSC-S as it implements CPOE and Med Administration Check.

Observation and Discovery Tool 2: Project Organization & Planning

Clinical Observation and Discovery Tool 3: Information Technology & System Integration

This portion of the assessment was omitted at the request of LSUHSC-S.

Clinical Observation and Discovery Tool 4: Clinical Operations & Workflow Design

During the course of this phase, the Siemens team identified enablers for success also known as “opportunities.” The opportunities identified in this summary are critical to the organization’s attainment of its objectives. Addressing and prioritizing these opportunities will enable and positively impact many areas of the organization. Areas such as vision, system enhancement, data integrity, workflow processes, staffing/organizational structure, technology, training/education, and performance metrics will be the principal benefactors of acting on these opportunities.

An Impact Rating scale has been assigned to assist LSUHSC-S in addressing and prioritizing its opportunities for change.

Impact Rating	Impact Rating Description
1	§ Highly Critical. Rate-limiting step. Cannot proceed without addressing this issue. § Will significantly impact adoption, implementation, go-live, project success. Resource intensive.
2	§ Moderately Critical. Should be prioritized as immediate, concurrent, or post-live. § Will provide moderate improvement. May impede go-live when coupled with other coexisting factors. May require moderate resources.
3	§ Ideal, but not urgent. May reflect a best practice scenario to adopt in a concurrent or post-live situation. Moderate resources required.
4	§ Ideal. May be adopted in post-live situation. Minimal resources required.

Detailed Findings, Opportunities, Potential Benefits, and Impact Rating

The following tables outline detailed findings and potential opportunities for improvement with associated benefits. These are organized by key process components.

Patient Identification

Patient Identification
Findings	Opportunities	Potential Benefits	Impact Rating
The admission process occurs in the following areas, with process variations among the areas. · Burn Unit · Emergency Room · Labor & Delivery · Bone Marrow · Cardio-Pulmonary · Admitting The process for requiring positive patient identification during the admission process, such as verifying a government-issued photo ID, is not consistent throughout the hospital. The patient addressograph plate is sometimes used for patient identification purposes.	· Standardize the admission process throughout the organization. · Require that the Admitting Director develop consistent organizational policies and procedures related to the admitting process, train all areas in this process, monitor performance on an ongoing basis, and provide feedback to ensure a level of performance that contributes to the achievement of organizational goals related to quality care and patient safety. · Require that all patients present a photo ID during the admission process. This will facilitate patient care and contribute to proper billing for services. · In anticipation of Med Administration Check, require all areas that admit patients to have the equipment to produce the bar-coded wristband that is necessary for Med Administration Check.	· Develop a consistent patient identification process. · Adhere to requirements necessary to implement Med Administration Check.	1
Bar-coding devices necessary to create patient identification bands do not reside in areas where an admission occurs at this time. To be effective, Med Administration Check requires a bar-coded identification band. These wristbands should be placed on the patient’s wrist during the admission process.	· Acquire equipment to produce bar-coded wristbands at all points of admission. · Create a plan to introduce bar-coded patient identification throughout the facility. · Develop a process whereby the bar code is printed directly on the wristband as opposed to placing a label on a plastic band. · Identify a unique number that can be used to identify the patient during the admission. Many hospitals use the patient account number. · Do not use the medical record or Social Security number on the wristband, as these numbers are not unique to the visit. · Place the bar code vertically on the wristband rather than horizontally. A vertical print allows the bar-code scanner to read the bar code more clearly, especially when printed on small bands such as those used in pediatrics and on newborns. · Develop a process for replacing a wristband while a patient is hospitalized to accommodate damaged or unreadable bands. · Ensure that the wristband only contains one bar code, that of the patient identifier. · Consider leveraging the bar-coded patient identification bracelet in other areas such as specimen collection and identification. The current Sunquest Laboratory system can accept bar codes.	· Adhere to requirements necessary to implement Med Administration Check.	1
The Radiation Oncology department takes a photo of the patient for identification purposes. The Burn Unit also maintains photos of patients.	· Consider scanning these photos into the PACS system for permanent maintenance and ongoing accessibility.	· Provide for permanent storage and online information.	4

Inpatient Order Processing

Inpatient Order Processing
Findings	Opportunities	Potential Benefits	Impact Rating
Order Generation
Physicians create orders by writing on a carbon-copy, two-ply Physician Order form (form #1138).	· Implement CPOE to eliminate the need for Physician Order forms.	· Improve legibility. · Establish a consistent ordering process.	1
LSUHSC-S has a policy that defines orders requiring cosignature. The policy addresses verbal and telephone orders and requires that these orders be signed within 72 hours. This policy is not followed consistently. The Health Information Management department flags charts for signature after patient discharge. It can take up to 30 days to get these orders signed. Delinquent physician signatures may result in suspension of hospital privileges. None of the physicians interviewed perceived that verbal orders will be eliminated entirely with CPOE.	· Implement CPOE. With CPOE: – All orders will be signed electronically. It is imperative that LSUHSC-S review state and federal electronic signature requirements. – System functionality will have to be assessed against current cosignature policy to ensure compatibility between LSUHSC-S’s policy and any restraints inherent to the system.	· Reduce delinquent charts associated with unsigned orders. · Ensure that the system can accommodate existing policy.	1
Identifying the wrong physician when entering verbal orders was reported as a common order entry error, especially for doctors with same or sound-alike last names. Recording the wrong physician can delay treatment as well as route results to the wrong physician.	· Implement CPOE to minimize the use of verbal orders. · For instances where a verbal order is necessary, develop procedures that will ensure the accuracy of data supplied for order entry purposes.	· Support quality patient care. · Improve medical record documentation.	1
Some of the physicians interviewed requested that the new system allow them to enter an indication for a consultation, procedure, or medication when entering an order. This will facilitate patient care and adhere to billing requirements, especially in the outpatient environment.	· Design screens in INVISION to accommodate the entry of an indication. Services that require an ICD-9-CM code can be entered to complete the order. For example, a drop-down box could be added to the screen in which the physician would select the proper diagnosis code. This will provide meaningful information to the receiving department and assist in billing issues.	· Facilitate regulatory compliance. · Prevent delays in treatment. · Improve the billing process.	3
Upon internal patient transfer from a critical care unit, current orders are discontinued and new orders are written manually. This is a practice that will need to be carefully evaluated upon implementation of CPOE.	· Evaluate existing policy in light of CPOE. · Develop processes that are compatible with INVISION system functionality and the needs of all services that provide care.	· Support quality patient care. · Improve physician productivity. · Improve communication with ancillary services.	1
Orders known to be prone to error include: · Continuous tube feeding orders; · Radiology special procedures.	· Use standard order sets, common lists, Fast Path order entry, and defaults to assist with complex orders.	· Facilitate patient care. · Decrease phone calls between services for order clarification.	2
Siemens identified 423 vendor-generated forms. These forms cover all servicing departments.	· As part of the CPOE implementation, evaluate all forms in circulation. If these forms communicate orders, eliminate them as order sets are created. Revise forms that document both orders and a consultation or treatment to eliminate the order portion of the document. This endeavor should be undertaken with the assistance of the Forms Committee.	· Reduce the cost of forms. · Automate portions of the record.	1
Medication Order Generation
Medication orders are comingled with other orders on the Physician Order form. This practice creates an opportunity for the Pharmacy department to omit a medication order. Pharmacy has reported that missed orders are a major problem.	· When implementing CPOE, develop: – Order sets by diagnosis or procedure; – Common medication lists that will highlight medications frequently used in a service area.	· Provide for consistent order entry. · Minimize omission of orders. · Improve medication turnaround time. · Facilitate CPOE.	1
Some new orders lack a date and time stamp. This may lead to missed or duplicate orders.	· Implement CPOE. CPOE will “stamp” the order with a system date and time when the order is signed or accepted.	· Provide for consistent order entry.	1
Physicians are not required to provide the indications for a medication on the Physician Order form.	· Build screens within the system that will prompt for a medication indication. Make this a required field. · The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) recommends that an indication be noted on all prescription orders. The notation of purpose can help further ensure that the proper medication is dispensed and creates an extra safety check in the process of prescribing a medication. At a minimum, PRN orders should require an indication. An order would not be considered complete unless an indication is noted. High-alert medications should also require an indication. See Attachment K for a listing of high-alert medications.	· Provide for an additional safety check by the pharmacist. · Enhance quality of care. · Enhance documentation.	1
Occasionally failure to renew medication orders renders a patient without orders. This delays medication treatment.	· Use the reporting functions within INVISION and Siemens Pharmacy to identify medications that are approaching expiration. For example, when using CPOE, upon displaying orders list the medications that will be expiring soon at the top of the page.	· Support prompt care. · Improve quality of care.	1
The Respiratory Therapy department utilizes its own order forms for medications and treatment. The initial INVISION order for respiratory therapy services is generic in nature. Following assessment by the Respiratory Therapist, specific orders related to medication and treatment are placed as verbal orders. A similar practice occurs in Radiology, CT, MRI, and Cardiac Catheterization.	· Develop order sets that can better define the treatments associated with a patient condition. · Develop CPOE screens and displays that will facilitate order placement for these services by both physicians and ancillary personnel when verbal orders are required. · Establish compatibility between verbal order policy and system functionality.	· Improve the order process. · Facilitate the capture of charges for ancillary services. · Support adequate oversight by the ordering physician. · Eliminate hard-copy forms.	1
There is a policy regarding duration of drug administration. · In general, the number of doses or number of days to administer a medication is required to be indicated. · Narcotic analgesics are to be rewritten every 72 hours. · Adult and pediatric total parenteral nutrition is required to be rewritten daily. · Ketorolac therapy cannot exceed five days.	· Build medication order entry screens consistent with LSUHSC-S policy.	· Support compliance with hospital policy. · Improve quality of care.	1
Per LSUHSC-S policy, all drug orders are required to be cancelled when a patient undergoes a surgical procedure, delivers a baby, receives a general anesthetic, or is transferred to another service from an Intensive Care unit. In practice, the Pharmacy department may not cancel or place orders on hold in the current Pharmacy system. With Med Administration Check, it will be important for medications to be cancelled or placed on hold according to policy. Medications that are not administered and are not identified as cancelled or on-hold will show as a discrepancy. This will be construed as a medication administration incident or error.	· Use the messaging function within INVISION to notify the Pharmacy department of medications that should be cancelled or placed on hold. For example, when a patient reports to the preoperative area, personnel can send a message to the Pharmacy department requesting that all medications be stopped.	· Support compliance with automatic stop policies. · Facilitate accurate reporting of patient treatment. · Facilitate accurate reporting of medication incidents and errors.	1
Order Transmission
Order transmission begins when Nursing unit personnel are notified that the physician or clinician has written an order. The notification to the nurse or unit clerk can be in a variety of ways. · Verbal notification · Folding or creasing the Physician Order form over the patient chart cover · Placing a colored flag on the chart Most nonmedication ancillary orders are entered into the INVISION system. Orders are identified as having been entered into INVISION by noting the INVISION order number next to the order on the Physician Order form. Depending on the Nursing unit, shift, or both, orders are pulled from the chart by the nurse or unit secretary who will enter the order into INVISION. CPOE will eliminate the need for the Nursing staff to note orders on the Physician Order form and transmit orders to the ancillary departments.	· Institute an interdisciplinary Clinical Workflow Redesign Team to assess the impact to the Nursing department, Medical Staff, and ancillary services, and to redesign existing processes. Best practice workflow diagrams are included with this report and can serve as a starting point for redesign. Include all stakeholders on this team. · Develop alternative ways to keep the Nursing department informed of physician-placed orders. Examples include: – Verbally notifying a unit; – Printing an “Order Session Summary” to a unit printer that can be placed on the chart or used as a worksheet; – Printing a new orders report throughout the day; – Developing an automated daily worksheet or Kardex; – Periodically reviewing online charts or order summaries.	· Provide for greater levels of nursing care for patients. · Improve nursing productivity. · Eliminate manual transcription. · Eliminate errors that result from a misinterpretation of what a physician has written.	1
Depending on the Nursing unit, charts with new orders are placed in various locations. Some Nursing units require that charts with orders be placed in a central location. Other units place their orders in various locations within the Nursing unit. This lack of standardization creates an opportunity for missed, lost, and late orders.	· As part of the CPOE project, standardize the order entry process so that it is consistent throughout the organization.	· Improve productivity. · Decrease training time. · Reduce errors as floats will follow a consistent process among units.	1
Colored note cards are used as part of a widely accepted manual process to communicate pending procedures, new orders, and other clinical information. These cards are generated by unit clerks the majority of the time. The note cards are clipped onto chart racks, charts, forms, Kardexes, or other artifacts as a prompt for Nursing staff to carry out daily patient-related activities. Part of this is due to the fact that the recurring order entry process within INVISION is not used at LSUHSC-S. Each day, Nursing personnel must enter the recurring order for the day. This will have serious impact on CPOE. Physicians will view this practice as redundant and time wasting.	· Implement the recurring order process in the INVISION system.	· Improve physician acceptance. · Improve quality of care. · Improve Nursing productivity. · Improve the turnaround time of results.	1
There is a high degree of dependence on the pneumatic tube system for the communication of orders to servicing departments. Some units do not have a pneumatic tube and must share a tube with another unit.	· Implement CPOE to eliminate dependence on the pneumatic tube. Orders will be transmitted in real time to the servicing department.	· Improve quality of care. · Allow for real-time transfer of orders. · Improve the turnaround time of results.	1
Order Verification
Nurse verification of medication orders appears to be a solo practice. Another nurse does not always witness high-alert medications, except in the case of chemotherapy drugs. This presents an opportunity for a medication error.	· Define what drugs will be considered high alert by LSUHSC-S. See Attachment K for examples. · Institute a verification process in order to support patient safety. · Implement Med Administration Check to provide a verification process for medication orders. In the Med Administration Check system, nurses can be required to verify a medication order prior to administering the drug.	· Improve patient safety. · Reduce the potential for medication errors.	1
Chemotherapy orders are verified by the Nursing staff in the following manner. · Initial orders are verified. · Calculations for body surface area (BSA) are verified by two nurses. · Calculated dosages on the order sheet are verified by two nurses. · All dosages are verified by two nurses.	· In Siemens Pharmacy, BSA calculation can use one of two algorithms. – Boyd-Brady – Dubois-Dubois · LSUHSC-S will need to determine the appropriate BSA algorithm and ensure that this algorithm is used throughout the facility.	· Standardize dosing guidelines.	4
Flowsheets used in the Critical Care units are hand-transcribed on third shift and are usually not compared to the original order. A Medication Administration Record (MAR) is used on all other units. The manual process used to create these documents lends itself to error.	· Replace manual flow sheets and MARs with Med Administration Check. Med Administration Check can serve as an automated MAR by verifying the drugs administered to a patient.	· Support patient safety. · Improve efficiency and productivity. · Improve the quality of documentation.	1
Night shift Nursing staff perform a 24-hour chart check against the hand-written physician orders. During this process, discrepancies are corrected. If a discrepancy is considered to be a minor error, it is not reported. If a discrepancy is considered to be a major error, a variance form is completed and reported. [FK1]	· Use the functionality within Med Administration Check to verify medication orders prior to administration so that this process can be eliminated entirely for medications. · Continue to verify nonmedication orders as in the past.	· Support patient safety. · Improve efficiency and productivity.	2
Observation and interview identified that few nurses recite a verbal order back to the ordering physician as a means of order verification.

Name	Title
Lee Bairnesfather	Customer Executive Sponsor
Glynn Johnston	Customer Project Manager
Shirley Taylor Barbara Hutto	Customer Clinical Analyst
Dr. Mansour	Customer Physician Advocate
Lee Bairnsfather	IT Steering Committee Chairman
To Be Determined	Clinical Workflow Redesign Team (Leader)
To Be Determined	Application Development & Conversion Team (Leader)
To Be Determined	Technology Infrastructure Team (Leader)
To Be Determined	Training & Education Team (Leader)
To Be Determined	Interdisciplinary Documentation & Transition Team (Leader)

Executive Summary

Background

Scope

Approach

Key Findings and Potential Opportunities

Next Steps

Summary of Findings, Opportunities, and Potential Benefits

Observation and Discovery Tool 1: Executive and Organizationwide Discovery

Key Physician Findings from CPOE Discovery

Observation and Discovery Tool 2: Project Organization & Planning

Clinical Observation and Discovery Tool 3: Information Technology & System Integration

Clinical Observation and Discovery Tool 4: Clinical Operations & Workflow Design

Detailed Findings, Opportunities, Potential Benefits, and Impact Rating

Patient Identification

Inpatient Order Processing