Friday, July 16, 2010

The bad news about CPOE and clinical protocols

So this week, the ONC released the final "Meaningful Use" rules. I'm still going through them, but in general, the response has been pretty warm. A lot of the regulations have been relaxed. Still, the overall message : Your hospital will still have to meet "Meaningful Use" if it expects to benefit from the government reimbursements.

So since I had a few free minutes, I thought I'd share the bad news about the conversion to CPOE. Wait - You probably already know. It's hard.

To get CPOE running effectively, you need complete organizational buy-in :
  1. Front-line buy-in, to help design meaningful order sets and implement them.
  2. Administrative buy-in, to help redesign committee structures and EMR governance, enforce the new rules, and help develop the flexible budgeting required for successful implementation.
And here's the hard part - CPOE is a major culture change for the culture of medicine. Some of our most sacred traditions start to fall apart in a CPOE culture.

"Like what?", you ask?

1. The order "Advance diet as tolerated" - You may have read this in medical school, or in your nursing textbook, but the truth is, this is essentially a protocol. In the paper world, it works reasonably well, because in most patients, nurses can figure out how to advance a diet, and what kind of diet to advance to. In the CPOE world, however, this generally becomes a clinical protocol. In the end : You may need the governance structure to build and approve this protocol.

2. The order "Up ad lib" - You may have also read this in medical school, or in a nursing textbook, and many nurses will tell you "That's part of our practice" - The problem is, in the CPOE world, this also becomes a bit of a clinical protocol. Again, it generally works in the paper world, because in most patients, nurses know how to ambulate someone safely. But in the CPOE world, it requires a better level of definition, and also often becomes a protocol. In the end : You may need the governance structure to build and approve this protocol.

3. The order "These orders only are active in the ED" - This type of order is also really a protocol, which basically instructs : "If the patient leaves the ED, then someone needs to discontinue these orders". This works in the paper world, because nurses (seeing this in an order section of a paper chart) will generally know which orders this statement refers to, and nurses elsewhere will then ignore those orders automatically. In the electronic CPOE world, however, it requires a protocol to make sure someone has discontinued the orders properly. In the end : You may need the governance structure to build and approve this protocol.

Yes, some of these most cherished traditions start to fall apart in the CPOE paradigm. See any of them in your current paper order sets? You can translate them to the CPOE world, but you will need to build a more robust way of accomplishing this same functionality - Unfortunately, it's not that easy to find evidence-based rules for developing these protocols.

Your alternative is to develop order sets without any clinical protocols. These will be easier to implement in clinical specialties which are in-house 24 hours/day (e.g. Hospitalists, ED, ICU, etc.), but will be more challenging for surgical specialties and others who manage outside practices. (E.g. they will get phone calls that they weren't used to in the paper world.)

This is why you will need workflow experts in your organization to help understand the exact details of these workflows, and help you develop your clinical protocols along with your order sets and CPOE. Doing them separately is a much more complex process.

So how does a small hospital tackle these challenges? This is tough! The government (and vendors) don't talk a lot about this part of the process - I can only repeat the mantra : "Installing an EMR is nothing at all like installing Microsoft Word into your home computer" - You should be prepared for significant cultural and organizational changes.

In the end, my honest feelings : An EMR will definitely help you organize and understand your own clinical processes. The lessons you learn are invaluable. The quality and control it can bring you are priceless. But you have to be prepared for the level of change. Are you prepared?

In the end, an experiences CMIO or other informatics professional can help you organize all of these changes. My advice : Doing this without expert help is a little bit like turning a battleship around in a bathtub - You *can* do it, but it's much easier to do with an experienced and knowledgeable navigator.

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