By now, many healthcare organizations are on the road to implementing electronic medical record (EMR) and computerized physician order entry (CPOE) systems that we optimistically hope will cut costs, improve quality, and reduce medical errors—as well as comply with federal and state regulations. Although some organizations are further along on this journey than others, we all could use a little encouragement that we're travelling in the right direction.
A recent study released by researchers at Lucile Packard Children's Hospital (LPCH) and Stanford University may be just the signpost we've been waiting to see.
For the first time, researchers have shown that a significant decrease in hospital-wide mortality rates can be associated with implementing a CPOE system that enables physicians and other medical staff to order medications, tests, and other treatments electronically. If configured properly, the systems can also provide decision support at the point of care.
LPCH correlated its information technology (IT) system from Kansas City, MO?based software vendor Cerner Corporation with a 20% decrease in mortality rates at the hospital over an 18-month period, which amounts to 36 fewer deaths. The hospital launched its IT system in 2007.
"It lends information to the current debate about why you should implement these systems," says Eric Widen, MHA, administrative director of performance improvement at LPCH. "These systems are very expensive to implement. That level of investment is now justified by understanding that you can have a very significant impact on quality, and that includes mortality rates."
The study contradicts previous findings that had actually shown an unexpected increase in mortality rates after CPOE implementation, including a landmark publication that Children's Hospital of Pittsburgh published in Pediatrics in December 2005.
"We compared ourselves to 42 other children's hospitals who submit their mortality data to the Child Health Corporation of America [CHCA] database," says lead author Christopher Longhurst, MD, medical director of clinical informatics at LPCH and clinical professor at Stanford. "In 2008 and 2009, we became the single lowest-adjusted mortality facility of any of these other 42 hospitals."
According to Longhurst, the authors of the study were pleased when mortality rates began to decline nine months after implementation. When they continued to decline after 12 months and then 15 months, authors went back and ran their statistics to verify the significance of their findings. At that point, they decided they needed to conduct a study to share these revealing data with other sites, says Longhurst.
Saving lives by saving time
Using the system to reduce unnecessary wastes of time was the biggest catalyst to lowering mortality rates at LPCH. When the hospital studied its turnaround times for laboratory, radiology, and medication orders, it found a significant decrease in the time from when a clinician placed an order to the time someone acted on it by conducting a radiology exam or administering medication.
"There's a lot of waste in the system associated with paper orders that involve faxing, tubing, or people having to find the order rather than having it pop up automated on a work list," says Longhurst. "In some of those cases, we cut those turnaround times in half. It's not hard to imagine that getting medication to a critically ill child five or 10 minutes faster can actually have an outcomes impact."
Speeding up order entry processes not only results in faster order completion, it also helps hasten a physician's access to laboratory and radiology results, says Widen.
"We think it has a benefit for those highly acute patients who require fast decisions," he says. "This gives our physicians quicker access to information."
In addition, all of the nursing and ancillary service documentation is available to physicians electronically. "That makes our vital signs and patient physiologic data available in real time throughout the hospital and outside the hospital," Longhurst says. The availability of that information could have also contributed to the mortality reduction, he adds.
Real-time, automated clinical decision support
According to Longhurst, physician ordering drives half of the resources in LPCH. And, as one might expect, there can be variability in physician ordering practices even for similar diagnoses, such as the request for a blood transfusion.
Clinical resource management programs can focus on educating physicians about such variances by trying to get them to change their ordering habits; however, LPCH discovered that it can hardwire such changes into its CPOE system. Widen refers to this as "building a better mousetrap."
For example, LPCH has data about transfusion thresholds in children that suggest that hemoglobin over 7 g/dl does not require a transfusion. Longhurst says that, traditionally, it would take five to 10 years to disseminate those data to physicians to standardize the orders they place—and it still wouldn't always happen consistently.
Instead, the hospital hardwired it into its CPOE system. Now, a prompt in the form of a decision support tool will display at the point of care when a physician orders blood products on a patient who has hemoglobin over the threshold that is set in the system.
"It doesn't force the physicians to change their minds, but it gives them important information at the time that they're making that ordering decision," says Longhurst.
The hospital will be publishing outcomes based on this example that Longhurst says will show a 50% decrease in transfusion utilization outside of LPCH ICUs.
"That's a huge impact, and it happened very quickly without a lot of broad education," he says. "It happened with a single system implementation."
It's about more than medication errors
Reducing medication errors is one of the most vocal arguments proponents of EMR and CPOE systems use when lobbying for greater adoption rates. However, Longhurst and Widen say that medication errors typically don't contribute to an increase in patient mortality rates, which is the indicator looked at by their study.
"We were already doing very well from a medication safety standpoint, and our data did not show a significant impact on medication errors," says Longhurst. "While medication errors are certainly serious, they're very rarely fatal."
According to Widen, many other factors contribute to advance quality efforts. While groups like The Leapfrog Group hold a magnifying glass up to medication errors, LPCH is using technology to help advance its quality efforts and having a bigger impact on mortality rates.
"There are a lot of things that we do as an organization to keep quality going in the right direction," says Widen. "Medication error doesn't necessarily lead to harm. When you study things like harm, this is showing that there's an actual reduction in harm to patients using technology in a smart way."
CPOE is a journey, not a destination
The Healthcare Information and Management Systems Society standards indicate that LPCH is a Stage 6 hospital, meaning that the hospital enters nearly all of its orders electronically. Prescribers such as physicians and nurse practitioners enter about 97% of all the orders, says Longhurst.
Clinicians enter the other 3% of orders, which get transcribed into the system as verbal orders that have been given over the phone or during an operation.
Widen says the hospital will soon be at 100% CPOE compliance. It has a cardiovascular ICU that will go live with CPOE this month and an ICU that hasn't started using it yet. The hospital decided that units with the highest acuity levels would receive the system last.
Looking back, Widen says LPCH saw the CPOE implementation as a work flow redesign supported by health IT. He says the implementation was less about technology and more about redesigning processes and work flows to be smarter and more efficient.
"We invested in as much process redesign and change management as we did in technology on this project," he explains.
Now that LPCH is almost fully electronic, the hospital is looking at other opportunities to leverage its data. In the future, Longhurst says it will focus on the following three key areas:
1. Leveraging analytics: Making better use of data in real time.
2. Empowering patients: Making data available to patients to allow them to participate in their care process. For example, LPCH is partnering with Google to allow patients to download their child's healthcare data from the hospital to Google Health, where they can organize, track, monitor, and act on the information.
3. Conducting research: Conducting groundbreaking research to develop better predictive algorithms.
"I think that a good lesson learned for other sites is that implementing the EMR is not a destination, it's a journey," says Longhurst. "The first conversion event is just the beginning of that journey. We're constantly trying to optimize our system to help deliver better outcomes in patient care."