HMT Denver Health and Hospital Authority (Denver Health) ranks in the top 5 percent of U.S. Hospitals in terms of size and provides care for more than 160,000 individual patients — one out of every four people in Denver. The organization comprises a 500-bed hospital, a 911 medical response system, a network of family and school-based health centers, as well as, public health resources, a Level 1 trauma center, the Rocky Mountain Poison and Drug Center, a correctional care facility, and Denver Cares, a non-medical detoxification center. Thirty-five percent of Denver’s children use Denver Health facilities, and patients from every county in Colorado, in addition to 28 other states, receive care at Denver Health’s facilities.

Since 1992, Denver Health has provided $3.1 billion in unsponsored healthcare, and even though it has just 12 percent of the beds in the metropolitan area, it provides 40 percent of all unsponsored care. We are the region’s primary safety net dedicated to developing and integrating ground-breaking healthcare information technology (HIT) to improve overall patient care.

Reducing Risk and Driving Efficiency

Much of our success in the past 15 years is due to our early adoption of HIT — spending more than $300 million in slightly more than 10 years. After implementing significant system updates, our IT department recognized that to reach the next level, and add measurable return on investment (ROI), we needed to deliver an integrated approach to clinical and non-clinical patient care. For this work, Denver Health collaborated with Siemens Medical Solutions to initiate our plans.

Although the time investment of the core physician team can be considerable, our experience has shown that this clinician participation was a key contributor to success.

The Denver Health/Siemens team identified computerized physician order entry (CPOE) as a key project that would have a direct and positive impact on ROI. We anticipated that the implementation would result in less potential for human error; reduced time to care (time between order placement and clinician availability; improved order accuracy and quicker order confirmation turnaround time; better clinical decision support at the point of care; timely availability of crucial prescribing information; and, enhanced communication between physicians, nurses, pharmacists and patients.

Implementation Strategy

From the beginning, our executives recognized how vital it would be to involve our physicians, nurses and other clinicians in the overall CPOE strategy and implementation process. We involved them every step of the way and provided them with avenues for feedback, as we moved through our rollout.

For more information on
Siemens CPOE solutions

We worked closely with our partners at Siemens to develop a plan for staff participation. First, the team worked together to form CPOE workgroups, which included physicians, nurses, IT staff and other relevant parties. Following the initial implementation of our new CPOE system, these multidisciplinary workgroups were tasked with determining rollout strategy and timelines.

We established one CPOE workgroup that served as the main governing body. Then, we formed various subgroups that reported to our main workgroups and worked to gather and provide critical feedback on the system and rollouts. We tried to create as many subgroups as possible to ensure we were gathering input from everyone who would have exposure to the system. This included pharmacists, nurses, clinicians, lab staff and technicians.

Achieving Physician Buy-in

Given their impact on decision making, resource utilization and workflow in patient care, physicians, in particular, are a key constituency in CPOE adoption. As we worked through the steps of cultural and technological evolution to achieve more advanced patient care, we needed to continually educate physicians and encourage them to support the CPOE initiative.

We recognized very early on that the clinical workflow is a dynamic process and must be flexible based on the needs of the patient population and the clinicians that deliver care, as well as the constantly evolving knowledge base in medicine and healthcare. CPOE systems, and the integration of these clinical systems with pharmacy, radiology and other ancillary services, is particularly important because it can support the creation of an interoperable health system in which patients and their physicians can access real time, patient-specific health information from multiple sites and points of care. Yet, getting our CPOE system up and running was a challenge.

From the beginning, our executives recognized how vital it would be to involve our physicians, nurses and other clinicians in the overall CPOE strategy and implementation process.

It was clear to us that unless our physicians could see the potential advantages of adopting a new workflow that included usage of CPOE, we would not be successful in securing their buy-in.

As a result, we worked to form a core physician design team which was engaged with the project from its early stages. This core physician team was tasked with analyzing the technology’s impact on their workflow and decision-making processes. These physicians participated in system selection, workflow redesign, content development, screen design and flow, activation strategy, and communication planning and training.

In our case, we found the most effective strategy was to assign a number of full-time clinicians and ancillary staff to learn the CPOE system and to help define its configuration. Upon adoption, this core group helps to facilitate knowledge transfer and support training for their colleagues. Although the time investment of the core physician team can be considerable, our experience has shown that this clinician participation was a key contributor to success.

Denver Health found the process to be most effective when we consulted regularly with our physicians about their expectations and needs, and when they discussed their priorities. These consultations helped us to assess physician readiness for change and their propensity to adopt the new CPOE solution. The role of the core physician advisory/design team in the adoption of a CPOE system cannot be understated.

One major hindrance to CPOE adoption by physicians is their perception that CPOE equals cookie-cutter medicine. One of the major tasks our physician group supported has been to help colleagues understand that CPOE implementation allows them to tailor care to individual patients. Physicians need to grasp the fact that CPOE does not supersede clinical judgment — it supports it. Physicians are still in charge of directing care for individual patients.

It’s important to note that physician-focused design groups must include not only physicians but also employees from nursing, pharmacy and other ancillary areas. This will ensure that order sets and other elements of the final implementation will truly reflect the hospital’s clinical workflow and decision-making process.

One of the most important tasks in building the physician support foundation for any advanced CPOE implementation is the development of physician order sets. Effective order sets support quality care and resource management in many ways. Developing order set templates with clear order categories and formatting allowed our physicians to select order sets for their individual practice preferences, as well as tailor ordering for individual patient needs. We have standardized more than 500 care process and more than 100 evidence-based order sets, which has become a major factor in physician CPOE acceptance.

Better Communication — Faster Results

We brought in various clinical resources who understood the challenges clinicians and physicians might face when using a new computerized system and who could anticipate some of the skepticism that might arise. These resources were to meet with staff members and speak with them about how the system could help them provide better quality of care.

Following the solidification of strategy and rollout timelines, we began educating all staff members on the benefits of the new system. Initially, training and education sessions were conducted on an ad hoc basis, once or twice a month. Our team realized this was not the best training model for Denver Health and quickly began executing more one-on-one classroom training for assistance with implementing the CPOE system.

The new model proved extremely successful. We began to see improved workflow, more fluid physician communication and faster results. Although adding clinical resources to training programs had been done in the past, we maximized this model to reap many benefits.

To date, 100 percent of inpatient beds now use CPOE. We have achieved an 83.4 percent reduction in medication availability time; a 54.5 percent reduction in laboratory turnaround time; and, a 61.5 percent reduction in radiology turnaround time. There are 600 unique users utilizing CPOE to place more than 200,000 legible orders each month.

Going Forward with CPOE

Today, healthcare enterprises face increasing pressure to improve patient safety and clinical care quality, to raise patient satisfaction levels, and to increase efficiency and cost effectiveness. CPOE has been part of our journey to meet these pressures. Organizations that also move to effectively implement CPOE solutions throughout their enterprises should be well positioned to achieve their goals.

People do not intend to make mistakes. They result from processes that hinder the timely sharing of accurate information. CPOE allows individuals to quickly access the information that they need and helps them to avoid making mistakes. CPOE supports a repository of knowledge that reduces dependency on memory and allows clinicians to proactively deal with issues surrounding patient safety and quality.

Gregory Veltri is CIO at Denver Health and Hospital Authority. Contact him at gregg.veltri@dhha.org .

• August 2008 FEATURE ARTICLES •

Clinical Information Systems: CPOE

Transforming Healthcare