Verbal orders won’t necessarily go away after CPOE implementation

AMN Healthcare: “A new AHRQ-funded study found that of roughly 973,000 orders that physicians at a large, Midwestern hospital gave nurses over a 12-month period, roughly 20 percent were verbal orders. The hospital transitioned from a paper-based to computerized provider order entry (CPOE) system during the study period. The new study is one of the first to examine how the content of verbal orders or the context in which they are given might increase risk of error. Although more hospitals are converting totally or in part to CPOE, most experts expect verbal medical ordering to continue to be used extensively for the foreseeable future. According to the researchers, who were led by the University of Missouri’s Douglas S. Wakefield, Ph.D., five factors potentially contribute to verbal orders causing medical errors—type of care setting; time of day or week; type of communication and related variables, such as the physician’s and/or nurse’s accent and articulation; the providers’ knowledge of the patients for whom the order is being given and previous contact experience between the physician and nurse; and environment including background noise and staffing levels. The study, “An Exploratory Study Measuring Verbal Order Content and Context,” was published in the April 2009 issue of Quality and Safety in Health Care.” “– There really are very few excuses for giving verbal orders in a facility that utilizes CPOE. A couple that come to mind might be in a true emergency or in the case of a physician being unable to get to a computer. Unfortunately physicians frequently abuse the verbal order system out of laziness, creating a dangerous situation. I’ve had to clarify my fair share of verbal orders that were poorly transcribed from the physicians lips, to the nurses mind, and finally onto paper. There are simply too many variable during the process. It’s like the old game where you start a rumor with one person and have them pass it on to someone else and so on down the line. At the end of the line, you have a garbled mess. Verbal orders are like that. CPOE is implemented as a safety feature to reduce prescribing and transcription error, but to benefit from the feature physicians have to use it.

Siemens Innovations ’09 – The End

Siemens Innovations has officially come to an end. My time in Philadelphia was good, but I will be happy to get home to the “dry heat”. The information I picked up was very valuable and I made some great contacts. I’m excited to get back to work and see what damage I can cause with my newly acquired knowledge.

As I wrap up my time here at Innovations ’09 a few thoughts come to mind:
Continue reading Siemens Innovations ’09 – The End

Siemens Innovations ’09 – Opening Session

This mornings opening session for Siemens Innovations ’09 was delivered by Janet Dillione, CEO of Health Services Siemens Healthcare. Not surprisingly, the opening speech was focused on the American Recovery and Reinvestment Act (ARRA) and healthcare reform. Healthcare information technology took center stage from about an hour.

Some items of interest to me were:

  • Based on the presentation slides, it appears that Siemens is betting on CPOE being the gate through which all hospitals will have to travel to qualify for “meaningful use” healthcare dollars. However, Dillione does not necessarily believe that most hospitals will be able to accomplish CPOE implementation by the end of 2011. This statement is particularly interesting when you consider that Siemens has a unique insight into their customer base, and would love nothing more than to install CPOE in hundreds of healthcare systems across the United States. It makes me wonder how hospitals will choose to handle CPOE over the next 18 months.
  • Soarian will be the focus of Siemens implementations over the next year as they build the foundation for CPOE with better clinical functionality and documentation. Dhillone spent a lot of time hyping the speed and stability of the most recent Soarian release.
  • Doing more with less was a common theme throughout the opening remarks. Focus was placed on hospitals doing a better job of managing patients with chronic healthcare conditions like diabetes, asthma, and heart failure by making better use of “clinical people”, specifically physicians and nurses. That’s right, pharmacists were never mentioned.
  • Not one time did Dillione mention pharmacists or advancing their line of pharmacy based products. I found this a little disappointing as pharmacists have been shown to be cost effective when used appropriately. In addition the Siemens Pharmacy system is tied into many other Siemens products, including CPOE, BCMA, admitting, financials, and lab.
  • “Integration” is out and “Interoperability” is in. Time was spent discussing the need to make Siemens products interoperable. I think we need to develop some standards for much of the software available in healthcare before claiming interoperability. As far as I’m concerned all Siemens products should be plug-and-play out of the box when utilized with other Siemens products. The problem exists when a third party vendor needs to tie into your primary system (i.e. Siemens Pharmacy, Siemens MAK, Siemens Soarian, etc.). To the best of my knowledge basic guidelines may exist, but there is certainly no standard. Did I hear someone say “cloud”? Well, I certainly think that’s an approach we should be investigating. It’s difficult to ignore interoperability when all the information is centrally located and all you have to do is create access to it.
  • Sessions I’m attending today include: Siemens Pharmacy/Med Administration Check Solutions Update, A Detailed Approach to Workflow Data Collection and MAK Design, and Barcoded Medication Administration: Is It a Luxury or Standard of Care?.

    More to follow…..

    Meditech Version 6 – Does glitz and glam equal better functionality?

    EMR Daily News: “A new KLAS report takes a closer look at the latest release of the Meditech electronic medical record (EMR) software and whether it’s a viable solution to help Meditech’s more than 2,000 clinical customers reach the meaningful use threshold. The release of Meditech 6.0 brings with it high expectations for making the software better suited for physician use, which is a key aspect of the federal government’s definition of meaningful use and a traditional weakness of Meditech systems. According to the KLAS report “Meditech Version 6: A Strong Step Forward?”, early adopters of version 6 are reporting positive results, including an improved user interface and easier navigation, but many obstacles still stand in the way of widespread adoption. “Meditech has long struggled with deep CPOE adoption, and version 6 is geared toward addressing that gap,” said Jason Hess, KLAS general manager of clinical research and author of the Meditech report. “However, several issues will likely impact how quickly version 6 is rolled out to the Meditech customer base.”
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    Cool Technology for Pharmacy

    This week’s Cool Technology for Pharmacy is a piece of software from Zynx Health called ZynxOrder.

    ZynxOrder is a knowledge management system for developing and maintaining evidence-based order sets, alerts, and reminders. According to the Zynx Health website: “ZynxOrder publishes the order set templates and software tools that enable you to measurably improve the quality, safety, and efficiency of care. The content includes more than 850 order set templates. ZynxOrder has four key components: Clinical Content, Implementation, Collaborative Technology, and Deployment.”

    Zynx Health is a company composed of physicians, nurses, and other allied health care professionals that continually review medical literature and use the information to develop guidelines in the form of evidence-based order sets found in ZynxOrder. The online work environment provides users several template options for medical conditions ranging from community acquired pneumonia and congestive heart failure to post-operative pain management and bowel care. Once a template has been chosen, the user selects evidence-based treatment options from a list. Nothing could be easier.

    I received a demo of the software several months ago and was quite impressed. Anyone that develops and manages hundreds of order sets will appreciate the functionality and user friendly interface that ZynxOrder offers. All order sets are stored in a centralized database and all changes are tracked via strict version control. ZynxOrder even offers an interface between the order set development software and the Siemens Computerized Provider Order Entry (CPOE) system, allowing the user to quickly upload new and revised order sets upon final approval.

    The only real downside to the software is the cost; however literature is available to support cost savings associated with systems like ZynxOrder. I think it’s worth a look.

    Zynx Health also offers a monthly newsletter called Evidence Alert. The newsletter offers the cliff notes version of findings from recent medical literature. It’s free and available to anyone willing to ask.

    A couple of articles on medication errors worth reading

    The entire June issue of the British Journal of Clinical Pharmacology (BJCP)  is dedicated to medication errors. It’s worth your time to browse all the articles, but the two below were of particular interest to me.

    Agrawal A. Medication errors: prevention using information technology systems. British Journal of Clinical Pharmacology. 2009 ;67(6):681-686.
    The article covers all the usual suspects when it comes to reducing medication errors via technology. Technologies discussed include CPOE, barcoding, BCMA, medication reconciliation, personal health records, automated dispensing cabinets and decision support systems. No great amount of detail was presented, but the article is well referenced. The entire abstract can be found here.

    Cheung K, Marcel L. Bouvy, Peter A. G. M. De Smet. Medication errors: the importance of safe dispensing. British Journal of Clinical Pharmacology. 2009 ;67(6):676-680.
    The article discusses several strategies for reducing dispensing errors, including barcoding and automated carousels. For each strategy presented, the authors provide some level of support found in the literature. The article is worth adding to your collection. The entire abstract can be found here.

    One final item worth mentioning is a brief editorial written by J K Aronson, the President of the British Pharmacological Society. In it he states “Computerized systems can contribute to prevention as well as detection, but they are expensive and can generate their own forms of error. Simpler and cheaper methods are available and should be widely implemented. For example, error reporting is important in both detection and prevention, and pharmacovigilance has a role to play. However, chief among the preventive methods is education.” – I find this statement both insightful and accurate.

    Length of time to implement CPOE

    Ok, I’ve taken a little heat since claiming that a “meaningful use” goal of 10% CPOE was weak, so I did a little digging. While collecting ammunition for my defense I came across a little blurb addressing this very issue.

    CHIME070909.ashxiHealthBeat: Thirty-five percent of hospital CIOs surveyed said it would take their facilities three years to achieve 100% adoption of computerized physician order entry, according to a new survey from the College of Healthcare Information Management Executives. Twenty-seven percent of CIOs surveyed said it would take their hospitals two years to achieve 100% CPOE adoption, while 17% of respondents said complete CPOE adoption would take four years and 13% estimated a five-year time frame to achieve 100% adoption. Only 9% of CIOs surveyed said full CPOE adoption could be achieved in one year.”  – Remember that the “adoption year” timeframe is 18 months away (2011) with a 2012 start date qualifying you for the full incentive potential. This means you could actually wait as late as 2013 for full adoption and still qualify for funding. I realize CPOE is a major project; we’re struggling with it right now. Bu I still think hospitals have enough time to do this right and still get 100% usage. As the saying goes, “nothing worth having comes easy”.



    “What’d I miss?” – Week of July 13

    As usual there were a lot of things that happened during the week, and not all of it was pharmacy or technology related. Here’s a quick look at some of the stuff I found interesting.
    Continue reading “What’d I miss?” – Week of July 13