The Need for Implementing Computerised Physician Order Entry - Term Paper Example

Healthcare Innovation: Reducing Medication Errors by Computerizing the Prescription Process Introduction One of the major problems in healthcare today is medication errors: errors in prescribing and dispensing medications (Eslami, de Keizer, & Abu-Hanna, 2008). These errors can have severe consequences, ranging from ineffective treatment of patient illnesses to the creation of new patient problems due to overdose, incorrect administration of treatments, allergic reactions to medications, and interactions between drugs. Medication errors are a major—and almost entirely preventable—source of morbidity and even mortality, and significantly add to the financial cost of healthcare. As such, any initiative that can significantly reduce medication errors will contribute significantly to effective, safe, and efficient healthcare. In order to reduce medication errors, many advanced healthcare institutions have adopted Computerised Physician Order Entry (CPOE)—a system to replace the old-fashioned pen-and-paper prescribing method with an interactive computer application based on a database of available medications, dosages, etc., often including information on interactions, indications, and other factors that reduce the possibility of incorrect prescribing. Even without taking into account the more advanced features of most CPOE systems, the simple change from hand-written prescriptions to computerized entry and communications is a powerful force in reducing error and improving efficiency: almost half of medication errors are the result of inaccurate or unclear prescribing, including poor handwriting and the use of non-standard abbreviations (Naylor, 2002). This paper will investigate the need for implementing CPOE in Riyadh Kharj Hospital (RKH), and the likely effect of implementing this technology in reducing the incidence of medication errors. It will first present evidence to substantiate the need for change from the current practice of prescribing medications by hand; it will then discuss how implementing a CPOE system can meet this need. Following this, the relation between the proposed CPOE system and current best practice will be examined and discussed in depth. Finally, a business plan for the implementation of CPOE will be introduced; this plan will encompass allocation of responsibility, transitional arrangements, resources and costs, risk management, evaluation, and dissemination of the new technology. The problems and risks of handwritten prescriptions, and the goals of the transition to CPOE In order to understand the necessity of change from handwritten prescriptions to CPOE, this paper will first survey the current literature to demonstrate the nature, incidence, causes, and risks of medication errors throughout the world. Medication errors significantly increase morbidity, mortality, and healthcare costs in most countries (Eslami, de Keizer, & Abu-Hanna, 2008); for example, such errors have been estimated to cause more than 770,000 deaths or illnesses annually in the United States (Koppel et al., 2005) and almost 80,000 hospital admissions per year in Australia (Roughead, 1999). An estimated 1 to 2 percent of all patients admitted to American hospitals receive medications in error (Dean et al., 2002; Gandhi et al., 2005). The cost of medication errors is high in financial as well as human terms: one study (Cohen, 2001) estimated the annual cost of morbidity and mortality due to medication errors in the United States to be $136 billion; while another study (Stafford, 2006) estimated that each patient illness created by a medication error resulted in increased hospitalization costs of $8,750, on average. Even when medication errors are identified before such harm is done, they impose a heavy (albeit difficult to quantify) cost on healthcare institutions: according to Glabman (2005), for example, some 150 million calls from pharmacists to doctors were required annually in the United States to clarify unclear or incorrect prescriptions. In the Kingdom of Saudi Arabia (KSA), a study of the prevalence of medication errors in primary care centres in Riyadh showed that more than 11.5% of all drug prescriptions issued had at least one error (Khoja et al., 1996). Moreover, a systematic analysis of prescribing patterns at KSA primary care centres found that more than 50% of medications were prescribed without a specific duration, and that 96.5% of prescriptions did not identify the strength of the prescribed medication (Al-Nasser, 1991). Medication errors can occur for both inpatients and outpatients; outpatient medication errors are more difficult to identify, as prescriptions are filled at multiple pharmacies and patients generally purchase and administer their own medications without professional oversight (Gandhi et al., 2005). It has been estimated that between 1.5 and 5.3 percent of inpatient medication orders have errors (Dean et al., 2002; Gandhi et al., 2005); and that around 7.6% of all outpatient drug prescriptions have errors (Gandhi et al., 2005). It is clear, then, that erroneously prescribed medication is a common and serious problem throughout the world. Accordingly, effective initiatives to reduce the incidence of medication errors should be a high priority. This is especially true for large hospitals such as RKH since, based on probabilities alone, the likelihood of serious medication errors occurring in such large hospitals is extremely high. Recognition of the prevalence and seriousness of medication errors, along with an adequate understanding of their causes, is crucial in designing efficient initiatives to mitigate this problem. In order to determine what measures may be effective in reducing medication errors, it is necessary to understand what these errors are and how they come about. Medication errors include all errors that occur in any of the five phases of the drug delivery process: ordering medication, transcribing such orders, preparing the medications ordered, distributing medications, and administering them to patients (Moyen, Camire, & Stelfox, 2008; Gandhi et al., 2005). A number of studies conducted to examine the occurrence of medication errors showed that most of these errors occur during the prescribing and administering phases. For example, a systematic review conducted by Krahenbuhl-Melcher et al. (2007) on publications between 1990 and 2005 found that more than two-thirds of medication errors were made either in prescribing or administering medication. Almost 50% of the prescribing errors result from the use of non-standard abbreviations or from poor handwriting (Naylor, 2002; Eslami, de Keizer, & Abu-Hanna, 2008). Other factors that may lead to medication errors are inappropriate labelling of medicines, the misplacement of decimal points, health professionals’ lack of knowledge, prescribers’ failure to communicate important information such as drug name, dose, duration, and administration route, and confusion between drugs that have similar names (McBeide-Henry & Foureur, 2006); understaffed units (Roughead, 1999); lack of patient monitoring (Jordan, Tunnicliffe, & Sykes, 2002); and the heavy workload of health professionals (Eslami, de Keizer, & Abu-Hanna, 2008). At RKH, physicians still use pen and pad for prescribing medications; as a result, the probability of occurrence of most of the above-mentioned errors is very high. There is thus good reason to believe that changing the method of ordering medication can reduce the incidence of medication errors at RKH, ultimately reducing mortality, morbidity, and costs resulting from these errors. The best available tool to improve the accuracy of prescribing and administering medication at RKH is a CPOE system—an electronic prescribing application for physicians and other authorised prescribers, such as nurse practitioners, to enter diagnostic and therapeutic orders instead of writing them by hand. Many studies have shown that CPOE applications efficiently reduce the incidence of errors in the medication ordering and delivery process (Doolan & Bates, 2002; Gay, 2006; Kuperman & Gibson, 2003). A time-series study conducted by Bates et al. (1998) six months prior to the implementation of a CPOE system and nine months afterwards assessed the efficacy of CPOE in preventing non-intercepted serious medication errors in an adult population. The study found that non-intercepted serious medication errors were reduced by 55%, and preventable adverse drug events were reduced by 17%. One year later, Bates’ group published another prospective time-series study, evaluating the impact of a CPOE system with and without decision-support logic in decreasing the rates of medication errors of three medical units over four years. This study showed that medication errors other than missed doses were reduced by 81% after the introduction of the CPOE system; much of that reduction was achieved after the addition of decision support features to the system (Bates et al., 1999). Finally, a retrospective cohort study by King et al. (2003) to assess the impact of a CPOE system on medication errors showed that the introduction of CPOE decreased the occurrence of medication errors by approximately 40%. Many other studies have demonstrated the benefits of implementing CPOE systems, especially when the installed system includes advanced features such as decision support, executable knowledge, electronic medical records, and alerting systems (Sittig et al., 2008; Doolan & Bates, 2002; Cerner Corporation, 2008; Gay, 2006). Clearly, then, CPOE is an effective tool for reducing the incidence of medication errors. The studies mentioned above generally measured improvements in the prevalence of erroneous delivery of medication to patients; in addition to this, it is important to note that by eliminating medication errors at the source, CPOE frees up staff time and resources that were previously spent on clarification of unclear medication orders and prevention of erroneous medication delivery. Further, CPOE improves efficiency by facilitating the fast and automatic flow of information among healthcare professionals, hospital departments, and institutions (Doolan & Bates, 2002; Cerner Corporation, 2008; Bates & Gawande, 2003; Potts et al., 2004). In addition to their basic function of eliminating the problems associated with ambiguous or illegible handwritten prescriptions, CPOE systems typically incorporate additional features that automatically check medication orders against patient data, including other medications that have been prescribed. Professionals issuing medication orders are thus automatically alerted to such factors as age-specific dosage requirements and potential overdoses, known medication allergies of the patient, potential drug interactions, and appropriateness of the medication prescribed to the diagnosed problems of the patient (Mekhjian et al., 2002; Bates & Gawande, 2003; Potts et al., 2004 The Leapfrog Group, 2008; Mekhjian et al., 2002). Such features not only eliminate many chances for dangerous and expensive errors to occur; they also reduce the time required to prescribe properly and carefully, and reduce the level of stress among hospital staff (Cerner Corporation, 2008). Because their features are based on a database of drug characteristics that is easily updated, CPOE systems can be readily kept up to date as new medications, dosages, and forms of drug delivery become available, and as knowledge of such dangers as drug interactions improves (The Leapfrog Group, 2008). While even the best CPOE system does not eliminate the need for ongoing professional education of medical staff, it is nonetheless true that routing medication orders through a properly updated CPOE system is the best known means of ensuring that prescriptions are being checked against the most current knowledge available. The centralization of knowledge encoded in CPOE systems also aids in standardizing treatment regimens and other practices ((Kuperman & Gibson, 2003) and imposing prescribing guidelines to reduce excessive or inappropriate use of medications (Shojania et al., 1998). Other advantages of CPOE use include features such as medication, test, and vaccination reminders (Dexter et al., 2001). Change strategy in relation to best practice Business plan Tasks to be carried out, allocation of responsibility, priorities, and deadlines In order to initiate the process of implementing CPOE at Riyadh Kharj Hospital, the heads of the medical, nursing, pharmaceutical, and quality management departments will draft a report documenting the problems with the current prescribing system and the proposed solution, and forward it to the Hospital Management Board (HMB) for its consideration. Assuming that a majority of HMB members agree to the suggested strategy, a second board meeting will be arranged to discuss the estimated cost of implementing the CPOE system, the availability of resources for the project, and other issues related to the project’s feasibility. Once the HMB is satisfied that the CPOE project is necessary, advisable, and within the hospital’s capabilities, the board will designate a team responsible for carrying out the project. Such a team usually consists of a physician chosen to lead the project, along with other members from various departments. Since the project team leader will be critical to the success of the project, s/he must be chosen carefully; in order to manage such a strategic shift effectively, s/he must understand the dynamics of the change process in order to minimize the impediments to a successful implementation—particularly “people barriers” such as resistance to change and negative assumptions about information technology (Jones & Moss, 2006). The rest of the project team should consist of members from a broad selection of affected hospital departments, so that as many employees as possible will have the project presented to them by “one of their own”; this will prevent or reduce the perception that CPOE is being imposed “from on high” (Gale, 2008; Sengstack & Gugerty, 2004). At the time the project team is created, an announcement will be made to all hospital staff to alert them of the project’s inception; the primary goal of this first “heads-up” announcement will be to create positive feelings about the impending change. Once the project team has been established, its members will consult with interested hospital staff to identify their needs and concerns regarding the new prescribing system; the team will also consult the professional literature, outside experts (particularly administrators of hospitals that have already gone through the process of CPOE implementation), and systems vendors in order to identify important issues, goals, and problems that will have to be taken into account in the course of the project. The team will use all this information to formulate a Request For Proposal (RFP), which will outline the goals, requirements, and time frame for the CPOE project. Once the RFP is ready, an advertisement will be posted in the local newspapers to alert interested information technology companies of RKH’s plan to install a CPOE system and encourage them to contact the project team to receive a copy of the RFP. Once the deadline for proposal submission has passed and proposals have been received, the project team will meet with those vendors whose proposals appear suitable. In addition to evaluating the proposed features to be delivered and the prices offered, the project team will check with vendors’ previous customers to ensure that the chosen vendor has a strong track record for quality, service, and reliability. The chosen vendor will be the one that offers the best combination of price, system features, reliable service and support, training, system quality, and reputation. The outcome of this phase of the project will be a signed contract with the chosen vendor. Once RKH has identified its supplier and signed a contract for the CPOE system, a second announcement will be sent to all hospital departments to introduce the chosen vendor and to describe the project in more detail than was given in the preliminary “heads-up” announcement. The project team will then organise a series of presentations and meetings to discuss the CPOE project in detail, and all hospital employees will be encouraged to attend these events. In these meetings, Management Board members, the project team, and representatives from the system vendor will be available to present and discuss the CPOE implementation plan and to reply to staff queries. Vendor representatives and project team members will explain in detail the requirements for implementing the project, the project’s expected timeline, and the sequence for implementation. Because of Riyadh Kharj Hospital’s large size, it would be impractical to attempt to implement CPOE simultaneously in all sections of the hospital. The project team, in collaboration with the chosen vendor, will divide the project into a series of phases; the first phase will include the installation of the central hardware and software infrastructure to support CPOE hospital-wide, as well as the local infrastructure to support the department(s) chosen to be included in the first phase. Subsequent phases will rely on the central infrastructure installed in the first phase, and will also benefit from lessons learnt during the first phase; it is anticipated that staff trained in the first phase will assist the project team and system vendor in spreading the use of the system to other areas of the hospital. For each phase of the project, implementation will follow a similar pattern—except, of course, that only the first phase will involve the creation of the central infrastructure to support CPOE. In each section of the hospital implementing the CPOE system, vendor representatives and the project team will discuss the CPOE implementation plan, training plans, and other relevant issues with senior physicians, head nurses, and ward directors. Once plans and preparations are complete, the contracted information technology vendor will begin to install the local hardware required for CPOE, while simultaneously beginning the staff-training process. The project schedule will evolve as the project progresses, from broad targets set forth in the RFP through a more detailed and concrete schedule incorporated into the contract signed with the chosen vendor, to still more detailed schedules for each phase of CPOE implementation as milestones are reached. A reasonable rough estimate is that once a vendor contract has been executed, implementation of the first phase of the project would be complete in around one year; complete implementation of CPOE throughout RKH would take approximately five years. Table 1 provides an estimated schedule for the most important tasks involved in the first phase of the CPOE system at RKH; a start date of 1 January 2009 has been chosen for purpose of illustration. Table 1: Estimated CPOE implementation schedule for the VIP building of RKH Task Start date End date Duration Type Install the necessary software applications 1/1/2009 1/3/2009 2 months Sequential Prepare the theoretical and practical materials for training the employees 1/1/2009 1/2/2009 One month Parallel Provide the first training session for the employees 1/2/2009 1/3/2009 One month Parallel Install applications required for clinical documentation 1/3/2009 1/4/2009 One month Sequential Install functionality needed to collect patient data 1/4/2009 15/5/2009 45 days Sequential Implement applications to provide 24 hour support 15/5/2009 15/6/2009 One month Sequential Provide the second training session for the employees 15/5/2009 15/6/2009 One month Parallel Promote access and connectivity (wireless in the hospital, home access) 15/6/2009 1/8/2009 45 days Sequential Install the necessary hardware applications 1/8/2009 15/9/2009 45 days Sequential Set up the system requirements such as tables, workstations, laptops and so on 15/9/2009 15/10/2009 One month Sequential Provide the last training session for the employees 15/10/2009 30/11/2009 45 days Parallel Test the overall program prior to allowing clinicians to use it 30/11/2009 30/12/2009 One month Parallel The estimated schedule provided above is intended to provide flexibility to respond to any internal or external events that impact the course of implementation. As soon as system installation, staff training, and switchover to the new system are complete for the first phase, the second phase will begin in the appropriate section(s) of the hospital. Applying change-management principles In order to avoid and overcome personal and technical barriers to successful implementation of CPOE, the project leader and team, as well as hospital management and the system vendor, must operation in accordance with sound principles of change management. Attitude and openness are very important in this regard; by demonstrating respect for all employees, providing them with adequate information and support (both practical and emotional), and incorporating them in the change process, those responsible for carrying out the project will gain maximum cooperation and enthusiasm (Gale, 2008; Lorenzi et al., 1997; Jones & Moss, 2006; Oregon Health & Science University, 2001; Daly et al., 2004). Change processes work best when employees feel empowered. Transitional arrangements Arrangements for the transition to CPOE will actually begin when the hospital’s director of finance states in the second Hospital Member Board meeting that there are sufficient resources to authorize the CPOE project to proceed. The second milestone is the announcement sent to all hospital departments notifying them of the implementation plan. The third step is the conferences for all hospital employees to discuss the CPOE plan in detail. The fourth step occurs when the representatives of the contracted vendor and the project team discuss the plan for implementing the CPOE system with the head of physicians, head nurses and ward directors of the VIP building. The fifth step starts when the contracted information technology vendor begins the process of implementing the CPOE system in the VIP building. The final stage in the initial phase of the transition to CPOE will start after the complete implementation of the CPOE system in the VIP building, once staff have completed the required training sessions and have demonstrated their ability to use the new system effectively. At this point, the change in the practice of ordering medication from handwritten to electronic prescriptions in the VIP building will be activated and closely monitored by the project team. This series of steps will all contribute to a smooth transition in the procedure for ordering medications; the change will be gradual, in order to monitor and carefully deal with any internal and external influences or risks. Resources & Costs The sole financial support for RKH derives from the government of the KSA; support for the hospital is included in the budget of the Ministry of Defense and Aviation (MODA) which regulates and controls RKH (Ministry of Defense and Aviation, 2008). The amount of money allocated to RKH is periodically adjusted based on the changeable requirements of RKH, such as increases in staffing levels, systems upgrades, and implementation of new projects. Thus, the resources for implementing the CPOE system at RKH will come from the MODA, which in turn is financially supported by the KSA government. As in other hospitals that have implemented CPOE systems, the costs of implementing the CPOE system at RKH should be separated into three categories: capital expenses, one-time operating expenses, and ongoing operating expenses (Gay, 2006). Capital expenses will include the costs of hardware, software, computer networking equipment, workstations, printers, handheld wireless devices, and implementation services. Table 2 illustrates the estimated capital costs for implementing the CPOE system at RKH (Gay, 2006). Table 2: The Estimated Capital Costs for Implementing the CPOE System at RKH Cost Item Cost Hardware $480,000 Software $450,000 Computer networking equipment $440,000 Workstations $185,000 Printers $10,000 Handheld wireless devices $135,000 Implementation services $175,000 Total $1,875,000 One-time operating costs will cover the leadership resources needed to guide the project and ensure clinicians’ active participation in designing, configuring and installing the system (Gay, 2006). In addition, this category will include incentive payments to physicians to facilitate their adoption of the CPOE system, and the training sessions, training materials, and other non-capital expenses required for the successful implementation of the CPOE system. (Gay, 2006). Table 3 shows the expected one-time operating costs for implementing the CPOE system at RKH. Table 3: Estimated One-Time Operating Costs for Implementing the CPOE System at RKH Cost item Cost Leadership resources to guide the project and ensure clinicians’ participation $50,000 Incentive payments to facilitate adoption of the CPOE system $20,000 Training sessions and materials $85,000 Other $15,000 Total $170,000 Finally, ongoing annual operating costs for the CPOE system will be estimated. These costs will cover maintenance of the hardware, software, network equipment, computer interfaces, and other devices involved, as well as the expense of updating the clinical rules as required (Gay, 2006). Table 4 indicates the expected annual operating costs for implementing the CPOE system at RKH. Table 4: The Estimated Annual Operating Costs for Implementing the CPOE System at RKH Cost item Cost Maintenance of hardware, software, network equipment, computer interfaces, and other devices $70,000 Updating the clinical rules $50,000 Total $120,000 As a result, the total cost of implementing the CPOE system at RKH and operating it for the first year will be approximately $2,165,000. The expected total cost for implementing the CPOE system only in the VIP building in RKH will be around $500,000. Risks The process of risk assessment/management is adopted from the Australia/New Zealand Standard, 2004, and includes the following stages: Establish the context of risks. Identify risks. Analyse risks. Evaluate risks. Treat risks. Two principles should be followed throughout the risk assessment/management process: Communicate and consult with other members. Monitor and review the whole process. Figure 1 outlines the process of risk assessment/management: Figure 1: Australia / New Zealand Standard, 2004 Evaluation Evaluation is the last stage in the change process, but actually begins well before the project is completed; it includes assessment of the change’s effectiveness, suitability, tolerability and satisfaction (Daly et al., 2004). Evaluation can be formative (Participant action research), addressing particular processes or aspects of the project, or summative, assessing the whole project and usually offering a number of recommendations on that project (Patton, 2002). Formative evaluation, unlike summative evaluation, can occur more than once in the course of a project (Patton, 2002). Each stage of the process of implementing the CPOE system should be individually evaluated and reviewed during each “informative” stage, as early evaluation and monitoring of the change process can enable the project team to deal effectively with internal and external influences and difficulties (Daly et al., 2004). Moreover, Balfour and Clarke (2001) recommend a system of ongoing, cyclical evaluation to identify and deal positively with the complex issues that result from introducing change, and thus support the introduced change strategy. In addition, collecting data on the prevalence, severity, and costs of medication errors at RKH before and after the implementation of the CPOE system and comparing the two sets of data “summatively” is an important step in evaluating the success of the change and documenting its outcomes (Cunningham, Geller, & Clarke, 2007). A number of additional tools can be used to evaluate the change and the change process; one of the most helpful techniques is a series of sessions held during the change process to evaluate the feelings of those who affected by the change (Douglass, cited in Daly et al., 2004). Other useful tools are surveys (Upperman et al., 2005), questionnaires, group discussions and the measurement construct tool (Carney, 2000). Tools should be chosen carefully, as each one has advantages and disadvantages; and typically each tool measures something slightly different from what other tools measure. Whatever tools and techniques are chosen, the evaluation stage will be very important to the successful implementation of the CPOE system, and should not be neglected by the project team and its leaders. Dissemination of the plan throughout and following the completion of the project The dissemination of the plan will begin after RKH has signed a contract with a company by sending an announcement to all departments informing them about the hospital plan. Additionally, specific conferences will be then organised to disseminate and discuss the hospital plan, the agenda of implementing the CPOE system, and the estimated timeline in depth. Then, the representatives of the contracted information technology company and the project team will disseminate where the CPOE will be initially implemented, in this case, the VIP building, and explain to the head nurses and directors of units the plan of implementing the CPOE system and the special procedures that should be taken by the employees. After the completion of the project in the VIP building, an announcement and memos will be sent and posters will be distributed to all the RKH’s departments and units to inform them of the completion. After that, a big celebration will be organised and a report will be made by the hospital director describing the plan, the actual timeline and the cost of this innovation. This report will be published in the local hospital medical journal and other national and even international newspapers. The hospital director will then announce to all employees in the VIP building the deadline of using handwritten prescriptions and the beginning of the electronic prescriptions. Hence, the plan of implementing the CPOE system will be disseminated to the employees at RKH throughout and following the completion of the project. Conclusion The use of proven, evidence-based best practices in eliminating or avoiding clinical risks is the best known way to enhance the quality of health-care in our communities. This paper has identified and substantiated the need for implementing a CPOE system, presenting evidence for the improvements in convenience, safety, and accuracy that will result from changing the procedure of ordering medication from handwritten prescriptions to a computerized system; it is clear that CPOE represents current best practice in this area. Further, this paper has shed light on the dynamics of the change process, as well as the strategies needed to overcome common barriers to smooth implementation of CPOE. Finally, a business plan has been presented for the implementation of the CPOE system at RKH, outlining responsibilities, transition arrangements, resources and costs, the risk management process, evaluation, and dissemination plans. In addition to good planning, skilled and dedicated health-care leaders and managers are a key factor in the success or failure of any such project. Overview of Health Leadership and Management Course (8021NRS): It can be said that this course has focussed on the role of health leaders and managers in the scientific analysis, assessment and management of the clinical risks and how to best treat these risks in a professional and advanced way through careful planning. I can say that this course as evidenced in the first and the second assignment has also emphasised the importance of communication with others, of monitoring any conducted step or process and teamwork in order to achieve the desired outcomes. It was worth spending time to study this course. I am looking forward to enrolling in other courses related to the role of health leaders and managers in the health care institutions. This is mainly because they are the first step in the success of any organisation, and we actually miss that in Saudi Arabia as it is a developing country. I appreciate your collaboration and assistance in teaching me this course.   List of references: Read More