Optimization

Initial goal is usually implementation and acceptance. Once that is near completion, it is time to optimize the system
What is optimization:

Continued enhancements to the CPOE system to fully realize the potential to improve quality of care and efficiency of the system. It is about getting the “juice for the squeeze,” and moving past having the clinicians serve as order entry clerks.

Tools of optimization

Standardization of orders and order sets

Moving from individual orders/order sets to group-based and/or division based (i.e. one post-op knee order set for all of the Ortho groups)
Decreasing the number of choices of medications or nursing orders

Moving from choice of three ambulation protocols to one
Eliminating multiple choices for aspirin doses, etc.

Refining of alerts and rules

May have started with the full array of drug-drug or allergy alerts. Next step is providing the ability for users to tailor the level of alerts based on their user class (nurse, med student, resident, attending, etc.)
If have started with NO alerts (to facilitate acceptance); need to implement CDS into the CPOE environment.
As users acclimate to CPOE, will be more accepting of increasing intrusions from alerts and rules. Therefore, optimization of the system

Re-organization of the orders module.

After the clinicians have been ‘banging’ on the system for a while; many of the initial design decisions may need to be revisited. Clinicians will have a new appreciation for the system and there will probably be requests to re-organize the medication lists, nursing orders, order sets.
Other ancillary departments (nursing, pharmacy, respiratory) will also have input regarding organization of the system, especially specific to their areas of use.

Maintenance

What is maintenance

Maintenance is the periodic review of the various parts of the CPOE system to ensure synchronization with hospital, regulatory and environmental conditions

What needs to be maintained

Medications –all instances of medication orders in the system should be synchronized with current formulary
Nursing orders should be synchronized with current protocols and care plans
Orders and order sets need to address current and new regulatory and compliance requirements (i.e. Core Measures, The Joint Commission requirements, etc.)
Order sets should be updated to include current therapeutic and care standards

How is responsible

Should be determined at an enterprise level
Usually falls to content experts for that area

Pharmacy is responsible for all medication orders
Respiratory therapy is responsible for all responsible orders
Physician owners of each order set should be responsible for updating their order sets

When should it occur

Pharmacy maintenance is usually an ongoing process due to changes in formulary, shortages, recalls, etc.
Order sets should be reviewed annually at the minimum
Departmental orders (respiratory, etc) should be reviewed annually or as needed

How is it tracked/reminded

A catalog or database of the orders and order sets should be created at the initiation of the CPOE process. The catalog should contain information regarding the creation date, owner and content of the orders.
An alerting system should be built from the catalog that provides a reminder to the appropriate owner/manager of the order/order set. This function may initially be centralized in I.T., and the CPOE Manager or Physician Champion may be responsible for reminding the content owners.

Metrics

Tools

CPOE Evaluation Tool – Test and Monitor Decision Support

About

The Leapfrog Group, through The Leapfrog Hospital Survey, has asked hospitals to measure and report on their progress in implementing CPOE systems since the beginning of the Hospital Survey in 2001. In 2008, Leapfrog added an additional component to their CPOE standard: the CPOE Evaluation Tool. Hospitals that come into the Leapfrog Survey and report that they have fully implemented CPOE in at least one inpatient unit are asked to take the CPOE Evaluation Tool. In 2009, Leapfrog began to include their performance score on the tool in the publicly reported score for CPOE.

Purpose

The primary purpose of the evaluation tool is to assess the ability of implemented CPOE systems to aid in avoiding medication‐related adverse events. This is accomplished by evaluating how the CPOE system responds to medication orders entered that contain such errors. Most of the orders used in the evaluation are of this type. To perform well, hospitals must use features of CPOE that detect situations that could lead to adverse drug events (ADEs) and respond to them (i.e., clinical decision support that advises the physician).

The CPOE Evaluation Tool provides a hospital with a set of patient scenarios, along with a corresponding set of inpatient medication orders that users enter into their hospital's CPOE and related clinical systems. Those conducting the test record the warnings or other responses, if any, from their hospital's CPOE system on an answer sheet, report those results back at this Web site, and receive immediate scoring and feedback summarizing the results of the test. The scenarios and test protocols include potential drug-drug or drug-diagnosis interactions, drug allergies, therapeutic duplication, and dosage error.

Relevant Documents

The Leapfrog Hospital Survey

Instructions for Completing the Evaluation Tool

Frequently Asked Questions about the Evaluation Tool

Understanding the Scoring of the Evaluation Tool

Development

The development of the CPOE Evaluation Tool and its accompanying order sets were funded under grants from the California Healthcare Foundation and the Agency for Healthcare Research and Quality. Order sets for pediatric and adult patients for the evaluation were developed, combining knowledge from published research with the experience and knowledge of the Institute for Safe Medication Practices and nationally recognized experts in the field of CPOE including Dr. David Bates, Dr. David Classen, Jane Metzger, Dr. Marc Overhage, and Dr. Thomas Payne among others.

Articles

State there needs to be a cycle of consistent development and review of order sets and a federal government oversight on these products and functionalities.
http://www.healthcareitnews.com/news/leapfrog-warns-cpoe-errors
http://www.healthcareitnews.com/news/cpoe-regulations-%E2%80%9Ctwo-edged%E2%80%9D-sword