Order entry rules: healthcare enterprise achieves physician acceptance, reduced medication errors and improved patient outcomes through CIS and CPOE technology - What works: clinical information systems - Sunrise Clinical Manager for Boston University School of Medicine

Health Management Technology, July, 2002

In theory, every healthcare organization supports the benefits that can accrue from utilization of clinical information systems. But theory and practice ate different animals. The key to achieving desired outcomes through technology lies with selecting the right technology, cultivating full user acceptance, and implementing according to a well designed plan.

PROBLEM

A primary teaching affiliate for Boston University School of Medicine, the 547-licensed bed Boston Medical Center provides a full spectrum of pediatric and adult care services, from primary to family medicine to advanced specialty care. In addition to having the largest Level I trauma center in the region, the medical center has 855 on-staff physicians, 550 residents, 1,160 registered nurses and a 92 percent annual occupancy rate.

Two years ago, driven by the competitive realities of the Boston healthcare market and the persistent effort to improve patient-care outcomes and reduce costs, we initiated a search for a new clinical information system. Like many healthcare organizations, we also were concerned about addressing emerging regulatory issues, such as patient safety and confidentiality-related HIPAA requirements.

Typically, we take a best-of-breed approach for our information solutions. With carefully delineated selection criteria, our goal was to provide physicians, nurses and clinicians with the best single clinical information system available. We needed to reduce paper-based ordering, charting and reporting, and provide the framework for increased patient safety. Moreover, we wanted to realize savings from automated management of medications. Specifically, we wanted to reduce adverse drug events and more easily determine when less expensive, equally effective medications could be used.

SOLUTION

We chose Sunrise Clinical Manager's order entry module for its capabilities to provide real-time clinical decision support for physicians during the ordering process, enabling realization of opportunities for concurrent expense control and clinical outcomes improvement. We found the system's database to meet our needs to support integrated, multi-disciplinary care management throughout the healthcare continuum, providing the foundation for a paperless environment.

With initial activation in October 2000, results were available ubiquitously via workstations strategically placed throughout the facility and in the affiliated community health centers. Remote access from clinicians' homes and offices was implemented in 2001. From all of these devices, physicians can access their patient lists, view laboratory and radiology results, and trend test results using online graphs.

Based on rules that we de fine and customize, automatic alerts inform the physicians of out-of-range test results received from their patients, ensuring that dangerous results ate flagged for immediate action. As a result of the activation, our physicians can make decisions based on real-time, pertinent data-including up-to-date patient information and just-in-time alerts accessible from every clinical workstation.

Additionally, rules are multi-factorial. Several types of patient data (i.e., patient age, weight, gender, current diet order, test results, and form of medication) can be used in one rule to produce the desired alert. If a physician selects an IV form of a particular medication for a patient taking an oral diet, a system alert can advise the physician that the medication can be administered by mouth.

Orders entered directly by physicians into the clinician order entry module ate processed immediately and are legible-eliminating the risk of misinterpreted handwriting, inaccurate verbal communication, lost orders, and orders delayed by incomplete information or routing to the incorrect department.

Currently, 94 percent of our inpatient ancillary orders do not need to be transcribed and reentered by the receiving departments since medication, clinical lab and radiology orders ate automatically interfaced to the departmental computerized systems. With workstations placed everywhere that our physicians might want to initiate orders for their patients, we have eliminated geographic barriers for computerized physician order entry (CPOE), reducing the need for verbal orders and potential errors inherent with this type of order. With more than 6,700 orders entered daily into the clinical order entry module at the medical center, that is no small accomplishment. To date, we have successfully processed more than 2 million orders.

By using a configuration tools and rules editor, our hospital ITS analysts can customize the system without relying on the vendor. Sophisticated ordering logic available in the system, such as weight-based dosing for our pediatric patients, helps ensure the highest level of patient safety. Since Sunrise Clinical Manager uses Arden Syntax, a standard rules engine language, we can also incorporate rules written by other healthcare organizations.