Computerized Physician Order Entry – CPOE at a Community Hospital: Beyond the Hospital Walls
January / February 2005
Computerized Physician Order Entry
CPOE at a Community Hospital: Beyond the Hospital Walls
Huntington Hospital, a 525-bed not-for-profit tertiary care community hospital, was established in Pasadena, California, in 1892; its mission is simply to excel at the delivery of healthcare to its community. The last two years have seen a whirlwind of activity on the technical front as Huntington Hospital planned, budgeted, and began to implement an aggressive, multi-phased healthcare information systems project. When the legacy clinical and administrative systems were replaced with updated technology, attention was turned to the introduction of new functionality.
Providing patient information at the point of care is a primary goal of automated health records. To meet this goal, as Huntington Hospital approached the go-live of its nursing documentation system in fall 2004, clinician access to computers at the patients’ bedsides was carefully considered. The house-wide wireless network was doubled in capacity, and a million-dollar budget was established for the purchase of portable data entry and viewing workstations. The entire nursing staff was invited to attend a “portable device” fair, where vendors provided hands-on demonstrations of their products. Clinicians voted their preference, and based on those results, 200 portable carts were purchased and deployed to the patient care units. These “computers on wheels,” fondly referred to as COWs, are the primary computer device used by patient care staff.
Surprising Result
As the COWs went into full use, the unexpected happened: Huntington Hospital suddenly experienced a chair shortage. As theory became practice, nurses found that rather than inputting and view patient data at the bedside, they preferred performing their computer work outside the patient’s room. The COWs were brought outside the room, lowered to desk height, and the closest chair was pulled into use. The unfortunate consequence was the lack of an available chair at the nurses’ station for desktop PC use.
With a new patient tower in the design phase, Huntington Hospital continues to monitor computer device usage to determine if this work pattern is simply a result of getting used to a new way of working, or reflects a permanent preference for data entry devices.
As Huntington Hospital stepped back to reconsider its computer device deployment strategy, the goal of providing patient information at the point of care was examined. A series of subsequent requests reframed the goal to provide patient information at the point of care and at the point of clinical decision-making — not only within the patient rooms, but often outside the hospital walls.
Remote Access, Interfaces, Ambulatory Health Records, and RHIOs
Huntington Hospital’s physicians and their private practice staff have incorporated remote access to inpatient information from their homes or offices into their daily routine. For two years, patient demographics, lab, and radiology results have been available via the hospital’s Citrix physician Internet portal. Remote usage increased exponentially following the implementation of the nursing documentation system, as physicians found they could obtain vital signs, point-of-care testing results, nursing and ancillary staff notes online. Huntington Hospital doubled its bandwidth to accommodate the additional volume, and provided updated training and access for private practice office staff.
Several of Huntington Hospital’s large physician groups, in the process of installing their own ambulatory health records, have requested interfaces of demographic, billing, and clinical data on their hospital patients. Such was the demand that a specialty interface engine, designed to filter data by physician, was purchased and installed. The first transmission of ADT, results, and reports data to a private practice ambulatory health record was accomplished by end of 2004. Six others are queued up to follow.
Though the large physician groups, by virtue of volume, could afford to purchase their own ambulatory health records, solo practitioners and small physician groups are stepping forward to ask for assistance in obtaining an affordable electronic health record for their own practices. Huntington Hospital is currently considering a number of support options, from consulting services for affordable system selection, to the business case for hosting an ambulatory health record to be leased back to physician practices. Long-awaited adjustments to the anti-kickback laws will certainly support such efforts.
To expand the circle even further, Huntington Hospital has elected to participate in a developing regional health information organization (RHIO). One of Huntington Hospital’s physicians serves on the board of the Los Angeles County Medical Association and informed the hospital of an effort under way to share patient data across the entire continuum of care, from physician offices, commercial labs, retail pharmacies, to outpatient clinics and inpatient hospitals. Huntington Hospital accepted the invitation to be part of the Health-e-LA coalition and attended its first meetings in December.
Health-e-LA is a growing stakeholder coalition that was started by L.A. Care Health Plan, the Los Angeles County Department of Health Services, and the Los Angeles County Medical Association. The mission of Health-e-LA is to coordinate and expand support for e-health activities throughout the greater Los Angeles region. Huntington Hospital jumped at the chance to support this effort as both an interested hospital and one whose employees maintain connections to professional associations eager to provide support for such development.
The lesson learned is that the point of clinical decision-making is not necessarily the point of care, and a strategy shift is often required to meet this goal. Bricks-and-mortar, or workstations-and-cabling, cannot be a limiting factor.
Readers are asked to submit comments and suggestions for Huntington Hospital’s quality healthcare automation efforts to maggie.lohnes@huntingtonhospital.com.
Maggie Lohnes is manager of physician computer services at Huntington Hospital in Pasadena, California. She may be contacted at maggie.lohnes@huntingtonhospital.com.
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Health-e-LA Participants
A number of organizations are participating in, or have offered early support to, the Coalition. Among them are (listed alphabetically):
- Community Clinic Association of Los Angeles County
- First 5 LA
- Hospital Association of Southern California
- Kaiser Permanente
- L.A. Care Health Plan
- LA Health Action
- Long Beach Department of Health and Human Services
- Los Angeles Area Chamber of Commerce
- Los Angeles County Department of Health Services
- Los Angeles County Medical Association
- Rand Corporation
- The California Endowment
- The Institute of Community Pharmacy
- University of California, Office of the President
Further Information
For further information, please contact:
Karen Elliott
L.A. Care Health Plan
(213) 694-1250 (ext. 4308)
kelliott@lacare.org