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Concord Hospital Utilizes CPOE to Fine-Tune Inpatient Diabetes CareBy Joel Berman, MD Chief Medical Information Officer Concord Hospital Concord, N.H.  A New CPOE Challenge At Concord Hospital, we have achieved success with computerized physician order entry (CPOE) in many areas. Since implementing the solution several years ago, we have reduced errors of omission, improved compliance with treatment guidelines and enhanced efficiencies. Recently, however, as the chief medical information officer, I was presented with a challenge to demonstrate the efficacy of CPOE. When several patients voiced concerns about inpatient diabetes care, the quality of diabetes management became a front-burner issue for Concord. In turn, I was asked if there was any way we could leverage information technology solutions to improve the care delivered to our diabetic patients. In essence, the challenge was to use CPOE to improve an entire process of care. It required an application of CPOE that is an order of magnitude greater than using the system to address a single risk, such as a potential adverse drug interaction. Beyond Error Reduction The challenge presented the opportunity to move beyond the incremental improvement we had already achieved through error reduction. It enabled the use of CPOE to redefine a care process and improve patient outcomes as a result. However, addressing inpatient diabetes care would require quite an effort. Managing the disease involves significant orchestration of many processes, and it is a complex multidisciplinary venture with intricate workflows. Although our journey toward improved inpatient diabetes care is still evolving, we already have discovered some strategies to successfully leverage CPOE to improve an entire care process: Ensure that the team has passion. To address inpatient diabetes care improvement, we assembled a team with the right clinical and technical knowledge: physician informaticists, nursing managers, diabetes educators, dieticians, pharmacists, nurses and others. The team members all have a real passion for diabetes care improvement, making it possible for them to persevere in an effort that takes considerable time and energy. The team has successfully re-engineered the complex inpatient diabetes care process from beginning to end. Focus, focus, and focus some more. Instead of becoming overwhelmed by the enormity of its mission, first the team made improvements to the non-technical aspects of inpatient diabetes management. After that, the team looked at how CPOE could be used to improve one specific process: glycemic control. The team focused on gaps in quality of inpatient diabetes care as cited in the American College of Endocrinology and American Diabetes Association consensus statement. For example, the team addressed the underuse of insulin in patients with hyperglycemia. The team also leveraged CPOE to encourage clinicians to order insulin as a three-component bundle of basal, meal, and correction doses. With our CPOE system, we enabled an automated alert that requires the clinician to address the insulin order before continuing — it is virtually impossible for the clinicians to overlook one of the components. Make sure clinicians are CPOE-savvy. Before addressing a complicated care process such as inpatient diabetes care, clinicians must be comfortable with the use of CPOE. We therefore had to ensure that CPOE users became proficient in using the technology. We feared that if CPOE slowed processes down, our clinicians would abandon CPOE as a care improvement tool. Ensure clinicians understand CPOE's role. We also worried that our clinicians would view CPOE as a system that would "make" clinical decisions and erode the importance of their critical thinking. To address this misperception, we made it clear that order sets are developed by clinical champions in each specialty in collaboration with our quality improvement team, to comply with best practices and our hospital policies. The team designs the order sets to empower clinicians to exercise informed judgment and make appropriate choices for individual patients. The CPOE system cannot and should not make care decisions for the physician. Capitalizing on CPOE's Potential As we leverage CPOE to improve an entire process of care and discover strategies for success, we are becoming more confident in its potential to improve inpatient diabetes management. Already, we have documented the following improvements in diabetes care processes:  Increased use of basal insulin from about 20% to more than 90% Increased use of prandial insulin from 10% to nearly 100% Reduced glucometer docking delays by more than 60%As the program is rolled out to additional areas of the hospital, we expect that these care process improvements will result in outcome improvements such as improved glucometrics and a reduction in diabetes complications. Our clinicians not only have become comfortable using CPOE for patient care, but now enthusiastically embrace the potential of the tool to improve patient outcomes. Joel Berman, MD, is chief medical information officer at Concord Hospital. Dr. Berman has been a New Hampshire family physician for 26 years before becoming Concord Hospital's first chief medical information officer in 2007. He has eight years of experience leveraging Concord's outpatient EHR to improve measurable quality in addition to deploying inpatient CPOE to improve outcomes. Dr. Berman is actively involved in industry organizations for physician and healthcare executives. He was the winner of the 2008 AMDIS Physician Award, which recognizes excellence and outstanding achievement in applied medical informatics.   |
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