Case Study: Governance, ProVation® Order Sets, Accelerate CPOE Adoption and Outcomes at Memorial Healthcare

Hospital Profile

Based in Owosso, Mich., Memorial Healthcare is a 154-bed facility with a medical staff of more than 170 providers. The organization cares for more than 4,600 inpatients, 25,000 emergency patients and 240,000 outpatients annually at its main campus and seven satellite locations.

The hospital has been widely recognized by leading accreditation organizations for meeting or exceeding care standards. This includes accreditation with commendation by the American College of Surgeons and accreditation by the Joint Commission and the College of American Pathologists Commission on Laboratory Accreditation. It has also received numerous national quality awards for its heart program, including a Blue Cross/Blue Shield Cardiac Center of Excellence and designation as a five star performer by HealthGrades.

Memorial has also achieved national recognition for its use of technology to address patient care, safety and service quality. This includes recognition as a Hospitals & Health Networks Top 100 "Most Wired" hospital 8 out of the past 10 years.

The Quest for CPOE

In many respects, Memorial Healthcare is a pioneer in the adoption of health IT. In 1993, it implemented the MEDITECH system, which is still in use today. To help guide care decisions, Memorial physicians utilize UpToDate®, an evidencebased, physician-authored clinical information resource from Wolters Kluwer Health that is also used by the hospital's quality improvement department. UpToDate covers more than 8,300 topics in 16 medical specialties and includes more than 80,000 pages of text and graphics, as well as links to Medline abstracts, more than 385,000
references and a drug database.

MEDITECH and UpToDate are just part of Memorial Healthcare's health IT strategy. The organization's ultimate goal was to deploy computerized physician order entry (CPOE) with advanced clinical decision support to drive improved core measures performance, quality and safety through increased standardization based on established best practices.
"For CPOE, you need order sets. CPOE would be too cumbersome without them," said Frank Fear, Memorial's vice president of information services.

As an example, he cited the process involved with admitting a pneumonia patient. It could potentially involve 30 separate orders. Without order sets in CPOE, the physician would have to look up each order individually.

"That's too slow and it's too easy to miss something," said Fear. "So order sets are the first key to CPOE. The second is having a way to rapidly create those order sets. Doing so on paper was taking us a minimum of six months, and they were not necessarily based on the latest or best evidence."

The long development process was due largely to the informal, primarily paper-based process Memorial had in place for order set creation. Typically, a physician would provide a nurse manager with the necessary information to create an order set.

The nurse manager would then take that to the hospital's Forms Committee, which would copy the information into the appropriate format. The draft order set would be delivered back to the original requestor for personal use, or it would be reviewed by multiple physicians and the hospital's quality review team. In some cases, it took more than a year to finalize a single complex order set.

"It was not efficient and often resulted in multiple order sets for the same diagnosis, or doctor-specific order sets," he said. "There wasn't an efficient review process, and the update cycle was sporadic."

Thus, with the full support of the vice president of medical affairs, chief of medical staff and physician champion for CPOE, the decision was made to automate the development process through deployment of an electronic order set solution. First, however, Memorial needed to revise its governance process to guide order set selection, streamline development, ensure quality and eliminate duplicates.

Governance First, Technology Second

The first step was to establish a formal policy by which order sets would be identified and created. It called for the hospital's CPOE administrator to determine which order sets would be developed and in what order.

"We started with our top 25 DRGs and core measures, with those measures we report to the state being the first order sets developed," said Jerri Hudson, Memorial's CPOE administrator. "We also needed a development process and a team to review the order sets."

In terms of the development workflow, Hudson works first with physicians and pharmacists to draft the initial order set. It then goes to the newly established Order Set Development Team, which consists of physician specialists; pharmacy, radiology and lab representatives (as appropriate); nurses from the impacted department and who were familiar with order sets within MEDITECH; and representatives from quality improvement and risk management.

The team has two weeks to review the draft and return any comments to Hudson, and another week to review any revisions. The order set then goes to the impacted department's medical staff for its review and approval. The last stop is the Medical Executive Committee, which also has the final say in any disputes about specific evidence or content of an order set. Once approved, Hudson builds the order set in MEDITECH for facility-wide access via CPOE.

With a formal governance process in place, Fear, Hudson and the Order Set Development Team turned their attention to evaluating the various electronic order set solutions. They focused primarily on solutions that offered:

  • Customizable templates that enable rapid draft development
  • Virtual tools and user-friendly dashboards for faster, more efficient review and approval and enhanced project management
  • Easy access to trusted clinical content, both during the authoring and review process and at the point of care
  • Automatic alerts when changes are made to supporting evidence or best practices that could potentially alter usual clinical practice
  • The ability to quickly and easily perform updates across multiple order sets

"For us, the ability to be kept up-to-date on evidence was critical to ensuring that we realized the full quality impact that evidence-based order sets can deliver," said Fear. "Evidence changes over time. If order sets are static, they aren't as powerful. So alerts and mass updates were important functional objectives."

Memorial ultimately selected ProVation® Order Sets, powered by UpToDate Decision Support, an easily customizable order set authoring and management solution from Wolters Kluwer Health. Built upon ProVation Medical's award-winning, clinician-designed technology platform, one of its primary values is the continuous updates to clinical content and medical evidence, including direct links to UpToDate.

Central to this capability is the One Click Updates tool, which leverages UpToDate's Practice Changing Updates ability by highlighting new recommendations that could potentially change usual clinical practice. Enabled by a unique, structured approach to data management, the One Click Updates feature alerts end users to evidence that may trigger the need to modify particular order sets. It then enables users to review recommended updates and apply them in a single step
across multiple order sets.

In addition to integrated links to UpToDate and other trusted sources of medical evidence, ProVation Order Sets offers the flexibility to link additional clinical resources based upon client needs and preferences. Further, to help facilities achieve the highest possible degree of automation, ProVation Order Sets feature vendor-neutral mapping and export capabilities that allow for flexible integration into any facility or vendor EMR or CPOE system.

"The idea of being able to click directly into the evidence was very appealing, as were ProVation Order Sets' quarterly updates and mass editing capabilities. Plus, the email tool with the virtual meeting room makes it very easy if we need to make any decisions as a team."

Added Fear: "We needed to rapidly roll out order sets and the only way to do that was with a virtual review tool that allowed users to look up evidence and provide quick feedback to Jerri. ProVation Order Sets had the most efficient tools for doing that."

Pre- and Post-CPOE Success

ProVation Order Sets was deployed six weeks before Memorial Healthcare went live with CPOE. This allowed Hudson and her team to have a sufficient number of finalized order sets in the MEDITECH system for immediate integration into clinical workflows. It also allowed physicians to become comfortable with using order sets prior to go-live, shortening the
CPOE learning curve.

Within five months of rolling out ProVation Order Sets, the development team had completed and built 20 order sets into CPOE with another 29 out for review. Plans call for Memorial to have at least 100 evidence-based order sets within its CPOE system. It is a goal that is well within reach, now that the time to develop a single order set has dropped from a minimum of six months to a maximum of eight weeks.

"I can pull up a template in ProVation Order Sets, make it specific to Memorial and send it out for review in two hours," said Hudson. "Once it comes back from the reviewers, I can have the edits complete in less than an hour. It takes a couple of hours to build it in MEDITECH and three days for it to be reviewed by all departments before it is activated."

Clinician satisfaction with the electronic solution is also high, even among those physicians who are not yet utilizing order sets within CPOE. "Order sets are available to everyone. We've gotten a lot of comments from physicians who say it has helped their decision-making," said Hudson.

This has, in turn, increased physician acceptance of and satisfaction with CPOE - a trend Memorial expects to continue as more departments are brought online. This will ultimately lead to greater acceptance of the next phases of Memorial's health IT strategy, which focuses on data exchange and patient portals.

As was the case with the selection and use of ProVation Order Sets, the governance process will be as critical, if not more so, to the success of future roll-outs as the technology itself. "If you plug a good tool into a weak process, you tend to get bad results," said Fear. "The process and the people in key positions are so important - the governance process, the people to manage it and the tool to work it. Our vision at Memorial Healthcare is to be a national model for excellence in personalized healthcare. ProVation is a tool that is helping us achieve this vision."