Eastern Maine Medical Center - Bangor, Maine

Computerized Provider Order Entry

Overview: Eastern Maine Medical Center (EMMC) is a 411-bed medical center that serves communities throughout central, eastern, and northern Maine.  EMMC is a member of Eastern Maine Healthcare Systems (EMHS), an organization of seven hospitals and other healthcare companies with more than 7,000 staff members.  EMHS provides and supports the information technology needs of EMMC.  The planning process for the implementation of an electronic health record (EHR) at EMMC was guided by the goals of the Patient First Initiatives (PFI) Program, which is a tri-fold approach to delivering high-quality patient care by transforming care delivery, adopting a patient-focused culture, and implementing a technology plan that supports, but does not drive, the care delivery process.  Over the past several years, EMMC has been steadily achieving various stages of EHR implementation.  Its most recent achievement was the implementation of Computerized Provider Order Entry (CPOE) for the inpatient care setting.

A pilot phase, called the Initial Launch (IL), was initiated on September 5, 2007, on the 25-bed respiratory unit.  The IL served as the first opportunity for the providers and ancillary staff to experience this care process transformation and the technical capabilities of the CPOE solution.  This phase also helped the Project Team evaluate the clinical staff's readiness to go-live and to practice and refine the go-live deployment process including adequacy of user training and the amount and type of support resources needed for the full implementation period.  An IL Plan was developed to address the following important considerations for selecting a pilot group: workflow during hand-offs, communication among caregivers, transfer process, group size and computer aptitudes of the end-users, and types and variety of orders.  Candidate pilot groups were rated on how they met the criteria against these considerations.

The Full Launch was implemented in three waves over a period of three weeks starting on November 1, 2007.  In April 2008, CPOE support was fully operationalized and handed over to the Information Systems Help Desk.

Impact: EMMC views the EHR as a major component of its strategic goal of improving quality of care for its patients.  Hence, the evaluation of the benefits from the EHR is not based solely on the financial benefits that can be derived from its products and outcomes.  It is a combination of the greater efficiency of clinician tasks and improved quality of care possible through the use of the EHR.  Over the last six years, the Project has achieved all of its key deliverables identified during the initiation phase.  The EHR has been instrumental in improving all areas of care delivery, such as patient safety and risk management, patient care and clinician workflow, order management, and patient satisfaction.

Challenges/success factors: In addition to ongoing communication of changes to come and formal training classes prior to any EHR implementation project, there were critical steps the Project Team took to help ensure a smooth transition to new processes for end-users:

  • Utilized Lean methodology during Conceptual Design sessions to eliminate waste and non-valued processes.  The team also involved end-users, subject matter experts, and providers in major phases of the project to ensure their buy-in for the solutions being proposed and implemented.  At EMMC, the Clinical Performing Group, a committee of 15 physicians from various specialties, made the system design decisions.
  • During extreme circumstances, allowed providers to write orders for the nurse or unit secretary to enter electronically up to three weeks after the go-live date.  This gave providers time to adjust to the new ordering process.
  • Established Patient First Care Coordinators (PFCC) composed of four staff members who are all registered nurses and report to the chief medical information officer.  One of the PFCC's responsibilities is to round with providers on a regular basis to answer questions on the use of EHR.
  • Developed standard care pathways (order sets) that reinforce evidence-based practice and improve convenience for physician ordering.  The team initiated these order sets three years prior to implementing CPOE, so the physicians were already familiar with using standard care pathways.
  • Transformed the role of the IS Education group to include process review.
  • Provided multiple ways for clinician training: classroom, Web-based training, and individual training.
  • Set up a Command Center staffed with clinical, IS Education, and clinical analysts, and led by a member of the Project Management Office during the first two weeks of the go-live date.  This service was well received since it provided immediate, at-the-elbow support on technical or process questions 24 hours a day, seven days a week.

Future direction/sustainability: HIMSS Analytics has developed a seven-stage maturity model for EHR implementation.  CPOE is considered stage four.  Eastern Maine Heathcare Systems is rolling out CPOE in one hospital at a time and is working on stage 5-closed loop medication administration, for example, bar coding.  They also have implemented an IS Governance Model for ensuring that IS resources are effectively and efficiently deployed in support of strategic and clinical needs.

Advice to others: Make sure you have a comprehensive change management plan in place.  EMMC's organizational change management plan was included in each of the implementation projects.  The plan included the following methods:

  • Enlisting the support of administration and medical staff leadership to provide both resources and visible support.  The EMMC medical staff voted to make CPOE mandatory and this was a key success factor.
  • Involving representatives from every service area in the design of their new workflows, which helped with the adoption of these changes since their ideas and suggestions became part of the solutions.  This ensured that broken processes were addressed before technical solutions were developed.
  • Improving patient safety through judicious use of important alerts and reminders.
  • Reinforcing provider education through rounding.
  • Providing targeted training for providers who need additional training.
  • Requesting Clinical Performing Group members to influence any providers who demonstrate continued resistance to these changes.
  • Communicating to the clinical staff that the Project Team would continue to hear their concerns and frustrations through EMMC's electronic feedback form.
  • Tracking the benefits of the system by determining areas where improvement is expected, measuring the baseline before system implementation, and measuring again after implementation.
  • Changing physician behavior on evidence-based practice by providing unblinded reports to clinical chiefs to track and communicate physician compliance with important safety initiatives such as VTE prophylaxis, anemia management, and prophylactic antibiotic use.
  • Analyzing failures for root cause and tightening processes to close patient safety gaps.

These methods helped minimize the impact of these changes on the end-users and ensured that all who were affected by the project received assistance to help them manage the changes in their areas.

Contact: Catherine Bruno
Vice President/Chief Information Officer
Telephone: (207) 973-7050
E-mail: cbruno@emh.org

 

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