HPG has worked with many customers who have begun using Physician order entry (CPOE) with PowerChart® and the PathNet® laboratory system. The process of integrating PowerChart® with PathNet® for use by physicians presents a number of high risk issues and challenges. We recommend that hospitals and health systems take a proactive, comprehensive and systemic approach to mitigate these risks to their CPOE project. A separate initiative within the CPOE project plan should be dedicated to ensure that the Physicians workflow and the laboratory workflow are integrated and easy to perform. A few of the risk areas that need to be addressed include:
- Physicians are not always sure as to the naming of the tests in the system. A simple example is that a test might be called ACE when it was implemented by the lab. The laboratorians are familiar with the test and know how to handle it. However, the physician may know the test by its long name “Angiotensin Converting Enzyme” and not think to look under ACE. Another example might be a Drug screen. Would it be under Drug screen, Urine Drug Screen, DAU, Drug Abuse screen, etc? Consequently, implementation of CPOE requires the creation of many synonyms in order to reduce physician frustration in finding the desired tests and therefore increasing physician adoption. This is a significant effort, as test catalogs are usually in excess of 2000 tests.
- PowerChart® tests can be ordered with a frequency and duration. The tests have a default frequency, duration, and defined times for those to be scheduled. So, suppose a physician orders a test 3 times per day (TID) for 3 days. The tests are scheduled at 8:00 AM, 3:00 PM and 9:00 PM in the background. In addition, the collection lists print at 2 hour intervals at 2:00, 4:00, 6:00, 8:00, etc. How will the physician know when the labels will print and when the specimens will be drawn? These matters are very complex and the build of the collection routes, runs and lists must be considered when defining the default frequencies or there can be considerable confusion as to when testing will be done resulting in lost labels, missed patient tests and the potential for significant disruption to the care process.
- The lab normally uses Department order entry (DOE) to order tests. When using PowerChart® and perhaps Requisition order entry (outpatients) the view and orientation are completely different. The list of required entry fields is different in each case (Order entry formats). One example is that in the lab the default for collection status is usually “Collected” because the lab usually has the specimen when placing the order. In PowerChart® the default should be “not collected” because the providers are requesting a new test. The order entry formats must be correct for the lab, inpatients and outpatients. Considerable design, and in many cases, a significant rebuild of the order entry formats is required.
- PowerPlans™ are frequently used when converting to CPOE. PowerPlans™ do not have the ability to order CareSets. Prior to PowerPlans™ being implemented, the lab usually builds a number of CareSets to support the ordering process. A CareSet may be for a thyroid profile which would include a T4 and TSH for convenience in ordering. The PowerPlan™ serves the same purpose many times during the CPOE based process. In the PowerPlan™ the choices of T4 and TSH would be there and the physician can select the desired tests. The problem is that sometimes CareSets are used for reasons other than ordering convenience. An example of this would be a CBC. The CBC CareSet normally contains two orders, a hemagram and differential. Including these orders in a PowerPlan™ will be confusing to Clinicians as the CBC is generally thought of as a single test. This and other PathNet® CareSets will need to be rebuilt so that they can be ordered in the PowerPlan™.
- Duplicate order checking becomes more important in a CPOE based ordering environment. Because of the frequency issue and ordering through multi-phase PowerPlans™, most organizations will see and increase in the number of duplicate orders.
In addition to the design and build issues outlined, some procedural issues are created when moving to CPOE. One example is the procedures for ordering tests that are sent out to reference labs or specifically the tests that are not built in the order catalog. It is normal that this change in workflow will cause confusion for physicians and careful planning, training, and new or revised policies need to be in place to avoid frustration. Additionally, frequently there are things that must remain on paper, and these things must also be identified. For a variety of reasons, it’s not always possible for all tests to be ordered through the system. Perhaps blood gases or blood bank or some other testing must be ordered on paper. These must be clearly defined to reduce confusion.
This document summarizes some of the matters that are usually seen when converting to CPOE when PathNet® is already in production. It is certainly not all inclusive, but serves to point out some of the pitfalls that the health system can expect to encounter. Our goal is to help the project team to identify these risks and make sure that appropriate plans to reduce these critical project risks are in place.
PowerPlan is a trademark and PowerChart and PathNet are registered trademarks of Cerner Corporation® and/or its subsidiaries. HPG is not sponsored by and/or affiliated with Cerner Corporation®.