CCHS-East Huron Hospital CPOE Project

In East Cleveland, a grant from the Agency for Healthcare Research and Quality (AHRQ) is helping one of America's oldest hospitals use some of the newest health information technology (IT) available to improve everyday patient care.

Huron Hospital, a 130-year-old acute care and teaching hospital serving a predominantly urban population, might seem an unlikely leader in the quest to integrate IT into health care. But the hospital and its partners in the Cleveland Clinic system are models for how to successfully incorporate computerized physician order entry (CPOE), electronic medical records (EMRs), and other advances into the day-to-day routines of patient care.

Today, rather than writing out orders, many doctors at Huron use one of the 230 computer terminals located throughout the 211-bed facility. AHRQ support is purchasing more of these CPOE workstations for the hospital. In this way, physicians can easily adjust medications or request tests, regardless of whether they are conferring with nurses, walking the halls, taking a break in a lounge, or even resting in the residents' sleeping area. AHRQ funding is also contributing to efforts to link physicians off-site so that they can manage patients from home via a secure, remote network connection.

Meanwhile, Huron and other Cleveland Clinic facilities are among the wave of pioneering providers making the switch to EMRs. These highly secured online data repositories pull together patient histories, physician orders, X-ray reports, lab results, and medication records into single, easy-to-navigate electronic files. Again, AHRQ funding is supporting expanded implementation of this technology.

The sophisticated IT tools employed at Huron are yet to be found in most community hospitals. These technologies offer very real benefits to this inner-city hospital's patients. Many people living in underserved areas do not have a primary care physician and, when sick, they tend to use the hospital emergency room as their main access point for health care.

"Lack of continuity is the biggest challenge when dealing with an underserved patient population," says Rebecca Kundtz, physician specialist in clinical informatics at Huron Hospital. "The ability to immediately access records helps us provide better and more consistent care."

Although the project has shown how IT can improve the efficiency and quality of care provided to underserved populations, the lessons learned at Huron apply to any facility that's considering adopting health IT.

One critical lesson: Be wary of becoming so enamored with new technology that you believe it will, by itself, transform a hospital's operations. Prior to putting any hardware or software on the floor, Huron administrators took a long, hard look at how the new system would affect the old ways of doing things.

For example, in a traditional hospital setting, physicians typically go to a nurse's station to write their orders. It's a routine that over the years has become a visual cue, alerting staff that the doctor is on the floor and seeing patients and that orders will be coming soon.

"With the new system, a physician can place an order from anywhere there is a computer terminal," says Barbara Moran, vice president nursing and chief of nursing operations at Huron Hospital. "Without that visual cue, we thought it was important to adopt policies and processes that require staff to periodically go into the system and check for new orders. We also emphasized that the new technology did not replace the need for direct communication among caregivers."

"The lesson here," she continues, "is that before you purchase any technology, you need to understand workflow in the hospital and how the environment will be affected by the change." Many IT implementation problems stem from poor workflow analysis, she says.

According to Cleveland Clinic Regional Vice President Michael Waggoner, M.D., who was at the time of the writing of this implementation story, also the principal investigator for the AHRQ project, another key to success involves understanding physician culture, particularly when it comes to persuading doctors to adopt CPOE over their traditional paper-based methods.

For example, CPOE systems can alert doctors to a potential medical error -- and thus improve patient safety. But sometimes the alert is a false alarm. Get too many of those, and physicians will start ignoring the alerts or go back to their old paper-based ways. For that reason, CPOE software needs to be calibrated so that alerts for drug interactions only "fire" when there is a clear danger or when the physician can use an alternative approach.

For example, the computer might prompt the ordering physician to use a more appropriate dose of a drug based on rules that are programmed into the system. Or the computer might remind the physician that the patient is allergic to a drug that's just been ordered so that the physician can change the order.

Indeed, Huron Hospital physicians are heeding their system alerts. During the first half of 2006, 36 percent of drug orders were cancelled or modified after the system generated an automated alert of possible allergy issues. In the past, these allergies may have been detected by a pharmacist who would have had to call the physician for clarification. And since implementation in July 2004, clinicians at Huron have placed nearly 2 million orders via CPOE -- information that automatically becomes part of each patient's EMR.

The hospital also has come up with a simple but effective way to address the security and privacy concerns that, nationwide, have inhibited widespread adoption of health IT. For example, to satisfy a state requirement for positive identification when ordering prescription medicines, physicians use a device next to a computer terminal that reads their fingerprint.

Buoyed by its success with CPOE and EMR systems, Huron Hospital continues to aggressively pursue new health IT. AHRQ funding is helping equip Huron pharmacists who accompany doctors on rounds with tablet PCs that link wirelessly to the hospital network. The devices allow pharmacists to view a patient's medication history and enter medication changes right at the bedside. And those medicines are increasingly likely to be delivered via electronically secured, computerized "medication carts" that include a built-in PC that provides access to patient records and the ability to document medication administration electronically at the patient's bedside.

In addition, AHRQ funding is helping to further imbed health IT into the workplace culture by supporting a PC lab in the Huron Hospital School of Nursing. This way, nurses begin their careers knowing how to use an EMR system.

Moran and Kundtz say they continue to seek new ways to maximize the benefits from their technology investments. "We are constantly looking for how we can make the system more acceptable and beneficial for our doctors and nurses," Moran says.

Kundtz notes that, ultimately, adopting CPOE, EMR, and other IT advances is not about being on the cutting edge, but about making a long-term commitment to improving quality and efficiency. "From our leadership's perspective, this is simply what we need to be doing to provide the best patient care," she says.