Evaluating the Impact of an ACPOE/CDS System on Outcomes

When it comes to implementing an e-prescribingsystem, project leaders at the Everett Clinic in Washington state have some advice:  Pay close attention to the people who will use your system. Start simple and slow, be prepared to change gears if it's the right thing to do, and be mindful of how the new technology affects the ways in which people do their work.

That advice comes from experience.

The Everett Clinic is a community-based, physician-owned integrated health system in the north Puget Sound area. With 16 locations, 250 physicians in 40 diverse specialties, and 1,300 staff members, the Everett Clinic serves about 225,000 patients, who make approximately 700,000 visits per year.

The Everett Clinic is serious about health information technology (IT): The clinic owns its own IT subsidiary and began developing it own electronic medical record (EMR) system in 1995. Its physician-owners decided to tackle e-prescribing in 2003. To date, the Everett Clinic has implemented its own e-prescribing system among all of its ambulatory care centers.

E-prescribing is widely seen as a way to reduce medication errors. To evaluate the impact of e-prescribing on medication safety, the Everett Clinic established a partnership with investigators from the University of Washington Pharmaceutical Research and Policy Program. With support from the Agency for Healthcare Research and Quality (AHRQ), project leaders are currently assessing the impact of that implementation on medication safety and staff workflow, while documenting important lessons learned from the project. In addition, the clinic plans to add a clinical decision support component next fall, following a switch from the clinic's home-grown EMR system to the commercial EPIC system.

But even in the midst of all this continuing activity, project leaders say they have learned some important lessons, including the following:

• An iterative approach is crucial. "Don't hit the physicians with everything atonce," says Jennifer Wilson-Norton, R.Ph., M.B.A., director of pharmacy at the Everett Clinic and implementation leader for the project.
• "Have a dedicated implementation team and a designated evaluation team. That way everyone contributes from their field of expertise," say Beth Devine, Pharm.D., M.B.A., and Sean Sullivan, Ph.D., faculty at the University of Washington and lead evaluators for the project.
• Prepare your users well for implementation and provide them with plenty of technical support. Everett's pharmacists made a point of being available for training, in groups and one on one, and for trouble-shooting and "just-in-time" support.
• Be flexible. "You can't be locked in to a technology if it doesn't work, or if you see a better alternative," Wilson-Norton says.
• Remember to be realistic about your time frame. "You still have to keep your core business going," Wilson-Norton points out. "You have to be careful how you balance urgency, because everything is urgent."

Wilson-Norton acknowledges that the mission to transform the clinic has gone through many phases, starting with "building our own system and now transitioning to a commercial-based system. This is part of being an engaged organization."

For the e-prescribing component, Wilson-Norton notes that project leaders decided to begin with "a very basic" implementation that focused on refill orders to make the adjustment easier for physicians and other staff users.

There's a lot to get used to. For example, physicians have to be more precise in the e-prescribing world than they were in the paper world, where misspelled drug names are often corrected by a pharmacist. In the e-prescribing world, misspelled drug names simply aren't recognized. 

The implementation team has been making adjustments in workflow as well. As the team began the process of installing computers in exam rooms, the issue of security versus ease of access arose. To expect busy doctors to manually log on and log off every time they entered and left an exam room was unrealistic. "That's just not a sustainable business model," Wilson-Norton says.  But the terminals had to be secured. The project team came up with a solution in the form of a card that recognizes and authorizes individual users, who have different levels of access to information. This both ensures security and permits the right individuals to access the right information.

The EPIC implementation this fall will bring another wave of change. Wilson-Norton says that the clinic's home-grown EMR system would be more expensive to maintain and more difficult to update and enhance in the long run; the switch to EPIC will improve care and be more cost-effective in the long run. That was not the case when the clinic decided to develop its own system years ago, but since then technology prices have come down, making a commercial system much more affordable.

But a new EMR system also means a new e-prescribing system -- EPIC's. Wilson-Norton says that some aspects of Everett's current e-prescribing system are more user-friendly. For example, Everett's system gives physicians a drop-down menu with a range of packaging options for a specific drug. But when using EPIC's e-prescribing system, doctors will have to enter the correct packaging size themselves.

But with EPIC in place, the clinic will be able to move on from a basic e-prescribing system to one that includes the more advanced features of clinical decision support. "Therein lies greater potential to prevent errors and improve medication safety," says Devine.  She explains that the project team will probably take a staggered approach to clinical decision support implementation -- again, to ease the transition and to avoid "alert fatigue," which happens when physicians who are flooded withcomputer alerts choose to ignore them.

As part of the AHRQ project, evaluators at Everett and University of Washington are also assessing the impact of e-prescribing technology on workflow through a time-motion study. Here again, the project team had to adapt when confronted with an unforeseen twist. The original plan called for laptop computers with wireless communications for every physician. But it turned out that the wireless communications technology was not reliable enough, so the laptops were abandoned in favor of the exam room desktop computers.

Although the time-motion study is still underway, the project team already has made some important workflow modifications. For example, in the newly outfitted exam rooms, a medical assistant takes each patient's vital signs and enters the data into the computer so that all the information is available when the doctor comes in to see the patient. According to Wilson-Norton, nurses now spend more of their time in front of the computer, communicating with doctors electronically.