Duke Health Uses IT to Get Beyond Doctors' Handwriting - ' Not a perfect fit '

Even once implemented, the CPOE will not be a perfect fit.

"In a paper world, so many processes are malleable in ways that they are no longer malleable [with CPOE]," according to James Tcheng, associate professor of medical health systems, who worked on the project.

He described one example. When heart doctors realize a patient receiving a cardiac catheter needs to be admitted to the hospital for cardiac care, the paper system would let doctors write orders before the patient is formally admitted, a process that was not allowed with the CPOE system and caused delays.

Tcheng recalled that it was not immediately clear what was causing the delays. "It took a bit of detective work."

However, once the problem was identified, a new unit was added to the CPOE system, allowing that cardiology unit to admit patients virtually.

Tcheng said that the technical solution was much easier than the political one of explaining to the admitting and billing offices why the cardiac unit needed to be able to "admit" patients on its own.

Administrators needed to be convinced that doctors wouldn't be violating regulations with a virtual admission process.

After examining the workflow in each department, the Duke team laboriously identified sets of activities that come together, with the idea of automating processes as much as possible.

"When a patient is admitted with chest pains, there's only certain ways to treat the patient, certain drugs, certain procedures," Ahmad said. "If you select cardiac admission [on the CPOE system], one click puts all those tasks on the side. The system will prompt you with all the things that are set up to happen."

The team first organized the order sets into a superstructure called the ontology, Tcheng said.

"We put together the ontology and populated it with order sets like categories of admissions, disease management, rounding."

Ultimately, each department needed to be represented by similar architecture. "We had to make it look fairly uniform across the hospital, when you open the CPOE you can get where you want to go promptly and understand how order sets were organized."

The result, said Ahmad, is a lot less "zigzagging" both in physical terms and in terms of communications between doctors and nurses, and an enthusiastically accepted system.

"Previously, the physician would round in morning and go from bed to bed and then go back to order book, go back to next room, and then go to computer in between to look at lab results. Now we have laptops on gurneys the physician can take from bed to bed and see everything they need at once."

In addition, orders sent to labs and pharmacists are clearer than orders scribbled on paper, said Ahmad, so doctors "get rid of nuisance calls from lab and pharmacy asking 'what did you really want?'"

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