EW: Other hospitals have varying degrees of electronic medical record, whereas many hospitals have talked about order entry. But a review by the Leapfrog Group noted that only 29 hospitals in the country have order entry, and only a handful have what we call 100 percent physician order entry. A lot of hospitals allow nurses and pharmacists to enter orders, but our system is a physician order entry system. The whole UPMC system has chosen the same vendor as their electronic medical record software. We are the only one in the system in the area that has chosen to do the order entry part of this first. I’m not aware of any other hospital in this region that has implemented physician order entry, where the physician is required 100 percent to enter orders into the system. We hope to set the example and are already receiving phone calls from people elsewhere about what we are doing.

EW: We reviewed a variety of different vendors that make software and the hardware for the order entry systems and we chose what provided the best system for our needs. It is a very sophisticated electronic computer database that allows the physician at the computer screening terminal to answer patient demographics, and then specifically the orders to the patient. They are able to choose from a variety of menus: the orders they use, the best drugs with the appropriate doses, x-rays, lab tests. Then those orders, once they are signed electronically, go to the pharmacist, the nurse, the x-ray department, and the laboratory instantaneously. In the past, all that information had to be transferred to a greater or lesser degree by faxes, by hand-carrying, by pneumatic tube systems, all of which had varying degrees of time it took for the actual transmission of the data to occur.

EW: Yes. This is all inpatient, not an outpatient process yet. It will be, ultimately.

EW: We already went through a very vigorous training system over several months. We trained 2,000 physicians, nurses, pharmacists, respiratory therapists. We have ongoing training for new doctors, nurses and pharmacists as they come on board. We went through almost a year-long process of building the system. We chose the vendor, which provides the framework for the system, then we customized the system based on our particular pediatric needs. We had to redesign processes that are different in the computer world from the written world. We had teams that included nurses, pharmacists, system analysts and physicians that together worked on these various redesigns. We also built a variety of order sets. In the written world there are a lot of order sets; physicians have developed encrypted favored orders. In the computer world we have order sets that are not just by physician, but by service, and it allows you very quickly to pick and choose the best types of treatment for that type of disease or post-operative situation. We built 150 of these order sets, then we trained our clinicians how to use the system. Beginning Oct. 24, we began the process of bringing this system up on different units over a six-day period, so we didn’t just suddenly one day implement it.

EW: This is a major change. I think everyone has his or her degree of ability to change—some better, some less. There was obviously some resistance, but I’m proud of the fact that our staff physicians, nurses and pharmacists all came together, saw the importance of this and have adapted very quickly. For some people it’s easy; some people aren’t as computer literate as others; some people fear having to use a computer. Our children use computers everyday and think nothing of it, but adults have a harder time adapting to email and the Internet, so some people felt uncomfortable with that. As they learned to use the system, that discomfort has lessened considerably.

EW: We had a physician advisory committee made up of physicians from multiple disciplines throughout the hospital. They met for almost a year on a weekly basis going over the various aspects of the system—the process change, the design of the system. We had one physician, Dr. William Neches, who was very involved in the electronic world for many years. He was our lead physician and spent almost half of his time over the last year just dealing with the development of the system. The other physicians have spent significant time as well. There were about 30 physicians on the design team.

EW: The Leapfrog initiative and others have identified this as a major safety initiative. We figure we’ll prevent errors—not so much identify them as prevent them. So many errors occur during the transmission of information. Physicians traditionally have bad handwriting and write quite rapidly and their orders are sometimes difficult to decipher, leading to confusion and sometimes mistakes. More often it leads to callback, where the pharmacist/nurse gets the order and calls the physician back, and that slows everyone’s work down and delays treatment to the patient. This system is already avoiding that with no written communication and all electronic communication, so there are no callbacks, unless there is still some question about the dose. Those questions are always going to occur between pharmacists and physicians and nurses. We’ve reduced those callbacks already by 50 percent. The reason we’ve reduced those types of callbacks, as I discussed this with the pharmacists, is because there is no confusion over the handwriting. This was the major cause for callbacks.

EW: One of the other advantages of the system is that as you enter the order, if the patient has an allergy to that drug, then it flashes up on the screen and tells you. In fact, the system will not allow you to enter orders on any patient without first entering any known allergies of that patient. Another important issue with pediatrics is that children dosing is much more weight-related than adult dosing. Adults’ weight range is pretty constant, so that most dosing is by unit rather than by weight. In children, almost all dosage is determined by weight. The system requires that the weight be entered up front so that weight is available to the pharmacist, nurse, as well as the physician, so that there can be rechecking of the dosage more readily.

EW: No one has to prescribe by algorithm. In some situations, it is a quick way to prescribe and many physicians in the written world have developed algorithms for treatment, so that is not the only choice. You can order any individual drug, individual x-ray and individual lab test without using an algorithm.

EW: The accessibility of information right at the patient’s bedside is a major benefit. In the past, you had to go to a nurse’s station and frequently someone else had the chart and it made getting to the information difficult. Now there is a computer terminal next to the patient’s bedside that the physician or nurse can log on and access. The degree of information we have available now—orders, patient’s vital signs, weight, lab work results, x-ray results—that information is available instantaneously to the physicians. If a physician is anywhere in the building, they can access the patient’s chart when they get a phone call about the patient from the family or the nurse. If the patient needs to be evaluated, they would obviously go up to the nurses’ station, but as many physicians are aware, there are many verbal orders written because the patient is in one place, the doctor is some place else, and the nurse calls. It has been a common practice to issue a verbal order that, just like the written orders, can be misinterpreted and there is even a greater likelihood of misinterpreting a verbal order because of language, hearing, etc. Now the physician from his office, clinic, x-ray department, can log on to a computer and enter the order directly to the patient’s chart and, again, no misinterpretation.

EW: The early phases, like everything else when you are learning something new, it takes a little bit longer to get up to speed, so it has taken a little longer for some physicians. The system doesn’t do everything. We are modifying it as we go, adding new components and pieces. Right now it does all the orders and has all lab work and x-rays. We are building more order sets, more rules for physicians, such as telling them what the best drug choice is for an infection. All that will be available. We are going to continue to grow, build and mature the system. We view this as a journey, not a destination.

EW: We actually have daily meetings about any issues that arise and correct those things that need to be corrected as they come up with the advisory committee.

EW: I can’t give you the exact dollar amount, but it’s in the many millions. This was a commitment of our organization. We looked at the benefits versus the cost and the board made a decision that this was something worth spending money on.

EW: We believe that ultimately there will be many cost-savings. We will be able to help physicians monitor the appropriateness of orders, use of various drugs versus other uses, one diagnostic test versus another. We’ll be able to store information better, retrieve it better. If you put all that together, it will decrease cost. We haven’t achieved that decrease in cost yet, but we believe that will happen over the next several years. I think it’s too early to really estimate that. When you put the cost of good health care against the cost of a computer system and what is best and safest for patients, the cost of this system is nothing compared to the value of the patient.

EW: Everything in the system is archived. All the data is stored forever and very securely stored, I might add. Not only is it very difficult, if not impossible, for anyone to get to that data that doesn’t belong there, but we audit every log-on to that patient’s record. In the written record, people walk onto the nurses unit and the doctor can pick up a chart of a patient he is not taking care of and open that chart. The nurse may question why that doctor is doing that, but there is no record of that happening. Every time someone logs on to the electronic chart, that person’s identifier is logged in, and associated with that patient’s record. One of the other advantages is that we can know quickly if someone has accessed that record. We can identify who did that, and if that person wasn’t the appropriate person, we can stop that.

EW: This is 100 percent compliant. That was one of the prerequisites of the system. Anybody that has access to the chart must sign-on with his or her electronic signature. Using someone else’s electronic signature is the same as signing their name, which is fraud and punishable by the government. If it’s an employee, it’s grounds for dismissal, so we don’t believe that will happen. When you log onto the system, there is a notice there that says, "It is illegal to use someone else’s name."