For the UHC project, Dr. Hoffmann and his team had to manually review charts and documentation to verify that the VAP bundle had been ordered and then utilized. “We looked at what documentation needed to be done, and we have modified nursing and respiratory therapy documentation to ensure that all these bundled-care process steps are adequately documented,” he says. The next step will be to tie CPOE with bedside charting and decision support, so that verification of order sets will also be stored in the hospital system’s information warehouse and will be accessible to physician researchers. The project is ongoing, states Dr. Hoffmann, and another evaluation will be conducted manually after a six-month interval to validate the data collection points that will be most useful in the automation process.
There are other ways to verify CPOE implementation. At BWH, says Dr. Gandhi, the electronic medication administration record (eMAR) provides a powerful adjunct to the CPOE.
“The fact that we have eMAR data is really advantageous,” notes Dr. Gandhi, “because now we can actually tell what patients have received.” For example, she says, Narcan (naloxone hydrochloride) is usually ordered and kept at the bedside for a patient receiving opioids in case the patient develops respiratory depression. Before institution of the hospital’s eMAR, “we could never tell how much Narcan was actually being given without doing laborious chart reviews. Now, with our eMAR, we can easily track how many times it was given, and this supplies a much better indicator of potential problems with the use of narcotics.”
At Vanderbilt, says Dr. Hain, a dosage checker application installed behind the CPOE has allowed his colleague Neal Patel, MD, MPH, to verify that medication errors in the Pediatric ICU dropped dramatically after its implementation. But, on other projects, researchers must know in advance that they intend to follow up on order entries so that they can convert order entries into binary procedures. The CPOE and EMR systems have the capability of inserting text boxes, drop-down menus, and click buttons for verifying medications, procedures, or even safety check-offs. If the CPOE is not set up in advance for this feature, however, it’s back to manual extraction to confirm the data—“a painful process, just as it is from paper charts,” Dr. Hain notes.
Privacy and Other Issues
Are there privacy issues of which hospitalists should be aware when using their hospital information system databases for their research?
“In general, if you’re doing quality improvement projects solely for the sake of improving the quality of patient care at your institution,” says Dr. Karson, “you do not need IRB [institutional review board] approval.” Whenever hospitalists plan to publish or present the data to external audiences, however, prior IRB approval must be obtained to show that patients’ identities will be protected and that use of the data will cause no harm.
There could be wrinkles in following these guidelines if the results of a QI project reveal surprisingly good results or important lessons about quality patient care that researchers think are worth sharing. Although it is possible to apply post-hoc for IRB approval, Dr. Gandhi and others suggest obtaining approval prior to the start of the project if researchers think there is any chance they may want to share results externally. Researchers must also adhere to the quality rules during QI projects, asserts Dr. Hain, to make sure patients’ identities are protected.
The IT/MD Interface
Whether hospitals use off-the-shelf or custom-built, institution-specific CPOEs, hospitalists are well positioned to play important roles in enhancing their designs, believes Dr. Karson. “If you’re going to support [clinicians’] decisions with computerized decision support, then CPOE systems are a great way to broadly affect the care of patients,” he says.