An Alphabet Soup of Clinical Transformation: IPOCs, CPOE, BCMA, and more!

The project I’m working on is a very complex one, with a number of things being introduced as part of the overall project to transform healthcare. This blog posting represents a quick summary of some of the reading I’ve done on the different pieces of what’s being developed

First, some acronyms and what they mean:

• BCMA – bar code medication administration
• CIS – clinical information system
• CLMM – closed loop medication management
• CPOE – computerized provider ¹“Provider” refers to anyone who can prescribe/give orders, such as physicians, midwives, nurse practitioners, etc. order entry
• EHR – electronic health record: “a longitudinal electronic record of patient health ifnormation, produced by encounters in one or more care settings” (cited in Staggers et al, 2008)
• EMR – electronic medical record
• DSS – decision support system
• HIMSS – Health Information Management System Society
• IPOC – interdisciplinary plans of care
• IT – information technology
• MAR – medication administration record

First, a definition is in order. On the Health Information Management System Society (HIMSS) blog, we find the following definition of clinical transformation:

“Clinical transformation involves assessing and continually improving the way patient care is delivered at all levels in a care delivery organization. It occurs when an organization rejects existing practice patterns that deliver inefficient or less effective results and embraces a common goal of patient safety, clinical outcomes and quality care through process redesign and IT implementation. By effectively blending people, processes and technology, clinical transformation occurs across facilities, departments and clinical fields of expertise.”

So, the goals are promoting patient safety and improving clinical outcomes for patients and this is to be accomplished through redesigning processes and using information technology (IT). There are many things that can be done to accomplish this – below are some notes from my reading on a number of different processes that can be used.

Medication Reconciliation

• medication reconciliation is “a formal process for creating the most completed and accurate list possible of a patient’s current medications and comparing the list to those in the patient record or medication orders” (p. 459)
• five steps to med rec:
  1. “develop a list of current medications
  2. develop a list of medications to be prescribed
  3. compare the medications on the two lists
  4. make clinical decisions based on the comparison
  5. communicate the new list to appropriate caregivers and to the patient” (p. 459)
• common issues with med rec:
  • often not a standardized process used
  • at least 3 disciplines involved (medicine, pharmacy, nursing) and often not clear role/responsibility delineation
  • often duplication in data gathering, documentation (which is often not put in one place within a chart), rarely any process to compare/resolve discrepancies
  • transitions are often a problem:
    • patients generally admitted to inpatient facilities for urgent and/or specific procedure and specialty healthcare often focuses on a single issue, not holistic view of the whole patient (could result in missing a conflict between different meds they are taking)
    • patients sometime discontinue medication they take at home when admited and with a formal med rec process at discharge, the need to restart those meds might get overlooked
    • orders from one unit (e.g., ICU) might get stopped when moved to a new unit, where new orders are written, and without a formal med rec process, may overlook meds that should be continued
• challenges with doing med rec:
  • likely take more provider time initially, though “may become more efficient once in place” (p. 462)
  • “data are only as accurate as what has been entered” (p. 463)
  • what has been prescribed is not necessarily what is being taken by the patient
  • patients are not always “accurate historians” (p. 465)/don’t always know all the details of their meds
  • electronic med rec process can –> decrease in discrepancies in med profile, but “developing and implementing an electronic reconciliation process requires technical support” (p. 463)
• potential benefits of med rec (esp. with electronic records):
  •  >40% of med errors are due to “inadequate reconciliation in handoffs during admission, transfer, and discharge of patients” (pg. 459)
  • ~20% of those errors –> harm
  • “computer order entry system can reduce errors at the time of discharge by generating a list of medications used before and during the hospital admission” (p. 464)
  • electronic systems – easier to access med histories, but need to keep up to date and need to correlate with actual use by patients
  • electronic system – “allows for decision support such as checking for allergies, double prescribing, and counteracting medications” (p. 464)
• research implications
  • a good area for research
  • most studies in the area: small sample sizes, single-site QI projects
  • need studies on how med rec changes workflow (e.g., can take 30-60 mins per admission initially)
  • need studies on sustainability (do people continue the process over the long haul?)
  • “studies should also address what techniques (e.g., the use of a medication card) work best to maintain an accurate list of medications” (p. 466)

(Source: Barnsteiner, J. H. (2008). Chapter 38: Medication Reconciliation in Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Hughes R. G. (ed.). Rockville, MD: Agency for Healthcare Research and Quality)

Interdisciplinary Plans of Care (IPOC)

• plan of care: “based on patient needs identified by assessment, reassessment, and findings from diagnostic tests; based on patient goals with time frames within which to meet those goals, as well as the settings and services necessary to accomplish the goals; an evaluation of patient progress toward achieving the goals; and a revision of the plan and goals based on patient needs” (Joint Commission definition).
• potential benefits of electronic IPOCs:
  • “improved interdisciplinary communication and collaboration
  • improve care transitions and hand-off
  • opportunity for patient and family participation in the care process
  • greater care efficiency” (p. 9)
• 5 key success factors for adoption & bedside use of IPOCs
  • “leadership
  • bedside clinician involvement
  • patient & family focus
  • usable workflow populated with coded evidence-based content that drives assessment and care planning and supports data collection regarding care provided and outcomes achieved
  • clinical, informatics, IT, evidence-based content, and EHR vendor partnerships collaboratively focused on the same goals” (p. 10)
• “Historically, members of each discipline did their own assessment, established their own goals, evaluated the patient’s progress toward those goals, and developed their own plan of care” (p. 10) –> interdisciplinary approach “required revised thinking, collaboration, trust in each other, and a central focus – the patient” (p. 10)
• evaluating the journey:
  • metrics they use include:
    • “% of admitted patients with an IPOC initiated
    • compliance of initiation within 4 hours (facility & unit)
    • compliance of ancillary documentation within the IPOC” (p. 12)
  • phase 2 they want to use quality metrics such as “falls prevalence, pressure ulcer rates, glycemic control outcomes, and readmissions […] nursing documentation time” (p. 12)
  • “At the end of the day, there needs to be clear demonstration that the IPOCs aren’t only being utilized, but they also have a positive impact on patient care, patient outcomes, clinical workflow, and length of stay” (p. 12)

(Source: Jones et al (2012). The journey to electronic interdisciplinary care plans. Nursing Management. 43(12): p. 9-12.)

Computerized Provider Order Entry (CPOE)

• essentially, this means that the provider enters their orders into the computer themselves (as opposed to writing it down and having it transcribed)
• can include other features, such as standardized order sets,  integrated alerts; integrated decision support tools; interface with pharmacy information system; clinical documentation included
• because there are many different ways that CPOE can be implemented, in evaluation , it is important to document all the features (as results you get with CPOE without clinical decision support tools could very well be different than using CPOE with decision support tools)
• “ordering is a process starting with entry, to communication, to processing by various recipients, and then to documenting actions against specific orders” (so need to think about which pieces of this are being affected by your CPOE and other features)
• “CPOE can substantially reduce overall (and many serious) medication errors if: (1) electronic communication and automatic order interfacs are in place, (2) basic order checks for completeness are present, (3) decision suppport at its most basic level is available – checking for drug-drug and drug-allergy interactions and for dosing ranges”
• benefits seen with CPOE included:
  • reduced time for order entry to electronic availability of results for lab and radiology
  • reduced time for pharmacy ordering to medication administration
• benefits due to increased legibility of orders and availability of information
• need to examine work processes when implementing CPOE to make sure you aren’t causing any unintended negative consequences
• for evaluation, need to document/measure other potential external influences (if you can’t control them), since you’ll be implementing CPOE in the real world, where other things are going on that can affect your indicators/outcomes
• “ordering is a complex, interdependent, and interactive process composed of at least these multiple, intersecting elements: systems design, interpersonal and intersystems communication, implementation processes, and organizational structure” (paper suggests qualitative/mixed methods studies needed to do it justice)
• studies on “what designs facilitate safer orders management; […] what designs facilitate effective clinical decisionmaking; and what design work needs to be in place for successful implementation of CPOE” recommended

(Source: Staggers et al (2008). Patient safety and health information technology: role of the electronic health record in Patient Safety and Quality: An Evidence-Based Handbook for Nurses.)

Barcode Medication Administration (BCMA)

• also known as closed loop medication management (CLMM)
• ordering –> dispensing –> administration
• errors can occur at any of the stages
• 38% of “potential and preventable adverse drug events occurred at the time of administration”
• most common errors were wrong dose, wrong route, then wrong drug
• CPOE ~ ordering
• BMCA ~ dispensing and administration
• when BCMA is integrated with the EHR, you have a “seamless flow of information following every stage of the medication administration cycle”
• process:
  • providers enters medication orders electronically via CPOE
  • pharmacist verification
  • pharmacist packs meds into a barcoded container, sends to nursing floor
  • meds stored in med cart
  • nurse scans own badge (or logs into EHR/BCMA system), scans patient’s wristband, scans medication
  • system automatically documents what drug/dose was given to what patient by what nurse and at what time into the EHR
• system checks the “5 rights of medication administration”
  • right patient
  • right drug
  • right dose
  • right frequency
  • right route
• BMCA benefits:
  • real-time validation at point of care (safety check)
  • reduces workload (by automatically documenting for the nurse)
• evidence demonstrates
  • BMCA –> decreased medication errors (though may also see increase in medication errors due to better documentation of late or missed doses)
• how BMCA “affects the dynamics of a complex hospital setting, in ways other than the reduction in medication error rate is lacking”
• organizations need to have a “transparent environment for the reporting of errors – rather than a culture of blame”
• “a seamless integration between the CPOE and BMCA” is important
• areas for future research:
  • what types of adverse drug events (such as preventable and potential (a.k.a., “near misses”) does BMCA prevent?
  • ROI and economic outcomes of BMCA (e.g., affects on length of stay, decreased need for nursing FTEs for med admin, decreased litigation)

(Source: Staggers et al (2008). Patient safety and health information technology: role of the electronic health record in Patient Safety and Quality: An Evidence-Based Handbook for Nurses.)

Decision Support Systems (DSS)

• DSS = “software designed to support or enhance clinical decisions[, including] information displays, alerts, reminders, or fully developed algorithmic computerized protocols”
• evaluation of the system should include “measuring the implementation itself, the work process changes, and the outcomes”

(Source: Staggers et al (2008). Patient safety and health information technology: role of the electronic health record in Patient Safety and Quality: An Evidence-Based Handbook for Nurses.)

Computerized Provider Order Entry (CPOE)

(Source: Staggers et al (2008). Patient safety and health information technology: role of the electronic health record in Patient Safety and Quality: An Evidence-Based Handbook for Nurses.)

Image credit:

• Alphabet soup image posted by Judit Klein on Flickr with a Creative Commons license.
• Closed loop medication management diagram tweeted by HIMSS Europe.
• Medications photo from Pixabay, free for commercial use.
• Typing photo from Wikipedia, in the public domain.