Cedars-Sinai Learns from Its CPOE Mistakes to Improve Workflow

SAN FRANCISCO — Some 20 months after Cedars-Sinai Medical Center shut down its computerized physician order entry system in the wake of a much-publicized staff revolt, the Los Angeles hospital is taking the failure as an opportunity to improve its workflows.

In a poster presentation Wednesday at MedInfo 2004, the triennial conference of the International Medical Informatics Association, Cedars-Sinai clinicians demonstrated how a comprehensive review of the CPOE experiment is helping to identify inefficiencies missed while building the technology.

"The success of this evaluation has provided a standard format to identify workflow processes in all procedure areas," the poster presenters said.

The 850-bed hospital grabbed headlines in late 2002 when management decreed that all physicians must enter orders electronically or risk losing staff privileges. Cedars began a planned 14-week department-by-department rollout of CPOE in November 2002, but abruptly pulled the plug in January 2003 after physicians complained en masse that the system was slow and unwieldy.

Cedars had planned to turn the system back on following some technical changes, but the management of parent organization Cedars-Sinai Health System scrapped that idea about a year ago.

In preparation for the second implementation that still has not happened, clinical and technical staff began a "failure mode effects analysis," a process that the Joint Commission for Accreditation of Healthcare Organizations defines as an ongoing effort to mitigate the potential for error.

Cedars started the review in its cardiac catheterization laboratory, a high-volume unit that performs lucrative but complex procedures, and found problems with both clinical and administrative workflows.

For eight weeks, a multidisciplinary team went through the lab, asking practitioners and administrative employees alike to describe their work processes in detail. The reviewers found plenty that was less than ideal.

"We couldn't attach orders to patients during the admissions process," said Patricia Clinton, R.N., project coordinator in the hospital's department of enterprise information services. Patients often arrived in the cath lab before their admission orders, so physicians had nothing to enter into the CPOE system.

"The secretaries were not using the scheduling system," Clinton added. Instead, they filled out a spreadsheet, then picked up the phone to relay the information to central scheduling.

Paper abounded, even though the critical-care areas of the hospital had electronic medical records before the CPOE went live. Computerized coding and charge capture functions were underutilized, Clinton said.

The review also is helping Cedars design order sets that are important to the success of any CPOE project, according to the poster presentation.


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