Pediatric Informatics: Computer Applications in Child Health (Health ...

74 M.A. Del Beccaro et al.
(“Big Bang”) deployment brought CPOE, including the electronic medication administration
record (eMAR) to all inpatient units (including psychiatry and rehabilitation
units), ICUs, ED and pre and post operative areas. Since then, the hospital has
expanded from 200 to 250 inpatient beds. All orders except chemotherapy are entered
by clinicians, with chemotherapy orders entered by pharmacists (based on physician
orders entered on paper templates). By June 2006, hospital ambulatory specialty clinics
(approximately 25 different clinics with 150,000 visits that year) went live with all
orders including future visit orders, electronic prescriptions and fee sheet orders.
7.5.2 CPOE in Pediatric Critical Care
Children’s also published one of two studies that evaluated implementation of a
commercial CPOE in academic PICUs 42,43 with different findings with regard to
mortality. The Children’s deployment and study benefited from the shared experience
of the University of Pittsburgh, and found that many of the same issues
in PICU with regard to CPOE were also important in the pediatric ED. Lessons
learned included:
The presence of an EMR/CPOE does not guarantee perfect communication:
Communication and workflow failures are frequently root causes in medical
errors. CPOE may: (1) remove informal but critical communication between
nurses and physicians during ordering (“technology does not replace talking”)
and (2) reduce workflow efficiency by requiring more operators during critical
situations (such requiring an additional physician to order medications while
resuscitation is progressing).
Order set design is crucial:
Order sets and prescripted choices for completing
single orders are powerful ways to supply decision support. These standards for
care must be accessible to users: (1) users must know they exist (education) and
(2) users must be able to find them (search mechanism with knowledge of the
proper terminology to find them quickly). This is especially true in high-stress
patient situation where nonstandard (verbal) orders may contribute to a high
chance of medical errors. 44 Order sets must be based on published evidence
and must be organized to guide provider choices and actions based on patient
attributes.
By “go live” Children’s had over 20 ICU and 20 ED specific order sets covering
general and specific conditions, including standard admit, intubation and tumor
lysis order sets for the PICU and new leukemia patient, diabetic ketoacidosis,
fractures, dehydration, and four different fever order sets based on age or condition
(neonate or cancer for example) in the Pediatric ED. Order sets configure the
appropriate routes, frequencies and other details to minimize effort (clicks) and to
standardize care. Orders can be generated from the ED or PICU within 10 min and
are immediately routed to the appropriate areas (nursing, laboratory, radiology,
pharmacy, etc.). In both PICU and Peds ED, additional order sets were designed