Thursday, August 02, 2007

CPOE for chemotherapy

A very small percentage of hospitals in the country -- about 10% -- have computerized provider order entry (CPOE) systems for medication orders. This kind of system eliminates hand-written orders and has features that warn against drug-drug interactions. It also helps reduce medical errors because the computer is programmed with strict parameters that make it very hard for a provider to make a dosage mistake.

Until a few weeks ago, no hospital in the country (to the best of our knowledge) had a CPOE system for dispensing chemotherapy drugs. Now, BIDMC does. Over the past year, we've completely automated chemotherapy ordering with our Oncology Management System.

Here's how it works. Research nurses and oncologists agree upon protocols for best practice cancer care. When a specific patient is to be treated, clinicians order the relevant protocol -- which then is automatically optimized for the patient based on his or her height, weight, and kidney function. Since doctors order a care plan and not specific medications, the accuracy of all chemotherapy doses and all related orders is guaranteed. So far the system is in place for outpatients. We plan to be in operation for inpatients within a few months.

This is a self-developed system. Our CIO, John Halamka, and his staff work closely with doctors and nurses to design a system that meets the needs of the providers in the hospital. Everything, including the look and feel of the ordering screen, is developed by the geeks with input from doctors and nurses. (Yes, we also purchase vendor-supplied applications when they have what we need, but often they are not available or not suitable for these leading edge applications.)

18 comments:

Heather said...

Hi Paul-

Looking forward to many more years of great blogging.

Hope I get to see you for a massage at PMC this weekend. Have a good ride.

Heather

Paul Levy said...

Hmmm, I'd better explain that, or people will start talking and my wife will wonder who Heather is!

The PMC, or Pan Mass Challenge, is a two-day fund raising bike ride that supports the Dana Farber Cancer Institute here in Boston. The ride is about 180 miles in two days, and at the rest stops, they have people (like Heather) who give really great massages to tired bike riders (like me).

Thanks, Healther!

Ileana said...

Paul,

That's wonderful. I would love to see this system.

It would be interesting to know how you guys are storing the rules and how easy it is to maintain them. As the article in the link suggested, these kind of systems are prone to be changed very often: for example, an alarm/warning fires up all the time and you need to modify the rule that fires this: either make it a note instead of a pop-up screen or fine-tune what triggers the warning.

Building the system and putting it in production is not as important as having it perform well in time and make it flexible enough that changes can be easily incorporated.

This is where the advantage of the internal team comes in very handy.

It is this kind of problems that are a leading issue with the software systems these days. One design error can double or triple the maintenance cost of the system.

Paul Levy said...

Thanks, Ileana. John tells me the following:

"The issue you raise was the primary design consideration. We hired two full time oncology research nurses before starting the project so they could be part of the design process and ensure our maintenance tools were easy to use. They keep all the rules and protocols maintained on a daily basis in collaboration with all the clinician users of the system."

Brett Stauffer MD said...

"Since doctors order a care plan and not specific medications, the accuracy of all chemotherapy doses and all related orders is guaranteed."

I think most CPOE planners and developers made similar statements with the first release of their systems! The enthusiam for the total elimination of errors has now been tempered by experience.

I don't doubt that the system will be a big improvement and hold benefits for providers and patients. I am just skeptical that it will guarantee error-proof administration of complicated chemotherapy regimens 100% of the time. Hopefully someone will be monitoring the system to identify and address problems WHEN they arise!

PS - Enjoy the column, keep up the good work!

Rich said...

John Halamka is a true techno geniuos. I hope he's compensated well. BIDMC is lucky to have such talent

Anonymous said...

Paul;

Very interesting post. Like Ileana, I'd be interested in followup reports at 3 and 6 mos on how well this system is performing over time and what its maintenance costs are.
While we're at it, I'd be interested in posts on other areas in your hospital where you have innovatively solved problems common to hospitals. Like, how do you deal with overcrowding/waits in your ER? What patient ID system do you use to minimize errors in your blood bank/transfusion service? How do you optimize patient flow to minimize length of stay? These are not specific requests, just examples. You get the picture.
The view of these areas from the CEO's perspective rather than the trenches where I grew up would be interesting. Also, whatever happened to "what do I do all day?" I enjoyed that one.

Thanks for educating us every day!

Dan M. said...

...and I assume a human being actually reviews the output of the system to verify it "makes sense"?

Any complex system, no matter how well implemented and tested, is almost sure to have bugs that will only appear after deployment.

Mark said...

I must inform you that several hospitals, including my own (Yale-New Haven Hospital), have been doing this for many years with the 'legacy' Eclipsys product, e7000. It may have different features and functions but it has been working well for us.

John Norris said...

Any thoughts on licensing?

I'd be curious to hear a general comment about internally created software and licenses in general...it does not need to be specific to this CPOE.

Congratulations to the team!

Vincent said...

In Ontario, Canada, Cancer Care Ontario's homegrown CPOE system is used in 8 cancer centres across the province for all their chemotherapy orders. In total, about 50% of all chemo ordered is via CPOE. The system has been in place for 10 years.

Paul Levy said...

Mark,
It is our understanding that the legacy Eclipsys product is basic order entry and order sets, not the sophisticated pre-hydration, chemo protocols, post therapy pain/emesis control that are adjusted automatically to patient body size and renal function that we built in collaboration with our heme/onc clinicians.

Vincent,
Would love to learn more about yours.

John,
We have an active intellectual property group for our scientific advances. We also sometimes explore the same for other IP, like IT applications, but it is a much more difficult market in which to make real progress -- and our focus is really on working internally to expand our own applications.

Dan M. and brett,
You bet! Good points, for sure.

Anon 10:04, stay tuned on several of those.

Michael Hassett said...

Congratulations on the introduction of your new CPOE system! Given the complex nature of chemotherapy orders and the potential risks of chemotherapy medications, this is an ideal setting for an IT-based solution.

The Dana-Farber Cancer Institute, Brigham & Women's Hospital and Massachusetts General Hospital jointly developed a chemotherapy computer order entry system that has been active since 2001. For each chemotherapy regimen, there is an 'order set' that includes orders for hydration, anti-nausea medications, growth factors, and chemotherapy medications. Protocols for the treatment of acute transfusion reactions are also included if needed. The system has an automatic dose calculation function (based on body surface area, weight, or renal function where appropriate), and decision support to facilitate chemotherapy-dose-modifications when lab tests are out of the normal range. Order sets are created for all regimens, including clinical trials. The system is designed for and used by physicians, nurses and pharmacists.

As one comment said, a computer order entry system by itself is not enough to guarantee error-proof administration of chemotherapy 100% of the time. However, when combined with an ongoing evaluation/improvement program, rigorous protocols for the development of new order sets, and a careful approach to the administration of chemotherapy (as has been done at DFCI, BWH & MGH), a computer order entry system can contribute substantially to an institution's goal of ensuring the safe and accurate administration of chemotherapy.

Dave Sweeney said...

Paul - FYI, you should check out Intellidose - it is a locally (Waltham) produced software package that is in place at about 50 hospitals (and many smaller practices) around the country. Many practices have used it for over 10 years, and it has millions of chemo admins delivered. I believe it does everything your system does, and can be licensed by any hospital.

Thanks
Dave
- Full disclosure: I was formally employed at Intellidsoe.

Paul Levy said...

Forgot to mention, our Oncology Management System is fully web-based and fully integrated into our comprehensive electronic record.

Vincent said...

Hi Paul,

Attached is an article about the homegrown CPOE system built by Cancer Care Ontario that used by 8 cancer centres in the province, accounting for over 50% of all chemo orders in the province.

http://www.longwoods.com/product.php?productid=18468

Vincent

Scot said...

Paul,

Very interesting project. Would you elaborate on the team composition beyone the two nurses you mentioned. Also, does any of the Chemo ordering piggyback on other CPOE systems previously in place or is it entirely centralized through your custom app?
Thanks!

Paul Levy said...

Sorry about the slow answers, Scot:

In addition to the two nurses who maintain regimens and provide training and support, the team included physicians, oncology nurses, pharmacists, practice administrators, and IS developers and analysts. This multidisciplinary group met weekly to oversee design, development, testing and implementation of the Oncology Management System.

The new system is an extension to our existing CPOE system. It centralizes chemo ordering and is fully integrated with our web-based electronic health record (also internally developed).