The Laboratorys Role in Computerized

Physician Order Entry

Eugenio H. Zabaleta, PhD

Disclosure

Dr. Zabaleta declares that neither he nor any

member of his immediate family has a financial
relationship with a company as defined in the AACC
policy on disclosure of potential bias or conflict of
interest.

Objectives

Specify the role of laboratorians and importance of

participating in the development of CPOE through the
creation of evidence based order sets
Justify laboratorians inclusion and participation on
CPOE development
Explain how the laboratory can contribute to
improved laboratory test utilization, improved patient
safety, decrease of errors and reduction of length of
stay through participation in and creation of order
sets
Champion the importance of laboratorians
participation in CPOE projects

MedCentral Health System

Mansfield, Ohio pop. 50,000

Service area pop. 400,000

351 beds

2,600 employees

250 physicians

Two hospitals (one critical access)

Level II Trauma Center

Heart Center

Cancer Center

College of Nursing

Seven outpatient facilities

MedCentral Health System

18,000 admissions

9,000 surgeries

70,000 emergency visits

300,000 outpatient visits

1,400,000 lab tests

160,000 radiology procedures

380 open heart surgeries

MedCentral Cardiac Surgery ranked

#1 in Ohio two years in a row

MedCentral Cardiac Surgery ranked

in the top 10 percent in the nation for
cardiac surgery three years in a row
(2008, 2009, 2010)

MedCentral Clinical Laboratory

Phlebotomy

(Before CPOE)

Outreach

Specimen Processing

Chemistry

Hematology

Coag/UA

Blood Bank

Microbiology

POCT

MedCentral Clinical Laboratory

Types of problems (most common):

Over Utilization
Under Utilization
Wrong Order
Off Label Use

(Before CPOE)

MedCentral Clinical Laboratory

(After CPOE)

George Lundberg (JAMA 1981:245:1762-1763)

The brain-to-brain turnaround time loop

Goal (LAB)

To perform the right test for the right

patient at the right time in order to
impact patient care, thereby allowing
the lab to become a true physicians
aid at the bedside.

What is Computerized
Physician Order Entry (CPOE)?
With CPOE, physicians enter orders
into a computer rather than on paper.
Orders are integrated with patient
information, including laboratory and
prescription data.
The order is then automatically checked
for potential errors or problems.

Specific benefits of CPOE include:

Patient safety
Decrease transcriptions errors
Prompts that warn against the possibility of drug
interaction, allergy or overdose, duplicated testing
Accurate, current information that helps physicians
keep up with new drugs as they are introduced into
the market
Drug-specific information that eliminates confusion
among drug names that sound alike
Improved communication between physicians and
clinical services (pharmacy, laboratory, radiology,
etc.)
Improved efficiencies & reduced health care costs

Order sets
Definition
A group of patient care orders
organized along a common theme:
Signs or Symptoms, Diagnosis,
Procedure, etc

Benefits of Standardized Order Sets

Legible, structured and complete

physician orders
Increase provider efficiency
Reduce practice variation
Reduction in the number of medication
errors and ADRs
Broad access to clinical literature at
bedside
Integration of clinical evidence to current
care processes

Electronic vs. Paper Order Sets

Electronic Order Sets

Paper Order Sets

- Easy access from anywhere

- Difficult to find

- Real time prompts

- Physicians unaware of paper order

sets

- Easy and timely updates

- Updates lag behind practice change

- Old version is replace with new

version

- Difficult to remove old version

from patients areas

- Ability to link order sets for

standardized elements of care

- Patients may need more than one

order sets

- Directly linked to evidence-based

literature

- Probably evidenced based

MedCentrals Physician Advisory Group (PAG)

responsible for CPOE Implementation

Physicians (14): Cardiology (2), Family Medicine (1),

Pulmonology (1), Emergency Medicine (3), intensivist (1), General
Surgery (1), Nephrology (1), Internal Medicine (1), Anesthesiology
(1), Hospitalist (1), & Administration (1)

Education Department (1)

IS Department (5)
Nursing (2)
Pharmacy (1)
Laboratory (1)

Order Set Creation

Prioritization of order set (Zynx Templates)

Laboratory and Pharmacy (editions/suggestions)
Physician reviews and comments (PAG)
Discussion/Modification/Education
PAG approval
Medical Executive Committee approval

Lab Check List

I.
II.
III.
IV.

Knowledge of Client/Lab Tests

I. Knowledge of Client/Lab Tests

Besides the Package Insert/Papers:
Who is using them?/How they are
being used?/What clinical decisions
are being made?
Does the analytics characteristics
match the clinical use? (limitations,
interference, etc)

Lab Check List

I.
II.
III.
IV.

Knowledge of Client/Lab Tests

Evidence Based

II. Evidence Based

EBM

above all !!!!!

Demographics? Disease
incidence? Chief complaints?
Meds? Test principle?
EBM must be available
EBM must influence, change,
and standardize medical practice

EBM Availability/Influence
(DKA Order Set)

Standardized

AMI/CP/STEMI - Admission

Change (standard of care)

Sepsis - Adult Admission CPOE

Change (standard of care)

Change (standard of care)

(Approved by MedCentrals Medical Executive Committee in May 2009)

Lab Check List

I.
II.
III.
IV.

Knowledge of Client/Lab Tests

Evidence Based
Accessibility (User-Friendliness)

III. Accessibility (User-Friendliness)

Ordering should be intuitive for the

physician
Easy ordering:

Name changes
Customized panels

PAG customized panels

DIC profile (PT, PTT, Fibrinogen, D-Dimer and FDP)

Urine Protein Panel (Urine Creatinine, Protein Urine

Random and the Urine Protein /Urine Creatinine ratio)

Urine Electrolytes Panel (Urine Creatinine, Urine

Urea Nitrogen, Urine electrolytes, Urine Osmolality)

Renal Serology Panel (Anti-GBM Abs, ANCA, ANA, ASO,

C3, C4, CH50, CRP, Cryoglobulin, Hepatitis Acute Panel & HIV)

IT Settings/Characteristics/Limitations

DIC profile (PT, PTT, Fibrinogen, D-Dimer

and FDP)
To avoid duplicated orders (most patient
will have a CBC done, which includes
platelet count)

Decision Support (to help order the most appropriated test)

Urine

Protein Panel (Urine Creatinine, Protein

Urine Random and the Urine Protein /Urine Creatinine ratio)

Renal Acute Failure Admit CPOE

Physicians/Practice Standard

Urine

Electrolytes Panel

(Urine

Creatinine, Urine Urea Nitrogen, Urine Electrolytes, Urine

Osmolality)

Physician Consultations

Easy Ordering

Renal Serology Panel

(Anti-GBM Abs, ANCA, ANA,

ASO, C3, C4, CH50, CRP, Cryoglobulin, Hepatitis Acute Panel & HIV)

Lab Check List

I.
II.
III.
IV.

Knowledge of Client/Lab-tests
Evidence Based
Accessibility (User-Friendliness)
Utilization/Feed Back/Education

IV. Utilization/Feed Back/Education

Change some order patterns/habits
Creation of Utilization Committee

General Postoperative Care Admit - CPOE

Check List

I.
II.
III.
IV.

Knowledge of Client/Lab Tests

Evidence Based
Accessibility (User-Friendliness)
Utilization/Feed Back/Education

Destructive Creativity
MedCentral has destroyed old practices to create new and better ones.

MedCentral Health System

Expert Care:

Pillars of Expert Care

TEAMWORK
..work together to
provide our
patients the best,
most reliable care
possible

Pillars of Expert Care

INNOVATION
..continually strive to
develop and work
with the latest
processes
available in every
department

Pillars of Expert Care

Quality
..known for
excellence in all
that we do

Pillars of Expert Care

CUSTOMER
SERVICE
..we are committed
to the individual
needs of every
patient

Why should laboratorians be

involved in CPOE implementation?

Because of:

The Patient