Analysis of CCHCS Medical Provider CPOE Practice

Wei Wu, BSN RN MSN Healthcare Informatics

CDCR Advisor/Mentor: Jeffrey Carrick M.D. & Eric Lee M.D.
Faculty Advisor/Mentor: Jonathan Mack, PhD RN NP

INTRODUCTION PROJECT APPROACH DISCUSSION

California Correctional Health Care Services (CCHCS) is
responsible for providing a community standard of health care
to California’s inmate-patient population across 35
institutions statewide. A milestone in accomplishing this goal
was achieved with the implementation of an enterprise-wide
Electronic Health Records System (EHRS), which now
provides tools to improve CCHCS’ ability to deliver
constitutionally-adequate care to the inmate-patient
population.
While adopting and implementing Cerner Millennium has
been a big change for all CCHCS clinicians, there has been a
particularly large impact to its medical care providers (MCP).
The Computerized Provider Order Entry (CPOE) process has
1. Use Cerner Command Language (CCL) to create queries to extract order data from Based on the collected data and compared metric
Cerner database. (Tool used: Cerner’s Discern Visual Developer) categories, the current order entry situation of CCHCS is
2. Obtain a comprehensive understanding of all orders entered by Medical Care dramatically inequitable. This situation puts much more
Providers (MCP) and non-Medical Care Providers (Non-MCP). burden on Medical Care Providers, especially on the
3. Stratify the orders into different categories based on professional roles and current categories of Pharmacy, DME (Durable Medical Equipment),
practice situations. and Patient Care. There are various types of orders can be
4. Compare the order entry between MCPs and Non-MCPs. delegated to non-MCPs to build a more equitable distribution
5. Analyze the categories of orders which can be delegated to other healthcare of order entry. The following are some thoughts on the
clinicians to assist medical providers with a team-based approach to patient care. delegation.
6. Ensure that the delegations are in compliance with CCHCS policies and procedures. 1. Pharmacy: The medication refill orders can be delegated
to other clinicians such as RNs (Kaiser Permanente: nurses
METRIC CATEGORIES COMPARED enter all the medication refill orders). The medication refill
orders cannot be extracted because many refill orders are
Order Category (MCP) Position Distribution
placed via the “Copy” function (use the same order details).
2.37% 1.97%

become time-consuming. This project sought to examine, 3.29%

1.80%
0.6

analyze, and create a more equitable order entry process that Pharmacy 0.5 47.87%

41.64%
There is no databased level artifact which can capture data of
orders placed by the “Copy” function. These orders are
Patient Care

is consistent with CCHCS’ Complete Care Model and team-

0.4
21.36% 44.61% Laboratory

Ambulatory Referrals 0.3

based approach to caring for the inmate-patient population. Radiology

0.2
demonstrated the same as new orders.
Consults
24.60%
DME

Other
0.1 5.70% 4.64%
2. DME: Evaluate the workflow to dispense DMEs to
0
0.14%
decide which types of DME orders can be delegated to other
PURPOSE Supervising Physician Physician & Surgeon Nurse Practitioner Physician Assistant Physician - OB/GYN

clinicians.
The distribution of order categories of Medical Care Providers (MCP). The distribution of Medical Care Providers (MCP) Positions.
“Other ” includes order categories whose percentages are less than 1.00% 3. Patient Care: The most patient care orders are follow-up
• To reduce the volume of and time spent on order entry by (e.g. Nutrition Services, Respiratory Therapy, Admit/Transfer/Discharge,
etc.) (Total number of orders: 118,115) orders. The follow-up orders should be given more attention
medical care providers Ambulatory Referrals
Radiology
2.28% Respiratory Therapy
0.92%
Admit/Transfer/Discharg Other
Order Entry Comparison
when deciding the delegations. Also, some monitor orders,
• To increase medical care providers’ satisfaction
e 0.41%
2.34% Pharmacy
0.19% DME

Consults
2.57%
such as vital signs, blood pressure, and blood glucose
•
6.66% Consults

To decrease the overall cost by a more equitable Patient Care

8.97% Physical Therapy Radiology
monitoring, can be taken into consideration.
12.42% Laboratory

distribution of order entry 63.25% Ambulatory Referrals

4. Laboratory: Even though the laboratory order category

•
Laboratory

To facilitate timely and appropriate patient care Patient Care

is not one of the top three inequitable order entries, this is the
Laboratory Physical Therapy Patient Care
Pharmacy
Consults
Radiology
Other
Pharmacy
Respiratory Therapy
Ambulatory Referrals
Admit/Transfer/Discharge
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
most order category entered by non-MCPs. The top five lab
Order Category (Non-MCP) Count (MCP) Count (Non-MCP)
orders (CMP, Hep related, CBC w/Diff, Lipid Panel, and Hgb
DATA SOURCE The distribution of order categories of Non-Medical Care Providers (Non-
The comparison of order entry between MCP and Non-MCP. The most
inequitable order entries include Pharmacy, DME, and Patient Care. A1c) can also be the subjects of the next step. For example,
MCP). “Other ” includes Nutrition Services, Speech Therapy, DME,
Occupational Therapy, Ambulatory Procedures, and Ambulatory POC. (Total Top 20 Patient Care Orders (MCP) Lipid panels and Hgb A1c are health maintenance laboratory
number of orders: 27,166)
The data for this study were extracted from CCHCS
MEDICAL CHRONIC CARE (CCP) FOLLOW UP 60
WEIGHT
277
327
tests that could be ordered by Non-MCPs as part of a team
DME Orders MCP vs Non-MCP FOLLOW UP RN 20

Cerner Production database. The study time range was from Non-MCP MCP PATIENT POSITIONING
406
484 based approach to patient care. This is not the case at present.
COMMUNICATION ORDER 560
7536 DME/Supply Receipt 0 INCENTIVE SPIROMETRY NURSING 562
02/01/2018 to 02/15/2018 (11 business days). Mobility Impaired Disability Vest Permanent 0
87

91
DRESSING CHANGE 695
REVIEW CARE PLAN 796

The positions of Mental Health Psychologists and DME Non-Formulary Temporary

Foot Orthoses Permanent

0

0
92

97
NEUROLOGICAL ASSESSMENT
ICE PACK APPLICATION
812
1087
NEXT STEPS & OPPORTUNITIES
Psychiatrists were excluded from this study. For non-medical Canes Permanent 2
114
FOLLOW UP RN 10
BLOOD PRESSURE
1090
1167
Wheelchair Supply 0
119 BLOOD GLUCOSE MONITORING POC
care providers (distinguished by the physician indicator), the Knee Braces Permanent 0
156 MEDICAL EPISODIC CARE FOLLOW UP 40
1193
1985

0
WOUND CARE ROUTINE 2487 In order to promote the major changes to the CPOE
order category of Mental Health was excluded also. Therapeutic Shoes/Orthotics Permanent

DME Non-Formulary Permanent 0

211
FOLLOW UP LVN 10 2828

All of the new order entries and related information in this Eyeglass Frames Permanent 3
243

490
MEDICAL EPISODIC CARE FOLLOW UP 20
VITAL SIGNS
3651
5159 practice and create meaningful changes, the future steps are
MEDICAL CHRONIC CARE (CCP) FOLLOW UP 40 5914

time period were extracted. However, order modifications

0 50 100 150 200 250 300 350 400 450 500
MEDICAL CHRONIC CARE (CCP) FOLLOW UP 20 6213 as follows:
0 1000 2000 3000 4000 5000 6000 7000
The comparison of top 10 DME orders between MCP and Non-MCP.
were excluded. The study only focused on new orders. 1. Focus on certain selected orders to calculate the time
Top 5 Lab Order Comparison
6000
5216
Top 10 Patient Care Orders (Non-MCP) Medical Care Providers spent on these order entries.
5000 4778
4622 VITAL SIGNS
RC INITIAL MEDICAL H&P 40
24
34
2. Look for data from other
MEDICAL CHRONIC CARE (CCP) FOLLOW UP 40
4000
3321
2906
FOLLOW UP RN 20
MEDICAL CHRONIC CARE (CCP) FOLLOW UP 20
36
48
49
healthcare organizations to
3000

2000
REVIEW CARE PLAN
FOLLOW UP RN 10
76
94
compare the order entry
1499 1593 FOLLOW UP LVN 10 160

1000
955
1255
1097 7362 RN INITIAL VISIT (ASYMPTOMATIC)
7362 RN INITIAL VISIT
235
804
situations to current CCHCS
0
0 100 200 300 400 500 600 700 800 900
CPOE practice.
CMP Hep Related CBC w/Diff Lipid Panel Hgb A1c

Count (MCP) Count (Non-MCP)

The distribution of top 20 patient care orders entered by MCP and the
The comparison of top 5 laboratory orders between MCP and Non-MCP. distribution of top 10 patient care orders entered by Non-MCP. For follow-up
(Hep related includes 14 Hepatitis related lab tests) orders, the number included means the length of the follow up visit.
(minutes).