The debate is long past. For better or for worse, electronic medical records (EMR) are the future of healthcare and the clock is ticking; among other things, the healthcare reform bill mandates that by 2015, Memphis area hospitals must have 80 percent of their medications placed by computerized physician order entry (CPOE).

But even before that bill was passed, Methodist Healthcare policymakers were ahead of the game, setting standards and deadlines of their own. The medical executive committee even made computer training part of the medical staff bylaws, reports Alastair MacGregor, MB, CHB, MRCGP, senior vice president and chief medical information officer at Methodist Healthcare (MLH).

“In 2001, Methodist Le Bonheur Healthcare awarded a major contract to Cerner Corporation for an acute care integrated electronic medical record—a very visionary decision at that time, because in the early 2000s, hospital health systems tended to buy ‘best of breed’: the best lab system, the best pharmacy system, the best electronic medical record system,” said MacGregor. “It wasn’t until the mid 2000s that the market realized that it’s better to have an integrated clinical system rather than stand-alone best of breeds.”

MacGregor compares it to the days when computers offered separate programs like WordPerfect, Lotus Notes, and Harvard Graphics—until Bill Gates packaged Microsoft Office Word, Excel, and PowerPoint. MacGregor, whose MB, CHB (the equivalent of an MD) was conferred by the University of Glasgow, Scotland, spent 11 years as Founding Medical Director of Cerner’s National Physician Consulting Practice, and refers to Cerner as the “Microsoft of Healthcare.” The company is the largest global electronic medical record system in the world, with more U.S. hospitals using its CPOE than any other—including several other Memphis hospitals following Methodist’s example.

When MacGregor left Cerner to sign on with Methodist in 2009, MLH had already turned on their first CPOE at Methodist North Hospital. Since MacGregor’s former job at Cerner was to ensure that all Cerner clients succeeded with CPOE, he was ideally suited to help MLH navigate through the shoals of implementation.

His initial step was to optimize the MLH approach to EMR and the implementation process, utilizing a staff of 250 — 90 of whom are clinical information systems specialists. CPOE was implemented first at all MLH emergency departments, followed by full implementation throughout Le Bonheur.

“It (CPOE) is all about patient care,” MacGregor stressed, and the benefits to patients are enormous. “It means that every order that goes into the system is legible, requiring fewer call-backs to physicians for clarification, fewer delays.”

Every CPOE order is also signed; orders for medications include the drug name, the route, the dose, the frequency, and the duration—all as basic information shared between the physician, the pharmacy, the nurse, and the patient. The system won’t allow any medication order to be processed unless essential details are complete; and although drug allergy and drug-drug interaction screening systems are in place, MacGregor reports that MLH is contracting with the University of Washington to help fine tune the drug interactions so they will fire at the point when the physician orders the medication.

“Another huge benefit that we see is the turnaround time,” said MacGregor. “The minute the physician clicks ‘sign’ on their screen, the medication or portable X-ray order turns up either in the pharmacy, the lab, or the radiology department for that test to be done. I’ve already heard from colleagues at University Hospital that, since the CPOE system has gone up, they are seeing ordered tests being performed while they are still on their rounds.”

Are there pitfalls other hospitals moving toward CPOE should beware of?

There are three critical areas, according to MacGregor:

• Leadership, both at the corporate level and at the hospital level, should set expectations that this is a better way of providing healthcare for patients.
• Very good system design should make CPOE as efficient for all users as possible.
• There should be a huge emphasis on training and support. Training doesn’t end at go-live; it continues forever.

The logistics of educating doctors, nurses, and pharmacists in the use of the system is as challenging as the mechanics of setting up such an integrated system, MacGregor points out.

EMR education is provided to the nursing side through classroom training that requires a total of about 12 hours—broken into three four-hour sessions—with competency tests for clinical users and medical staff. All medical staff are trained on-line, and on-line training for pharmacists was recently implemented.

Medical staff also receive continuing medical education credits; University of Tennessee offers credits for medical education for candidates who take the course and pass competency tests.

“Keeping everyone using CPOE optimally—nurses, physicians, pharmacists—is an unending process,” MacGregor warned. But the methodology for maintenance and continuous updates is already in place, and the system allows him to monitor every physician and nurse. “If some people aren’t using it, a team will meet with them and help them become more efficient and effective using the system.”

The hardest step in the implementation process is sustaining change, says MacGregor, but the normal cycle of change, through resistance to adoption, has progressed already to the stage where significant numbers of users have embraced it with enthusiasm.

“Change is hard,” said MacGregor, “but overall, there’s been a sea change to adopt CPOE across the nation. This is now seen as the way forward for providing safer and better medical care to patients.

 “Despite the complaints at the immediate go-live period, if we had an unplanned down time three months after we went live with CPOE, my phone would be melting with complaints that the system was down!” MacGregor predicts wryly.

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