Oroville Hospital has implemented computerized physician order entry (CPOE) into VistA, their already robust electronic health record system. This makes Oroville Hospital the first individual US hospital to successfully adapt the full scope of services provided by the Department of Veterans Affairs' highly regarded electronic health records (EHR) system. This milestone was made possible by seven years of work in developing a standardized evidence-based paper order set system and three years of self implementing VistA and adopting it to a private hospital setting. The Oroville Hospital staff was able to convert their order sets from paper to electronic, while maintaining complete control of content and format.

As a result of all the work and preparation, the go-live day for CPOE was relatively “uneventful” compared to other hospitals’ experiences. There was already buy-in from Oroville’s medical, nursing and other staff since they had participated in the development of the order sets and the CPOE, thus making it easier during the transition from paper to electronic.

As described by Dr. Matthew Fine, Oroville Hospitals' Chief Medical Officer (CMO), “After a whole year of using paper and electronic charts the staff was chomping at the bit to go live and the anticipation outweighed the fear… so turning on CPOE was almost a welcomed event.” His conclusion is that, “The inadvertent strategy of having hybrid charts seems to have been a good way to make full conversion to EHR/CPOE more palatable.” CPOE went live on October 15, 2012 and by the end of the first week nearly 70% of the orders were electronic. Currently approximately 80% of the orders are electronic.

Computerized physician order entry (CPOE) allows medical practitioners to move beyond paper records and enter instructions for the treatment of patients, improving the overall patient care and patient safety. These electronic orders are communicated through an EHR, in this case VistA, to the nursing staff and appropriate departments (pharmacy, laboratory, or radiology, for example) responsible for fulfilling the order. CPOE decreases delay in order completion, reduces errors related to handwriting or transcription, allows order entry at the point of care, or off-site, provides error-checking for duplicate or incorrect doses or tests and simplifies inventory and posting of charges.

From Paper Charts to CPOE

A critical element to Oroville's success has been the level of effort and time invested in developing an evidence-based order set system and aligning members of the medical staff to agree on concept and standard of care. The complex but functional process also involved close cooperation between clinical staff and EHR staff. The order set process was started in 2005 and by 2011 the staff had developed almost 100 paper order sets that were in daily use.

For the transition to CPOE, the Oroville team developed a mechanism for systematically converting order sets to an electronic format. Dr. Narinder Singh, the Chief Medical Informatics Officer (CMIO) lead the team that included Dr. Fine, various EHR lead members as well as Clinical Access Coordinators (CACs). Each order set was then reviewed by the Physicians Medical Information Technology (PMIT) committee, which included in general 20-25 additional staff, depending on the order set. This larger group was comprised from department heads or section heads, to physicians, nurses, pharmacists, nutritionists, laboratory staff and in general anyone who would be involved in carrying out the orders in the order sets. This process allowed us to create electronic order sets, while retaining or improving the content, meaning and work flow.

The Open Source Advantage

One of the critical elements behind the success of Oroville's CPOE implementation is that VistA is an open source solution. The IT staff downloaded, installed and adapted VistA from the internet. This involved phenomenal effort, but resulted in Oroville Hospital having complete control over their EHR system and saved the hospital millions of dollars in implementation and customization costs. This process was detailed by Dr. Fine in this blog post.

Prior to making the decision to use VistA, the EHR spearhead team researched and found that resident physicians and other staff that worked at both VA and non-VA hospitals universally preferred VistA over proprietary EHR systems. After implementation, they heard similar feedback. Nurses who also worked in other local area hospitals thought VistA was more advanced and preferred it over other systems.

In addition, since the source code is available, users and developers have been able to configure the order sets in VistA on an ongoing basis to maintain and advance the functionality necessary to meet their responsibilities. Oroville does not have to wait months or years that it takes a proprietary EHR vendor to customize the forms (if even possible), while charging substantial fees.

Next Goal: 100% CPOE

Oroville's goal is for 100% of the orders to be electronic. That goal is still in the works as the hospital came up with a major challenge. Oroville Hospital was unable to adapt VistA’s original CP Flowsheet module for use in the hospital. As a result, several areas in the hospital have not been fully converted due to the difficulty of developing well functioning flowsheets. These areas include outpatient surgery and the Post Anesthesia Care Unit (PACU). To overcome this challenge, as well as to have a more systematic way of improving and enhancing VistA, Oroville Hospital created a code development office as outlined here. As part of this effort, Oroville has a team of developers working on developing its own Flowsheet Module. This module will be used as the basis for anesthesia, obstetrical, and infusion center flow sheets. Development of this module should be finished in the next three to four months.

Some other highlights of Oroville's EHR and CPOE deployment include:

• Paper records that have been converted into their corresponding electronic form include: lab, imaging, dictated reports, ECGs, echocardiograms, cardiac stress test, vitals, and ABG.
• All nursing notes and most of the progress notes are being documented on the computer. Some information still has to be scanned into the system.
• Developed a real-time patient-dashboard application. This breakthrough application uses data from VistA to show real time status of patients in one screen. The idea is to replace the manual white board used by the hospital to keep track of patients. The dashboard monitors orders and other patient activity.
• Wrote a pediatric chart application that has allowed the pharmacy to create weight-based medication orders for pediatrics.

Both the EHR implementation and the CPOE deployment have been achieved for less than $7 million as detailed by CEO Robert Wentz during a presentation at the 26th annual VistA Community Meeting in Sacramento, CA. That is less than a quarter of the average cost of implementing a proprietary EHR in similar regional hospitals. Stage I meaningful use was achieved in 2011 and 2012 for the hospital and most of the clinics. Oroville Hospital is currently working on Stage II meaningful use qualification.

About Oroville Hospital

Founded in 1962, Oroville Hospital has grown from a modest community hospital supported by a small staff of dedicated doctors into a 153-bed acute care facility specializing in a broad range of inpatient and outpatient services, including multiple physician practices. Oroville Hospital is a private, non-profit corporation serving the citizens of the Oroville area and Butte County by OroHealth Corporation. With a medical staff of more than 130 physicians, Oroville Hospital prides itself on providing the highest quality medical care in a friendly and compassionate environment.

For more information, please contact:

Shanna Roelofson
Director of Marketing
Oroville Hospital
sroelofson(at)orohosp(dot)com
(530) 532-8044
http://www.OrovilleHospital.com