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How CPOE Adoption Helps Clinicians Treat Stroke Effectively

By Kyle Murphy, PhD

In the emergency department, clinicians must move quickly to treat patients with serious conditions with little margin for error. Based on findings of a recent Kaiser Permanente study, computerized physician order entry (CPOE) can make a meaningful difference when treating individuals presenting with acute ischemic stroke.

Led by Kaiser Permanente's CREST Network Co-Chair Dustin Ballard, MD, MBE, a team of researchers conducted a retrospective study of a CPOE order set and its effect of administering a clot-dissolving treatment at the right time.

"Not every disease condition is going to be amenable to this sort of CPOE," Ballard tells EHRIntelligence.com. "Stroke is maybe a very nice and specific example of when it can be and you can meld the best practices of quality initiatives and CPOE and improve care."

The study found that CPOE adoption led to the injection of the blood thinner, tissue plasminogen activator (tPA), quickly enough to prevent blood clots from blocking blood flow to the patient's brain:

Of the 10,081 patients during the study period, 6,686 (66.3 percent) were treated in medical centers after computerized physician order entry had been implemented. IV tPA was administered in the emergency department (ED) to 8.9 percent of these patients, compared to 3.3 percent of patients in EDs at medical centers without the new technology — more than doubling the rate of IV tPA administration. When the stroke order set was employed in combination with the computerized physician order entry, IV tPA administration increased to 12.7 percent — a nearly three-fold increase. Even after accounting for variable factors, these differences held steady.

According to Ballard, the uptick in CPOE use was able to benefit from the staggered implementation at Kaiser Permanente for the Joint Commission's certification for stroke centers.

"It became a natural fit, a natural experiment that we could study because there was a staggered rollout of CPOE and Primary Stroke Center Certification," he explains. "We got lucky to notice that there was a natural experiment in play that would allow us to make a meaningful comparison."

What makes ischemic stroke an ideal candidate for CPOE, says Ballard, is the mixture of inclusion and exclusion criteria for tPA couple with a risk score and swallowing evaluation, the latter of which the Joint Commission uses as a quality measure for stroke patients. "So it embeds a number of things in it that help the clinician remember what to do," he adds.

For the co-leader of the multi-center collaborative network for emergency medicine research, the combined use of CPOE and new technology could end up having an enormous effect on the well-being of stroke sufferers moving forward.

"It is a time matter situation," Ballard maintains. "It has become even more so for stroke in the last seven months because now there is a whole new set of technology with stent retrievers that are probably going to do for stroke care what cardiac catheterization did for heart attack care. Going forward it will become even more important that things are activated very early on, and the new technology for stroke will still include giving tPA, which is the blood thinner, right off the bat."

In the here and now, CPOE use for acute ischemic stroke is a means for emergency clinicians to avoid failing to perform the appropriate activity at the appropriate time for primary and secondary interventions alike.

"It helps move things along faster and it eliminates errors of omission in terms of forgetting to do a swallow study, which isn't on the top of your mind necessarily when you're seeing a stroke patient because you're thinking about giving a clot-busting drug, calling the neurologist, and getting a CAT scan," he notes. "That's a secondary type of intervention, but it's an intervention that can make a big difference downstream."

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