Successful Implementation of Clinical Information Technology: Seven Key Lessons from CPOE.

OBJECTIVES: To identify and describe the most critical strategic and operational contributors to the successful implementation of clinical information technologies, as deployed within a moderate sized system of U.S. community hospitals. BACKGROUND AND SETTING: CHRISTUS Health is a multi-state system comprised of more than 350 services and 60 hospitals with over 9 000 physicians. The Santa Rosa region of CHRISTUS Health, located in greater San Antonio, Texas is comprised of three adult community hospital facilities and one Children's hospital each with bed capacities of 142-180. Computerized Patient Order Entry (CPOE) was first implemented in 2012 within a complex market environment. The Santa Rosa region has 2 417 credentialed physicians and 263 mid-level allied health professionals. METHODS: This report focuses on the seven most valuable strategies deployed by the Health Informatics team in a large four hospital CHRISTUS region to achieve strong CPOE adoption and critical success lessons learned. The findings are placed within the context of the literature describing best practices in health information technology implementation. RESULTS: While the elements described involved discrete de novo process generation to support implementation and operations, collectively they represent the creation of a new customer-centric service culture in our Health Informatics team, which has served as a foundation for ensuring strong clinical information technology adoption beyond CPOE. CONCLUSION: The seven success factors described are not limited in their value to and impact on CPOE adoption, but generalize to - and can advance success in - varied other clinical information technology implementations across diverse hospitals. A number of these factors are supported by reports in the literature of other institutions' successful implementations of CPOE and other clinical information technologies, and while not prescriptive to other settings, may be adapted to yield value elsewhere.

Simultaneous administration of multiple model substrates to assess hepatic drug clearance.

We have evaluated a method to simultaneously assess three major processes involved in hepatic drug clearance using three model substrates administered simultaneously as a 5-minute intravenous injection. Lorazepam, indocyanine green, and antipyrine are used to assess conjugation, liver blood flow, and microsomal oxidative metabolism, respectively. These substrates were administered individually and as a mixture to 10 healthy adult male volunteers to determine if clearances of any of the compounds were affected by simultaneous administration. Mean clearances of the substrates were not different when administered alone (9.97, 0.78, and 0.53 ml/min/kg) vs. together (11.5, 0.89, and 0.52 ml/min/kg), using a paired t test. Since we were using this method to assess hepatic drug clearance in children with leukemia, the effect of short-term allopurinol was assessed. The three model substrates were administered to the volunteers after 0, 1, 8, and 22 days of treatment with allopurinol, 200 mg t.i.d. There was no change in mean clearance of any of the three compounds at any point during allopurinol treatment (repeated-measures ANOVA). We conclude that this technique is a simple and valid method to simultaneously assess three major processes involved in hepatic drug clearance and is not affected by up to 22 days of oral allopurinol treatment. This simple technique, requiring a single set of blood samples, has potential applications in the assessment of developmental changes in hepatic drug clearance, as well as the effects of environmental, therapeutic, and pathophysiologic factors on three major processes involved in hepatic drug clearance.

Specific disappearance of translatable messenger RNA for elongation factor one in aging Drosophila melanogaster.

The molecular basis was sought for the previously observed drop in the synthesis of elongation factor one (EF-1) and subsequent decline in overall protein synthesis in aging Drosophila melanogaster. It has been found that translatable poly(A+)RNA for EF-1 disappears at about the same time that EF-1 synthesis decreases. This disappearance is specific for EF-1, since overall poly(A+)RNA levels and their translation to cellular proteins remain constant over the life-span of the organism. The disappearance of translatable RNA is not the result of a specific loss of the polyadenylate segment of poly(A+)RNA, since poly(A-)RNA exhibits a similar specific loss of translation ability for EF-1.

Decline in synthesis of elongation factor one (EF-1) precedes the decreased synthesis of total protein in aging Drosophila melanogaster.

The decrease in the rate of protein synthesis in aging adult Drosophila melanogaster was found previously to be due, to a great extent, to a drop in the rate of peptide chain elongation, and principally to lowered activity of elongation factor one (EF-1). This decrease does not appear to be caused by appearance of an inhibitor of peptide chain elongation. Instead, the synthesis of EF-1 declines markedly early in adult life. This decrease is followed by lowered activity of EF-1 and by a drop in the synthesis of most of the cellular proteins.

Effects of age on the post-initiation stages of protein synthesis.

The peptide chain elongation stage of protein synthesis in Drosophila melanogaster was found to decrease markedly with age. The decrease paralleled the age-related decrease in overall protein synthesis. In contrast, the termination stage showed little decrease until the organisms were very old. Of the three reactions that comprise peptide chain elongation, the binding of aminoacyl-tRNA to ribosomes decreased greatly with age, and the decrease paralleled that of peptide chain elongation and of overall protein synthesis. The peptidyl transfer reaction decreased moderately, and the translocation reaction exhibited no measurable decrease with age. Thus, decreased binding of aminoacyl-tRNA to ribosomes appeared to be a major contributor to the age-related decreases in peptide chain elongation and overall protein synthesis.

The effect of age on the initiation of protein synthesis in Drosophila melanogaster.

Polyribosome levels exhibited a marked, age-related decrease in adult Drosophila melanogaster. Since decreased polyribosome levels can be due to decreased initiation of translation, initiation was measured by determination of methionyl-tRNA binding to the 40 S and 80 S initiation complexes. Compared with 1-day-old adults, 48-day-old adults exhibited no more than a 12% decrease in methionyl-tRNA binding to 40 S subunits and a 20% decrease in binding to 80 S particles. Increased age, therefore, had relatively little effect on initiation, and the decreased polyribosomal content was probably due to the deterioration of some other component of the translation system.