CPOE: Convincing Caregivers They Need It

More healthcare facilities are implementing computerized physician order entry software as the technology is seen as a means to increase patient safety, reduce medical errors and improve overall patient care by adding intuitiveness over the conventional pen and paper process. Early CPOE adopters have demonstrated that implementation is no easy task but healthcare providers en route to scrapping pen and paper are benefiting from their lessons learned.

"[Implementing CPOE] is very much not an IT project; this is a clinical project that has huge IT aspects to it," says Mike Russell, MD, associate chief information officer and a practicing physician at Duke University Medical Center in Durham, N.C.

CPOE goes beyond the realm of electronic ordering. The systems are integrated with clinical decision support tools that provide physicians, nurses and other staff members with additional information at the point of care to help make optimal ordering decisions. These "alerts" are used for allergy checking, drug-drug interaction and to check for duplicate orders. Order sets, another element of CPOE, speed up the ordering process and enhance efficiency.

In a CPOE environment, the number of physicians who utilize the application and the percentage of orders made via computer gauge success. However, few healthcare providers boast 100 percent utilization. For one, introducing CPOE into daily workflow and patient care flow is no easy feat.  

Duke's Russell explains that CPOE is all about a change in the practice of medicine. The cultural changes posed by CPOE, plus the idea that physicians can be resilient to computer technology, the limited amount of CPOE products on the market and the complexity of implementation has hindered adoption.

CPOE's saving grace, especially in lieu of the 1999 Institute of Medicine "To Err is Human" report that said medication errors alone contribute to 7,000 deaths annually, is that it helps prevent medication errors and adverse drug events; thus improving patient safety and overall patient care. Both are top priorities for healthcare organizations, according to healthcare IT executives who participated in the HIMSS (Healthcare Information Management Systems Society) 2005 Leadership survey in February. Respondents identified clinical applications such as clinical information systems, barcode medication management and CPOE software as important future applications for their healthcare organizations.

Moving forward, CPOE implementers will be academic medical centers and smaller community hospitals as well as community practice physicians. KLAS Enterprises estimates in a new report that 4 percent of hospitals, with an estimated 113,000 physician users, will be using CPOE in 2005 - up from 2.8 percent of hospitals and 45,000 physician users in 2003. There was a 163 percent growth in non-teaching facilities using CPOE, compared with a 60 percent increase in teaching facilities, KLAS said.

Out with the old

CPOE is not a stand-alone application; it must be interfaced with clinical information systems used in pharmacy, the laboratory and radiology. Using a PC located in a patient room, a laptop attached to a mobile cart, or a tablet PC in a wireless environment, physicians place orders, identify adverse reactions to different drugs, view patient records and calculate drug dosages. Manual steps between order and execution are limited, thus reducing cycle times for medication administration, radiology image acquisition and laboratory turnaround times.

A report conducted by Long Beach, Calif.-based First Consulting Group (FCG), in conjunction with the Massachusetts Technology Collaborative and the New England Healthcare Institute, found that if CPOE systems were operating in all acute care hospitals in Massachusetts, patient safety and the quality of care could be greatly improved, and costs could be substantially reduced - to nearly $275 million in net cost savings annually to the state's healthcare system. Full installation of CPOE systems could be completed for a capital expenditure of $210 million.

However, installation of CPOE in all Massachusetts hospitals would be a long time coming. According to Erica Drazen, vice president of research at FCG, the long-term goal of the Massachusetts CPOE initiative is to have all hospitals on board with CPOE in four years.

"CPOE represents a huge change in operations for the hospital," says Drazen. "It involves a change in physician practice. Not only because the physician is being asked to enter orders on the computer rather than scribble them on a chart or call them in on the phone, but the whole value of this is in the decision support and the standardization of care. Order sets are developed for certain diagnoses and the doctor is expected to use them. Other staff members are affected because some of the task used to be done by the unit clerks, some of it used to be done in pharmacy, and some in nursing."

The challenges of CPOE

"Probably the largest barrier [to CPOE adoption] is the cultural one," says Narendra Kini, MD, executive vice president, clinical and physician services for Trinity Health. The Novi, Mich.-based healthcare system, which operates 45 hospitals, is rolling out Project Genesis to develop an enterprise-wide digital environment and CPOE is a crucial component.

According to Kini, five hospitals in the system are live with Cerner Corp.'s CPOE technology. Battle Creek Health System, a 383-bed medical center in Battle Creek, Mich., was the fourth hospital to implement CPOE. Currently, between 60 to 70 percent of all orders are entered via CPOE.

"We are in the middle of a generational change in physicians," says Kini. "It's difficult for physicians who have been in practice for a decade or two to adopt computers in medicine.

"Then physicians are asked to adopt order sets," continues Kini. "Most [physicians] recognize that medicine is a combination of science and art. As you go to order sets, you are taking out a bit of the art and that is another barrier [physicians] have to overcome. Thirdly, these are not out-of-the-box applications that hospitals can just use intuitively. It takes a bit of learning, which has been a significant challenge for clinicians. The systems are not written for the way clinicians work. It has been a growing process and we are constantly working to improve this application."

The University of Pittsburgh Medical Center (UPMC) St. Margaret, a 259-bed, acute-care community hospital primarily staffed with private practice attending physicians, deployed Cerner Corp.'s Millennium CPOE in September 2004. More than 90 percent of the 250 active staff physicians now enter medication orders and diagnostic treatments electronically. Joel Diamond, MD, chairman of the UPMC St. Margaret physician advisory committee, says a significant barrier was physician comfort level with computer technology.

"We did a readiness assessment early on in the project to see what [our medical staff's] familiarity was with different computer technologies," says Diamond. "We addressed this early on so it would not be a barrier later on in the project."

John Fitzpatrick, MD, director of medical informatics at Forrest General Hospital (FGH) says the biggest barrier the hospital first encountered with CPOE was that it took too long to use and was not intuitive for physicians. The system, he says, was originally built for ward clerks and pharmacy clerks, not for physicians.  After major reconfiguration of the system from a physician's perspective, Fitzpatrick says the current limiting factor is human resources to train doctors on how to properly use the system.

FGH, a 537-bed community hospital in Hattiesburg, Miss., implemented Misys Healthcare Systems' CPR (computerized patient record) system in 1997 and went live with the physician order entry module in March 2005. As of now, more than 10,000 orders per month are entered directly by physicians.

Plan of action

FGH faced the problem of encouraging 360 physicians - 95 percent of whom worked in private practice - to utilize CPOE on a daily basis. What was their strategy? Target highvolume physicians, says Fitzpatrick, which include hospitalists, intensivists, nephrologists, infectious disease doctors, trauma surgeons and neurologists. "It turns out that 50 to 60 physicians actually enter 50 percent of the orders," explains Fitzpatrick.

"We take one doctor from each specialty and our strategy is to have those physicians be able to enter 100 percent of their orders electronically," he continues. "We don't want all of the doctors entering 30 percent of their orders. If we can get one hospitalist entering 100 percent, we can get 10 and so forth. Building order sets is a limiting factor to the speed of implementation. Once the order sets are built for the specialists, the other doctors can use them."

Fitzpatrick recommends that healthcare providers in private hospitals find a CPOE system that physicians can enter the orders in as fast as doctors can hand write them or else the chances of success will be slim. "If the system can be made faster than on paper, all you have to do is incentivise the doctors through the learning curve," says Fitzpatrick.

"We are paying the pilot physicians for a limited time frame for their efforts acknowledging that at least initially it takes more time than on paper," he continues. "However, as they become more comfortable with the system, they get faster and faster at entering orders. Our original incentive plan was structured based on an incremental target for percentage of orders entered spread out over six months.  However, most of the physicians are entering more than 95 percent of their orders from day one, and are probably reaching paper neutrality within six weeks."

Physician use of McKesson Corp.'s Horizon Expert Orders at Duke University Medical Center began in September 2004, starting with Duke's Heart Center.  With nearly 400,000 orders each month entered by the physicians, more than 590 beds and 1,600 users are on system, says Russell. Rollout to all adult beds in the hospital was completed in June.

Russell, who provides direction and coordinates the implementation of the CPOE initiative at Duke, says their strategy is to "stitch" in the technology. "We brought CPOE into our computing infrastructure environment so that it becomes a relatively seamless member of the other IT capabilities.

"We decided to deploy CPOE floor by floor, unit by unit," Russell continues. "Each floor consists of three units: two regular wards with an intensive care unit between them. We wanted to get our feet wet and make sure we had ironed out any glitches in each area. That way we could understand what the operational workflow changes were going to be and what the impact was going to be. As you go in on each floor, you have to build order sets. Thoracic surgeons are very different in terms of their patients and the techniques for caring for their patients than the neurology service or the renal service. You have to tailor the system to meet their needs."

The benefits

"We have greatly increased our standardization of medication dosing for specific diseases," says Russell. "We have put in order sets for specific diseases. This is particularly valuable in the Heart Center where there is acute coronary syndrome or congestive heart failure and the patients are supposed to be on specific medications. The difficulty is not so much knowing what to do but making sure that you in fact do it. We have seen a tremendous standardization of the dosing of medications."

FGH's Fitzpatrick says the benefits of CPOE include legibility and timesavings. "When the doctor enters the order directly, it's entered immediately," says Fitzpatrick. "This is opposed to on paper where an order is handwritten and sits in a box until a ward clerk enters it into the system. When physicians login in the morning to check their patient lists, they will often see things that they can order right there rather than waiting until they make their rounds. Another advantage is the ability to enter orders remotely. A physician can key in an order remotely without having to be physically present to write the order in the chart."

Across Trinity Health, nearly 70 percent of orders are being entered electronically. "There is a striking change in the way rounds are done," notes Kini. "Physicians order what it is they need to order, review the results at a terminal and then spend more time regardless of where it is, whether it's bedside or out, it really depends on the physician practice."

Less time is spent hunting and gathering. "Pharmacists spend less time tracking down physicians to clarify an order," adds Kini. "Throughout Trinity Health, the system has generated 30,000 alerts where orders had to be changed to make them more appropriate."

Success factors

Manuel Lowenhaupt, vice president, clinical transformation solutions for consulting firm CapGemini, says that CPOE is a tool, but it's not a solution. "Be realistic of your expectations," advises Lowenhaupt. "Understand what the system can and can not do. CPOE is all about moving from using paper tools into an electronic environment."

Here are some other recommendations:

  • Emphasize clinical value "I think the key is recognizing the value for the physician," says Lowenhaupt. "What is in it for the busy physician to utilize a system like this? A key motivator is quality of care for the patients. Prove to the physicians that if they use this system, their patients will get better quicker."
  • Please don't waste my time "As you think about how to get your staff to use the system, absolutely focus on making this an efficient, easy system for physicians to use," suggests Lowenhaupt. "Don't waste physician time with complicated login sequences. Don't make it hard for physicians to find patient information. Focus on streamlining the interface between the physician and the computer."
  • Identify staff needs "Make sure you build a system that addresses and supports the medical staff's needs," says Lowenhaupt. "That is different than understanding what your hospital needs are and addressing your hospitals' needs."
  • Clinical leadership "You have to view this sort of implementation not as a technology or as an operational project, but as a clinical project," emphasizes Lowenhaupt. "A clinical project needs clinical leadership. The steering committee should be dominated by physicians and nurses.
  • Culture shock "Expect many bumps on the journey to implementation," Lowenhaupt continues. "CPOE can improve patient safety. But it must be a component with a larger culture of patient safety, and it must be a component that is used carefully."