Computerized physician order entry (CPOE) can improve efficiency, reduce medical errors, and save hospitals money. So why have less than 2 percent of American hospitals implemented the tool? Implementation is not for the faint of heart, according to clinicians who have been through the process. The vendor selection, build, training, installation, and migration are complicated but very necessary steps of the process.
From buy-in to build
State University of New York Upstate Medical University (SUNY Upstate) in Syracuse has reduced pharmacy order verification time by up to 88 percent, reduced allergy errors by 40 percent, and reduced the time to complete a STAT portable chest x-ray by 49 percent through implementation of INVISION from Siemens Medical Solutions. Neal Seidberg, MD, served as physician leader of the project. Going with Siemens for CPOE was an easy choice for SUNY Upstate, says Seidberg, because the facility was already a Siemens house. “CPOE grafted on relatively painlessly.”
Starting the facility off on the right track was the fact that “our buy-in started from the very top,” says Seidberg. “All the divisional and department chairs agreed that this was the right thing to do.” The next step was working from the bottom up. Much of the design of the system was led by physician, nurse, and ancillary design teams, he says. Before CPOE, any orders physicians wrote were entered by nurses. “That gave us 900 experts who knew the system when the docs went live,” says Seidberg. He recommends taking a good look at your institution to determine which areas are successful and why. “The goal should be to implement CPOE in a way that’s complementary to how your hospital works, not destructive.”
After the build, the facility prepared for a phased rollout. The implementation team made training available in a variety of formats. Everybody learns differently, says Seidberg, and has different hours, so each person could learn the system through their choice of training session, a CD, or an online tutorial.
Then, SUNY Upstate made CPOE mandatory. Seidberg explains, “We said, ‘This is the way business will be done here.’ That culture change is a big piece of getting people to use it. You have to explain that this is how orders get processed and this is why — they get through the system safer, faster, and without all the possibilities for being misinterpreted.”
Veteran user upgrades
CPOE is nothing new for The Queen’s Medical Center in Honolulu, Hawaii. The facility first implemented CPOE in 1995 but in 2003 decided to upgrade its clinical systems with a single-vendor solution. The organization “was very computerized but highly interfaced with best-of-breed systems,” says Sean Thomas, MD, medical director for clinical decision support and assistant medical director for clinical informatics.
Epic Systems was chosen, and then Thomas led an 18-month build. He got physicians involved in the design and build, particularly with order sets. Department by department, his implementation group was proactive, getting medical staff members to assess their documentation tools and suggest improvements to workflow. “Communication is important and being responsive to the physicians. The more docs you can get involved early, the better the buy-in.”
The need to communicate with physicians can’t be overestimated, Thomas says. “It’s critically important, and the physicians don’t necessarily realize that until you go live. Saturate them so at least you know you’ve done all you can in that respect.” Fortunately, physician buy-in was not as big an obstacle for Queen’s as it might be for other facilities, Thomas says, “because we came from a CPOE system.”
With a less interfaced system, Thomas says there’s no need for concern about whether an order was successfully translated to the pharmacy system. “I’m placing the order in the pharmacy system myself.”
Focus on safety
Another relative veteran of CPOE is Children’s Hospital of Wisconsin in Milwaukee. When their administration order entry system was phased out by the vendor, the facility’s leadership “recognized that there was potential to help with medication safety by implementing CPOE,” says Carl Weigle, MD. The search for the right CPOE system began. “We went through a pretty exhaustive and exhausting process to test all the vendors that we could find in the marketplace, including having the four leaders in for demos.” The demonstrations took place during all shifts so that as many people as possible could learn about the systems. “We really worked very hard to avoid surprises,” says Weigle. All the “tire kicking” led the facility to what is now the CPOE solution from Eclipsys.
Children’s Hospital of Wisconsin initially went live with mandated CPOE use in three inpatient units in June 2000, with the expectation of going live hospital-wide in September 2000. There were some glitches, but “we had all been in agreement that we had made the best selection, so we needed to work through the problems we encountered,” says Weigle. The physicians also accepted that CPOE was inevitable. With that in mind, implementation went fairly smoothly, Weigle reports, and “user adoption was really fantastic. By the end of September, we were at 95 percent or better compliance with online order entry, and by the end of 2000, it was 98 to 99 percent and better than 99 percent ever since.”
Lab results are one area in which physicians appreciated the new system. They used to just get paper printouts. With CPOE, “information is easier to digest in an online version. Plus, you can change the display to suit your needs. People took to that very quickly,” Weigle says.
Being a teaching institution probably helped with the CPOE implementation, he says. “We are all here to learn, so this was one more thing.” The students and residents were avid students of CPOE, he reports. It was a little harder on the more experienced physicians who had been using for years the same system that they knew they could rely on.
After a visit to another McKesson CPOE site, representatives from St. Dominic’s Hospital in Jackson, Miss., decided to implement McKesson’s Horizon Expert Orders. “We felt that it was fairly easy to use from the doctors’ perspective,” says Tom Herrin, MD, medical director. The ability to customize the system and standardize orders was a draw, he says, as well as the fact that St. Dominic’s was already a McKesson site with the vendor’s physician portal already in use.
The facility implemented the system earlier this year with an initial group of doctors that Herrin hand-picked — they were supportive of the system and writing order sets and active on the medical staff. Fourteen doctors went live the first week, and now there are about 30 using the system, with a goal of the entire medical staff by the end of the year. Not forcing physicians to go on the system has been a key to the initial success of CPOE, says Herrin.
As the system rolls out, there will be errors and glitches to address. The first group of physicians in the rollout “likes helping us find problems,” says Alan Peeples, MD, physician liaison for the CPOE project. Several doctors regularly ask him when they can start using CPOE, so the buzz is good. Meanwhile, “we’ll drag the resisters along later,” says Peeples. “Most of the resistance is a little bit of fear of technology.”
So far, Herrin and Peeples report that their best success story is a physician notorious for his illegible handwriting. Staff from every location who received his orders had to call to find out what he had written. “His partners couldn’t read his progress notes,” says Herrin. Now everybody can easily read documentation from him.
Another task on the agenda is establishing processes for performance metrics. “We discovered that once we got this going, we had a pretty large animal on our hands,” says Peeples. The two people currently running the system are not adequate, he says. It will take four or five staff members, he says, because as physicians are added, all of their orders sets must be added as well. And staff must be able to put out the fires that come with it. That’s before considering the ability to “mine all these data and get good metrics,” says Peeples. “That takes sleuthing and a lot of computing work.”
“Be prepared for how big this task really is,” Herrin warns. “It is a hospitalwide initiative, and it takes a lot of people and ongoing support. It’s not a system that you turn on and it runs by itself and perpetuates itself.”
‘The right thing to do’
Many consider CPOE a building block of an electronic records system. Penn State Milton S. Hershey Medical Center in Hershey, Penn., took that idea and raised the bar, deciding to implement not only Cerner’s CPOE system but also its electronic medical record system. Christopher J. DeFlitch, MD, director and vice-chair of the department of emergency medicine, was tapped to serve as the physician leader for the project throughout the facility. “We implemented this because it was the right thing to do for patients and for the institution,” he says. “It wasn’t a solution to a problem.”
The project began in April 2003 with the signing of a contract with Cerner. The entire facility went live in May 2005. Now, “we are live with 100 percent true physician CPOE. Physicians are entering orders across the entire facility.”
Getting to that point took some time and careful consideration. “We decided we were talking about the care of the patient, not just an order entry piece,” says DeFlitch. “It’s not just about physicians entering orders; it’s more about how the patient is provided care from ancillary services to the attending physician and everybody in between. That is driven by CPOE.”
It was an implementation of a clinical information system, however, not an IT project. “Anybody who approaches this as an IT project will fail miserably,” says DeFlitch. The involvement of active, clinically credible physicians is an essential piece, he says.
The implementation team started by conducting a current state analysis to determine everyone’s jobs and how they do them. That helped DeFlitch gather feedback from the eventual users of the system: “That combination of keeping people involved in the project and reaching out to them was key.” Plus, the facility trained and paid residents to back-end orders before they go live. “If you don’t have order sets in an electronic order entry system and you intend physicians to directly enter that information, it won’t be successful,” DeFlitch says. The facility went live with 45 specific order sets in the emergency department and 352 disease-based order sets institutionwide.
Honesty was another way DeFlitch kept the project on the right track. He never told the physicians that CPOE would save time. “We demonstrated that the integrated nature is the benefit of the system” as well as improved efficiency, such as fewer phone calls from pharmacists about medication orders.
Implementation went smoothly, DeFlitch says. A phased-in approach was always the plan, but the facility took each phase live earlier than expected. A group of super-users was available everywhere in the hospital 24 hours a day, seven days a week, for several weeks. For a successful CPOE implementation, DeFlitch says, “Ask why you’re doing it. If you can’t answer that question, consider it even harder. You have to understand why you’re embarking on something very complex and pretty hard to do.”
With successes such as these, how soon can we expect CPOE “believers” to increase? “We’re getting to a perfect storm of government and regulatory pressure to do this,” says Thomas. The first adopters have started to give way to later adopters, “which makes a huge difference in comfort level of implementing something.” Plus, the products have matured, meaning “it’s a very ripe time for people implementing these systems.”
However, “CPOE is still in its infancy,” says Seidberg. “We’re still learning the best way to do this. It really does have a lot of great patient benefits, but because it is so new and folks are still learning, there are a lot of drawbacks to implementing that make initial adoption slow.”
Another factor holding many facilities back is the cost. “It is a big financial burden,” says Peeples. “It’s worthwhile, but a lot of hospitals are going to have to think long and hard about how to finance it.”
But because several regulatory organizations, such as the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), are pushing for CPOE, Peeples says there could be some type of decree within the next 10 years for hospitals to use it. “When you look at the whole system, there is an increase in safety for patients, an increase in quality of care, and a shorter length of stay because hospital operations are more efficient,” he says. “Overall, you’ve got a savings for the patient, the insurance company, and the hospital. Eventually, this leads to evidence-based medicine. That’s good for everybody because you’re using the best pathways of medicine, which tend to be the least wasteful and least expensive.”