CPOE: Gaining Physician Buy-in

Like the old adage goes: no pain, no gain. CPOE is one of those areas where the pain of implementation and physician training is certainly worth the gain of better patient care.

CPOE use is now a requirement for achieving meaningful use and the commensurate incentive payments: For Stage 1 compliance, hospitals must be able to demonstrate CPOE use for at least 10 percent of all orders. However, there is no one-size-fits-all way to implement CPOE, and it can create communication issues even as it solves others. And make no mistake: CPOE requires practice changes, and snags will emerge during deployment as practitioners adjust to it.

CPOE requires continuous fine-tuning to accommodate unique patient and care settings, close supervision of overrides caused by automatic systems, and training, testing and re-training of all users. No wonder a recent study published in Health Affairs found that hospitals’ adoption of CPOE is increasing—but slowly.
 

‘Devil in the details’

“There was a learning curve” when a home-grown CPOE system was deployed at Massachusetts General Hospital (MGH) back in 1994, says Claus Hamann, MD, internist geriatrician and assistant medical director of information systems projects at MGH, a Partners Healthcare facility in Boston. 

Shortly after the system went live, it achieved a physician adoption rate of 75 to 80 percent, Hamann says. There was significant decision support surrounding the CPOE, and now that rate is closer to 100 percent. Caregivers employed at the hospital “cannot function at all without it” now because the CPOE is linked “seamlessly” to the discharge and medicine reconciliation system, he says.

At the start of MGH’s medicine reconciliation implementation in 2007, however, Hamann notes that there were communication problems. Physicians were approving global medication lists for patients consisting of drugs taken on entry and an intended list at discharge, instead of approving each medication. This meant nurses had to call the physician back to understand his or her intentions for the patient and move forward with discharge planning.
 
After “returning to the development cycle,” Hamann says, the system in place currently is one that went from the global acknowledgment of the medication list, to an individual medication-by-medication approval process that has been embraced by physicians.
 
“The nurse must absolutely know your intention because you can’t be there in person all the time,” he explains. “Now, there are far fewer call-backs, which is a big advance. Call-backs are a symptom of a system that isn’t quite working right.” 

MGH is doing a variety of gap analyses to see what it must modify for its CPOE system to comply with new meaningful use requirements, Hamann says.

CPOE has long been touted as providing error-checking for duplicate or incorrect doses or tests, reducing errors relating to handwriting or transcription, decreasing delays in order completion, enabling order entry at the point-of-care or off-site, and simplifying inventory and charges. David Bates, MD, and colleagues reported in the Journal of the American Medical Association in 2006 that CPOE reduces the medication error rate by 80 percent, and by 55 percent for errors with serious potential patient harm. But system implementations have certainly backfired as well. One well-known example is Children’s Hospital in Pittsburgh, which saw an increase in mortality in the pediatric ICU after introducing CPOE.  The researchers recommended that “institutions should continue to evaluate mortality effects [during CPOE implementation], in addition to medication error rates, for children who are dependent on time-sensitive therapies.”

Unintended consequences of CPOE may be due to the culture and not only the software, Hamann says. His advice for others? “Get all stakeholders involved,” he says. “Have everybody share the version and the same platform. You have to have enough physician leaders, nurse practitioners, physician assistants and a whole army of trainees around the table. You have to have enough leaders say that this is something that needs to be done and make sure there is enough time to work out some of the bugs.”

While there may be “a lot of devil in the details” in terms of CPOE implementation, “this is the way to get us into the 21st century … to have solid clinical IT to support our care of patients in ways we can’t imagine doing on paper,” says Hamann. 
 

Reward outweighs risk

Lucille Packard Children’s Hospital (LPCH) in Palo Alto, Calif., began implementation of its Cerner CPOE system with a two-phase big-bang, says Chris Longhurst, MD, medical director of clinical informatics at the hospital.

Although this implementation style may not be suitable for all facilities, Longhurst says it’s helpful during a change in care processes to do it across the house in the same fashion. “We chose a go-live date and changed the way the hospital ran on that day,” he explains. “We did it in two subsequent phases, where the first phase replaced the legacy information system for results viewing and the second phase brought up our new clinical functionality. That evolution approach didn’t require learning a new system and adding new functionality at the same time.”

Currently, CPOE usage rates at LPCH exceed 97 percent housewide, notes Longhurst. These orders are entered electronically and the remaining 3 percent of orders are verbal, allowing the system to “without question” help the hospital in achieving meaningful use standards.

It is important that physicians and nurses understand that CPOE is not intended to replace verbal communication, Longhurst says. “We constantly teach that if you would have talked to the nurse when you wrote the order on paper, then you still must talk to the nurse.”

The benefits of CPOE far outweigh the risks, according to Longhurst. However, he notes, “I think it is still important that CMIOs recognize that CPOE systems can introduce new errors into the care process and work to negate those unintended consequences.”
 

No turning back

Before deploying CPOE, facilities should first understand their workflow, then create and execute a plan of process redesign that will work for them, says William F.  Bria, MD, CMIO of Shriners Hospitals for Children in Tampa, Fla. and president of the Association of Medical Directors of Information Systems (AMDIS).

CPOE might not speed up workflow and allow physicians to fit in more patient visits, but the system should allow for crosschecks with regard to safety and quality issues, as well as the ability to capture information as the caregiver does, Bria notes. There is “no question” that CPOE can create communication problems between physicians and nurses, he says, citing a CPOE implementation at one facility where antibiotics were added to the system. The facility chose to list the drugs alphabetically—and as a result, one of the first “A” antibiotics, which was selected approximately 10 percent of the time before the automated system was put in place, was being selected a staggering 70 percent of the time afterward.

“It was on top of the list, so people thought that it was the right one,” explains Bria. “That is not the right way to make medication decisions.” Noting that human nature must be taken into account and “overwhelming and overloading” the users could potentially lead to unintended consequences, Bria says, “due to what needs to be done and don’t try to do too much too soon.”

It’s important to understand that implementing CPOE means helping people transition between one complicated way of doing things on paper and one on a computer, Bria notes. To make the transition easier, the expectations from a national leadership perspective need to be set properly for caregivers who will be users of the CPOE, he says. “The idea of going backward is the one thing we should say you can’t do. That’s not an option.”