The Top 10 CPOE Challenges
Health Data Management Magazine, July 2004
At the heart of this revolution, next to electronic medical records systems, sits the seemingly innocuous concept of computerized physician order entry. It's regarded as a way to improve patient safety while also upgrading provider organization operating efficiency.
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But changing culture on such a broad scale means people must act and think differently. And such changes top the list when provider organizations discuss the main challenges to implementing and using CPOE.
The health care revolution promises to be less violent than those conducted on a societal scale, but it's proving so far to be traumatic nonetheless, experts say. "Health care needs to look at changing its culture, but it has no strategies for nurturing a new culture," says Marion J. Ball, vice president at Healthlink Inc., a Houston-based consulting firm. The national focus on health information infrastructure will be the motivator. "The president wants us to look at electronic medical records and CPOE over the next 10 years," Ball says.
The size of such an endeavor equates in scale with what President Dwight Eisenhower did in the 1950s with the national highway system, she notes. In the minds of many, CPOE and electronic records systems will be the catalysts for wholesale change in health care. But implementing and using CPOE systems poses some heady challenges.
These challenges can be classified broadly as cultural, technological and financial. But all are surmountable, experts say, if given the proper attention-beginning with initial and continuing support from the highest management level in each provider organization.
CPOE refers to the act of a clinician entering an order for patient services into an information system via personal computer, laptop computer, PDA or tablet computer.
The rewards, both actual and anticipated, are significant and start with improved patient safety. CPOE assists with multiple patient care processes, and while its focus has been on physician-or the more generic "provider"-order entry, it goes well beyond that. The technology can include assessing and tracking medication administration, recording patient vital signs, offering decision support, and even interacting with medical devices.
Successfully implementing and using CPOE technology depends on climbing intermediate information system steps, including components of an electronic medical records system. Many provider organization CIOs using or implementing CPOE insist it must be preceded-or at least accompanied-by electronic medical records. They call for automating as much information as possible. Otherwise CPOE will not be able to interact with laboratory, pharmacy and radiology information systems, among others.
Following are the top 10 CPOE challenges and suggested solutions, as described by CIOs and other information technology experts.
Physicians often are cast as the villains, prone to resisting CPOE implementation efforts due to impatience and skepticism regarding the technology, reluctance to put their work on hold to learn a new way of doing things, or just plain stubbornness. Painting all doctors with this broad brush isn't fair, CIOs say. But when it comes to developing order sets to streamline the most common types of physician orders in a given area, or evaluating workflow, a few vocal opponents can squelch CPOE implementation before it starts, they add.
1. Physician Resistance
For Berkshire Health Systems in Pittsfield, Mass., implementing a multifaceted health care information system from Medical Information Technology Inc., Westwood, Mass., and bringing physicians along step by step, were parts of a measured approach to CPOE.
The Meditech system installation began in early 2001 and included an electronic medical records application. It was part of an overall strategy to automate nursing units as much as possible with online documentation and electronic medication administration modules, says Chuck Podesta, CIO at the two-hospital delivery system. Berkshire Medical Center is the flagship, 306-bed, not-for-profit community hospital, which also is a teaching hospital affiliated with the University of Massachusetts Medical School.
Getting ancillary systems up and feeding into the electronic medical records application enabled I.T. staff to work with small groups of physicians to get them accustomed to working with the system, Podesta explains. "You need to take `baby steps,' " he says, "and make sure it's a positive experience for clinicians" before broaching the subject of CPOE.
Berkshire Health began implementing the CPOE application in late 2002 and Podesta continued with tried and true techniques. If the system needed to be adjusted along the way to accommodate physicians' needs, then installation was put on hold until the vendor was able to respond.
"If you hit snags, you've got to pull back," Podesta explains. "You can't force it, especially on a few vocal physicians."
Satisfying noncommittal doctors meant showing them the technology's value and where it fits into overall patient care processes, he says. "It's important for them to know the entire ordering process so they can see the patient gets medications faster and in a safer environment."
Where some organizations have problems is in viewing such tasks simply as implementing CPOE, as opposed to the tasks being part of an enterprisewide automation strategy, he adds.
Berkshire Health relies on resident physicians to handle much of the order entry. But getting attending physicians to use the technology means seeking out those who are established as performing best care practices, Podesta says.
"If you can get them involved up front and using the system, acceptability among other doctors goes up." He estimated that about 70% of the 350 physicians and residents would be entering orders online by this month.
2. Top-Down Committment
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