Any organization that has implemented computerized physician order entry systems has learned the project is fraught with technological and cultural minefields.

The clinical decision support that goes with CPOE changes clinician workflow beyond what the basic technology already does, with such potential intrusions as forced documentation templates, alerts and pop-ups. To ease the process, three-hospital Lehigh Valley Health Network in Allentown, Pa., started implementing CPOE in 2001, incrementally adding decision support functions over time, and waiting for four years until mandating its use.

Donald Levick, M.D., medical director of clinical informatics at Lehigh Valley, calls the slow phase-in “the continuum of intrusion,” but it made acceptance easier than forcing so much change so quickly. It wasn’t a smooth, quiet process, but at no time during the initiative did the delivery system have to back up and withdraw a function because of too much resistance, he notes. “We learned things without revolt, that’s for sure.”

But there are unintended consequences to CPOE and other clinical decision support systems, and they are the focus of an educational session during HIMSS12 in Las Vegas. Levick will explore the consequences with Dave Pucklavage, R.N., a manager at Lehigh Valley.

For instance, a hospital without full clinical documentation systems to capture core regulatory and pay-for-performance measures may need to tweak the CPOE system to capture some of those data elements. That means forcing physicians to enter information that normally would be in a progress note into specific fields in the system. That may bring blowback, but not revolt, if phased in, Levick says.

Adding such functionality also changes the nature of CPOE because it’s no longer a decision support tool to help clinicians, but to also a technology tool to get needed data, he adds.

And as order entry and other processes become more automated, hospitals could experience decreased face-to-face verbal communication between physicians, nurses, pharmacists and other clinicians, Levick advises. That brings a potential for miscommunication if they rely too heavily on the technology. In a paper world, if a physician ordered a medication be given now--not knowing another physician gave the same order an hour ago--a nurse likely would question it. But if the computer says to give the dose now, the nurse might give it even if the order doesn’t pass the smell test. “The issue that the computer said so is a potential consequence,” he adds.

Levick and Pucklavage in the session will give other examples of how clinical systems can become not just part of the solution, but also part of the problem. “Thorough analysis of workflow and cultural change is required for maximized potential of these systems,” Levick says. Lecture 127, “The Unintended Consequences of Improving Care Through CDS,” is scheduled on Feb. 22 at 2:15 p.m. More information is available at



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