The Santa Rosa region of the CHRISTUS Health System, serving San Antonio and surrounding areas, launched computerized physician order entry software in January 2012. By late summer, a pattern was clear. Hospitalists and emergency room physicians--the initial target audience--became the heaviest users and were the reason why 65 to 75 percent of all orders soon were electronic, recalls George Gellert, M.D., regional CMIO.

But to get to the 90+ percent level would require CPOE adoption by low frequency users such as consulting, specialist and subspecialty physicians who have privileges at multiple hospitals also adopting CPOE. And that was going to be tough because not all hospitals in the region are pushing CPOE, which Gellert calls “as big a paradigm and workflow change as this generation of physicians has seen.” And he didn’t want physicians leaving Santa Rosa hospitals and going elsewhere where CPOE isn’t being pushed.

Consequently, Gellert and the CHRISTUS informatics team developed a half-dozen options to support low frequency-users (LFU) because while they don’t use CPOE a lot, they are present in large numbers (40-50 percent of attending physicians) across hospitals during any day of the week and every shift. These options essentially assist doctors at the elbow in navigating CPOE to complete orders so they don’t have to commit to memory every process in the multiple different EMRs they may work in across different hospitals.

During an education session at HIMSS14, Gellert and Luke Webster, M.D, system CMIO at CHRISTUS Health, will explain the options and the expectation over time that the physicians will become independent CPOE users, as they experience its ease of use.

The options for supporting LFU physicians are: having a hospitalist or other physician enter orders on behalf of a LFU, or a mid-level practitioner enters with the physician interpreting all CPOE alerts and decision support, or a dedicated nurse super-user not on a clinical shift enters with the physician interpreting alerts, or unit clerks trained to be super-users to assist LFUs, or deploy dedicated CPOE support staff for LFUs, or train a rotating cadre of university students in various health fields to provide at-the-elbow support. All non-physician support staff would assist the LFU only with navigation, with all clinical decisions made exclusively by the physician. Through this dedicated LFU support strategy, Webster and Gellert believe overall facility CPOE rates will increase substantially.

Most importantly, Gellert says, the strategy will move the CHRISTUS Santa Rosa hospitals toward complete elimination of paper orders, reducing the risks to patients when paper orders and CPOE co-exist. This transition, he adds, is a high risk period when paper orders can be missed or delayed in execution.

Now, Santa Rosa hospital leaders have been asked to map which service lines within their facilities will use which strategy. Eventually, the support can wind down as other hospitals in the area adopt CPOE and physicians lose the “safe harbors” of facilities without the technology. With assistance to start, and by setting up physicians with their favorite frequently used order sets, Webster and Gellert expect that once physicians see how easy CPOE is, perhaps half of them will become independent users.

Education session 48, “Supporting Low Frequency Users of CPOE,” is scheduled on Feb. 24 at 1 p.m.

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