Why those studying CPOE usability are asking the wrong questions
Healthcare IT has caused angst among physicians for decades. The evidence bombards us:
- The American Medical Association has mounted a campaign to bring physicians’ complaints to the attention of healthcare policy makers.
- A survey on physician use of electronic health record systems found that more than half of all respondents reported their EHR system had a negative impact on costs, efficiency or productivity.
- Now another study from the Mayo Clinic reports the use of EHR systems and computerized physician order entry (CPOE) reduces physician satisfaction and contributes to higher rates of burnout.
In the case of CPOE specifically, poor adoption plagued the technology in the United States from the first deployment in the late 1960s up until the advent of the HITECH Act and Meaningful Use. In 2010, KLAS reported that fewer than one-sixth of U.S. hospitals were doing even a nominal amount of CPOE, and less than 6 percent of hospitals had all their physicians using a CPOE system (most of those had lots of residents to help out). In short, CPOE as a technology was a 40-year failure.
Times have changed, and now the global CPOE market is projected to reach $1.9 billion by 2024. Still, while CPOE deployment and usage has skyrocketed, user satisfaction has not.
So what exactly is the problem?
Current mainstream hospital order-entry systems were designed from the hospital perspective out to physicians, rather than from the physician’s perspective into the hospital. Put another way, they focus on the way hospital departments want to receive orders, instead of how physicians think about patient care. Most CPOE systems are a component of a hospital information system and, for the most part, force the vernacular and constructs of the hospital order processing infrastructure onto their physicians.
If you couple this with the fairly strict requirement that most of these systems impose to standardize all orders, rather than just evidence-driven ones, you can quickly get a system that requires physicians to spend more time ordering with CPOE than using paper. No wonder physician frustration is rampant. This isn’t good for physicians, patients or hospitals.
The dialogue in the healthcare IT industry is largely about minimizing physician productivity loss with CPOE—essentially, trying to make using CPOE as fast as using paper. Although this is proving challenging for most of the industry, CPOE falls short. The goal should be for CPOE to make physicians more effective and efficient, and to make the computer an indispensable tool in the care delivery process, so that a physician wouldn’t even consider ordering on paper, and certainly wouldn’t miss it.
To make CPOE systems more “physician-friendly,” there are a few priorities:
Order sets and order terminology should reflect the way physicians practice medicine and describe orders. Everyone would agree that practicing evidence-based medicine is important. Unfortunately, most of the orders in an evidence-based order set aren’t evidence driven. Most CPOE systems force hospitals to gather their physicians and develop a single “consensus-based” order set. Modern software can do better. Why not enable physicians to take an evidence-based order set and tailor the non-evidence-based components to their practice? If a physician always has to add an order to an order set, why not add it automatically? If a physician never orders half of the non-evidence driven orders on the order set, why show them?
CPOE needs to save physicians time. Change is hard enough when the change benefits you. However, changing in a way that doesn’t benefit you, doesn’t save you time and simply frustrates you is a non-starter; this is the historical challenge of CPOE systems. CPOE must save physicians a meaningful amount of time. This requires, among other things, screens that are easy to navigate, that the software maps to physicians’ workflow, and that clinical decision support be implemented in a way that doesn’t drive physicians crazy and cause them to ignore or curse all alerts and messages.
CPOE has to support physicians who are responsible for their patients 24-by-7 and on the run. Making CPOE as easy to use on a smartphone or tablet as the rest of the world uses e-mail and apps on these devices is critical to physician adoption and eliminating verbal orders.
There’s much more to effectively optimizing CPOE for physicians than simply listing a few design priorities; ultimately, it’s all about execution. That execution must include physician engagement, such as doctors actively participating in health IT product design and implementation processes. Physicians don’t have to code, but they do need to collaborate with those who do. If software developers and installers are given a view inside a physician’s day and into physician workflow in the hospital, they should be able to translate those insights into features and functions embedded in the products they design and deploy.
CPOE optimization is work, but the effort is well worth it, because giving physicians back some of the time they’ve been wasting—and then some—will yield both patient care and professional satisfaction benefits.