HEALTH-SYSTEM EDITION
TECHNOLOGY

Considering CPOE? Here are lessons from early adopters

What can hospitals moving to computerized physician order entry (CPOE) learn from early adopters of this technology? Hospital executives came away with a wealth of ideas from the recent annual conference of the Healthcare Information and Management Systems Society in San Diego. HIMSS devoted at least a dozen sessions to the topic.

According to the speakers, the challenges to CPOE have been technological, cultural, and financial. Physicians and other medical providers are not uniformly enthusiastic about changing the way they enter orders. The initial "technophobia" and the likelihood a prescriber will take more time to enter an order electronically—especially at first—are barriers to acceptance of CPOE.

In a session titled "Update on CPOE: The Good, Bad, and the Ugly," David Classen, M.D., VP of First Consulting Group in Long Beach, Calif., reported on the adoption of CPOE at six hospitals: Five of the hospitals implemented it successfully; one aborted the plan after four weeks. But, according to Classen, these hospital experiences reinforce the idea that the technological challenges of CPOE implementation are minor relative to cultural challenges. Fortunately, early adopters have come up with useful approaches to foster physician acceptance.

Classen discussed some of the lessons learned from early adopters. One of the features most common to successful programs is the joint leadership involvement of physicians and executives. Information technologists, hospital managers, and physicians must share a vision for the project. The support of dedicated, influential physician champions is key.

"The benefits of CPOE, including 'what's in it for me,' must be clearly communicated to physicians," said Classen. Physicians spending as much as or more time and effort on order entry than on handwritten prescriptions may not recognize that time will be saved by fewer phone calls from pharmacists to clarify medication orders. Physicians also need to know that claims related to patient benefit are not mere speculation but are based on real data from real hospitals.

Fast, user-friendly computer interfaces are also essential for success, Classen told the audience. In addition, computer systems must be tailored to the needs of the site and adaptable to the unforeseen user needs; they must be able to be redesigned quickly in response to user input in a live situation. Long downtimes to tweak the system can alienate users.

Successful CPOE adopters also agree on the importance of training. Prescriber instruction on the use of the computer interface is mandatory, as is the easy availability of computer support staff on-site—especially during the first few weeks of implementation. Diligent training decreases the time needed to complete orders and helps promote physician satisfaction. It is worth noting that the study hospital that aborted its CPOE program had mandatory CPOE for physicians but no mandatory training.

Classen discussed as well the role of order sets in simplifying order entry for physicians. An order set is a collection of orders for one particular diagnosis, which can be entered in one step. Programming order sets into the system can save time with order entry and can also foster standardized care.

Classen gave a final suggestion on raising the level of physician satisfaction: Minimize the number of alerts physicians encounter as they enter orders. One perceived value of CPOE is its power to automatically generate warnings and thereby prevent possible errors (warning about patient allergies is one example). Classen suggested limiting the system to no more than 10 alerts, to avoid interrupting the prescribers.

Classen discussed the costs borne by the five hospitals to implement CPOE and how they can be used to predict the costs for typical hospitals. To implement CPOE, he said, a typical 500-bed hospital, with about 25,000 admissions per year and a modern network infrastructure already in place, can expect a one-time initial cost of about $8 million and ongoing costs of about $1.35 million per year—as baseline. In the five hospitals in this study, the time needed to implement CPOE varied from 12 to 24 months. Although it is anticipated that CPOE costs are offset by savings in other areas (for example, in eliminating the need for clerical staff to transcribe prescription orders and in reducing litigation costs), such savings have not yet been completely assessed.

Classen added that many hospitals institute wireless ordering systems. These systems make ordering more convenient for prescribers and reduce the time between the prescriber's decision to place an order and delivery of the drug to the patient; prescribers can enter orders without having to go to workstations. Wireless systems added between $400,000 and $1.1 million to the initial costs of CPOE in three of the study hospitals that instituted them.

Lorraine Lica, Ph.D.

The author is a writer based in San Diego.

Lorraine Lica. Considering CPOE? Here are lessons from early adopters.

Drug Topics

Apr. 21, 2003;147:HSE40.