Federal policy makers have set 2014 as the target year for all Americans to have an electronic health record. While researchers claim that health information technology (IT) holds great promise to improve the quality and efficiency of healthcare delivery, the path to effecting the transition to computer-based documentation systems is fraught with obstacles. In addition to large initial capital investments for upgraded hardware and software, hospitals face other barriers to IT adoption. The challenges experienced by hospitals making this change include steep learning curves, workflow disruptions, and time delays.
—Richard Todd, MD
Advancements and Glitches
A 2005 American Hospital Association (AHA) survey of 900 community hospitals found a wide range of IT usage. Some hospitals have completed installation of bar coding for medication management, while a small minority are using advanced computerized physician order entry (CPOE) systems.1 Typical of many hospitals in the AHA survey, Abbott Northwestern Hospital in Minneapolis chose an incremental IT implementation approach.
Academic hospitalist Debra L. Burgy, MD, is the lead physician in Abbott Northwestern General Medicine Associates Group, affiliated with the internal medicine program at the University of Minnesota (Minneapolis), where she is also adjunct assistant professor of medicine. Hers was the first group of physicians to go live with the hospital’s electronic documentation system 16 months ago, in July of 2005.
“We went up on July 1 because we thought it might be an advantage to have a long weekend with a lower census,” she recalls. As it turned out, her group of academic hospitalists was caught short-staffed on the holiday weekend, having to adjust to their new IT roles, take care of patients, and orient the brand-new interns.
“It was kind of a sad weekend for me,” she remarks wryly.
Of the launch in July 2005, Dr. Burgy observes that the learning curve “was longer than I expected, but once you achieve it and you’re adept at most of the functions I do find [electronic documentation] better overall in many ways.”
One advantage: As an academic hospitalist, she consults with her residents and emergency department admitting physicians in real time by pulling up patients’ charts from any location.
Dr. Burgy and her colleagues still find the time required to enter the narrative part of the patient’s history of present illness difficult, as well as the discharge notes. Another bug: The system is designed to prompt the physician to complete medication reconciliation (Medication Administration Record, or MAR) at admission, transfer, and discharge. Because the medications are not organized in alphabetical order or side by side, however, the logistics of reconciling more than a few medications can be frustrating.
“Most of us end up printing out the current MAR, which seems to defeat the purpose of the computerized record,” says Dr. Burgy.
A Staged Approach
According to Mary A. Dallas, MD, chief medical information officer for Presbyterian Healthcare Services (PHS), an integrated healthcare delivery network in Albuquerque, N.M., PHS launched CPOE in the main hospital’s inpatient services area as the final step in the pharmacy automation process designed to improve patient safety and prevent medication errors.
Five years ago, the main hospital began the process of developing a closed-loop pharmacy order system. Now, with this system in place, medication orders go directly from the physician’s fingertips to a pharmacy work queue. The verified drug order is then messaged to the pharmacy robot for packaging. On the floor, nurses’ hand-held devices flash a message that the drug order is ready. Upon delivery to the floor, a nurse scans the bar code on the packaged medication, matches it to the patient’s bracelet bar code, and scans his or her badge before administering the medication. This verifies the 5 “Rs” of medication safety: right medication, right dose, right route, right patient, and right time, as well as concurrently creating the electronic MAR.
As the former medical director of the hospital’s Adult Hospitalist Service, Dr. Dallas understands the physician’s point of view. When launching the hospital’s CPOE, she was aware that, “especially in the hospitalist arena, we were adding some extra learning curve to their day.”
She also admits, “It does take longer to log onto a computer system and wait for the program to boot than it does to just scribble a medication order on paper. There’s no way to avoid that.”
As she has worked to build order sets tailored for various specialties, however, Dr. Dallas has been sensitive to challenges that can be softened. Automatic prompts at the point of order entry are carefully monitored, she points out because “surplus of medication” alert pop-ups can sometimes produce physician “alert fatigue,” and doctors may begin to ignore—rather than address—the alerts. “You have to start light and then work to get more stringent as people tolerate and get used to that system,” she says.
Getting Physician Buy-In
The launch of the CPOE system at Presbyterian Hospital in Albuquerque was the fourth such experience for Richard Todd, MD, medical director of the hospital’s Adult Hospitalist Group. He sees speed—or the lack thereof—as a major barrier to physician adoption of computerized documentation systems. He has observed that some hospitals don’t invest in the appropriate hardware required to handle such technically demanding software. As a result, a user may have to wait 25 or 30 seconds for an order entry system to boot up.
“That is an eternity in computing time,” he says, and a physician who experiences this difficulty more than twice may no longer have the patience to work with the system.
—Richard H. Bailey, MD
Physicians should be part of the IT design and selection process, Dr. Todd believes. “To get a successful adoption by physicians, the engineers need to come to the physicians’ table and not the other way around,” he says, pointing to the success of Wiz Order, Vanderbilt University School of Medicine’s order-entry system, which is part of an electronic medical record custom-built with input from doctors.
“The biggest mistake you can make is to have physicians feel that you’re forcing something down their throats that slows them down,” says Dr. Todd. “Every physician is under tremendous time pressure to get the primary job done, so if you do anything that even makes them perceive that it’s going to make them less efficient, you’re not going to get buy-in.”
S. Trent Rosenbloom, MD, MPH, trained as an internist and pediatrician and spent some time as a hospitalist early in his career. Currently, he is assistant professor in the departments of Biomedical Informatics, Internal Medicine, and Pediatrics, and in the School of Nursing at Vanderbilt University Medical Center. He and his research colleagues have investigated the factors which influence providers’ perceptions of clinical documentation tools.2
“The key issue is not so much time, but the perception of time and work flow,” he explains. “It [a computerized documentation system] could be twice as fast, but if I have to go out of my way to do it, then I might perceive it as taking more effort and more time.”
For instance, writing a drug order on paper can appear to be a faster process than finding a computer, sitting down, logging on to the system, finding the patient in the menu, opening the patient file, and then entering a drug order. Dr. Rosenbloom points out that when physicians think about these two processes, however, they may not factor in the other time factors for the paper order, such as walking to the chart, finding the chart, turning to the right page, and entering the drug order. And although computer systems are not error-free, CPOE tends to reduce transcription and other errors that in themselves can be time-consuming, if not life threatening, for the patient.
Keys to Success
Sources agreed that IT adoption by physicians increases in direct proportion to their participation in the process. “[Hospitalists and other physicians] need to make sure that their hospital includes physicians in every step of the due diligence process: looking through systems, going to the sales, actually banging on the product, and making sure that they perceive it as meeting their needs,” advises Dr. Rosenbloom.
Vendors differ in their methods for bringing client hospitals online. “A staged approach is probably best, based on what we know currently,” he suggests.
Finally, flexibility is key—for vendors and users. Dr. Rosenbloom advises teams to “expect to fail, and learn from that.” It’s important to recognize, he says, “that even if you’re putting in a computer system that has been implemented in 50% of hospitals—which hasn’t yet happened—there are idiosyncrasies and differences in your own center that will cause the implementation process to be different.”
Given hospitalists’ interest in hospital processes, leading the IT adoption effort is a natural role for hospitalist leaders, believes Richard H. Bailey, MD, medical director of Inpatient Care and Hospitalist Services at Saint Clare’s Hospital in Weston, Wis. “I was one of the most computer illiterate people I knew,” he relates. “But somehow, I got thrown into the role. We took a potential lemon, embraced it early on, and made lemonade.” TH
Gretchen Henkel also writes about benchmarking hospital medicine programs in this issue.
- American Hospital Association. Forward momentum: hospital use of information technology. October 2005. Available at: www.aha.org/aha/research-and-trends/AHA-policy-research/2005.html. Last accessed November 29, 2006.
- Rosenbloom ST, Crow AN, Blackford JU, et al. Cognitive factors influencing perceptions of clinical documentation tools. J Biomed Inform. 2006 Jul 8; [Epub ahead of print].