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High-Tech Nightmare


 

Joseph Heaton, MD, a hospitalist with Kaiser Permanente practicing at Exempla Good Samaritan Medical Center in Lafayette, Colo., has spent the past three years helping develop an electronic medical record for the hospital.

The project includes computerized physician order entry (CPOE), which was rolled out Oct. 2. He estimates he has dedicated anywhere from 20% to 50% of his time to technology implementation.

“I’ve been the physician champion for the project, working alongside the IT (information technology) development team,” Dr. Heaton explains. “I was chosen not for any particular computer expertise but because of other leadership roles I have played as a hospitalist and my involvement in quality projects. I see CPOE and electronic medical records as obvious extensions of the other quality projects hospitalists participate in.”

Dr. Heaton’s experience in implementing a CPOE system highlights the barriers faced by those charged with advancing technology critical to hospital medicine.

He says he has learned a lot about computers along the way, but the technology is a snap compared with the challenges of managing change and making sure physicians are in tune with the new system.

“Not only was I representing other hospitalists, but also a broader group of physicians with privileges at the hospital, as well as other employees, including nurses and pharmacists,” he says. “Much of what I did was to translate language about workflow from the clinicians to IT, and then report back to the clinicians.”

But it wasn’t as easy at it sounds.

“Unfortunately, in this institution there is no single, agreed-upon communications venue for reaching all of the physicians who practice at the hospital,” says Dr. Heaton. “So we’ve had to use e-mail, voice mail, noon bag-lunch demos, mailings, departmental meetings and classes—multiple opportunities to make sure that physicians feel informed. That way, when they show up for their actual training in how to use the system, they’re not still asking questions like, ‘Why are we doing this?’ ”

Practical Intervention

Some ways to prevent or overcome physician resistance to CPOE implementation in the hospital.

  • Hospitalists and other clinicians need to be actively involved in developing and implementing major computer technology such as CPOE. Depending on the scope of the project, it is reasonable to dedicate part of one physician’s salaried position to work on implementation.
  • A major role for the physician dedicated to CPOE is to give other physicians practicing in the hospital a voice in the project’s development—even when they aren’t eager to become engaged. The hospitalist assigned to the project serves as a bridge between other physicians and the technology professionals, communicating what clinicians need and what is possible.
  • Collaboration and give and take among clinician representatives and IT professionals is essential to CPOE development. Clinicians must prioritize what they want to achieve and not get stuck on esoteric issues
  • CPOE should be approached, as much as possible, from a workflow perspective, adapting and customizing the product to fit how physicians actually practice at the hospital, instead of just asking them to adapt to the system’s features. This requires clarifying what hospitalists’ workflow entails, perhaps by having someone shadow a hospitalist for a shift while taking notes about care practices. But also be open to opportunities to change and automate routines in need of updating. Members of the hospitalist group with particular clinical affinities, for example, for pneumonia or diabetes may be called upon to help develop standardized order sets for those diagnoses.
  • Plan for computer crashes and system downtimes. Is there an alternative computer network available in the hospital? If not, how quickly and easily can physicians revert to paper-based ordering processes? Be aware that problems never envisioned by the planners will emerge. —LB
CPOE implementation

Blessing or Curse?

CPOE, of course, refers to the process by which physicians and other clinicians directly enter medical orders into a computer application. CPOE can be independent of other computer applications or part of an electronic medical record or other computer system.

Standardized order sets, decision support tools, and other customized methods can make hospitalists’ jobs easier—if the system is well-designed. It’s not uncommon for CPOE to add time-consuming new tasks and functions. For example, hospitalists may be asked to enter information they’ve not previously been asked to supply. But CPOE is also touted as a way to reduce medical errors and improve quality.

“It’s a good thing to do,” Dr. Heaton concludes. “Six weeks into the implementation of CPOE here, medication delivery is much faster. There are efficiencies to be had. For the most part, the high-volume users, including hospitalists, are fine with it, even if they’re not taking full advantage of the system’s capabilities.”

But Campbell, et al., describe a number of unintended adverse consequences that have followed CPOE implementation.1 These downsides include unfavorable workflow issues, continuous demands for system change, untoward changes in communications patterns and practices, generation of new kinds of medical errors, and negative emotional responses to the system by clinicians. Physician resistance can derail costly, complex CPOE projects.

A widely cited example of such barriers comes from Cedars-Sinai Medical Center in Los Angeles. An institution known for its pioneering medical techniques and technologies, Cedars-Sinai was forced in 2003 to shut down implementation of CPOE after three months because of a full-blown staff rebellion, according to an article in The Washington Post.2 Various explanations have been offered for this failure, including inadequate training for users, intrusive decision support queries, and other provider frustrations with the system. The hospital’s public relations department declined a request to comment for this article or provide an update on the current status of CPOE at Cedars-Sinai.

Doing the Best We Can

The importance of CPOE to hospitalists is illustrated by Duane Spaulding, MD, FACP, president and executive contracting officer for Advantage Inpatient Medical Specialists, practicing at Penrose-St. Francis Hospital in Colorado Springs, Colo. Half of his 11-member hospitalist group could be considered “power users” of the hospital’s current, DOS-based CPOE system—but Dr. Spaulding is No. 1. “I enter more CPOE orders than any of the other 600-plus physicians on staff here,” he says.

For some hospitalists, computers are a passion. For others, “they are just a tool for getting from Point A to Point B,” he says. “I have probably spent 1,500 hours over the past decade on committee after committee, putting together computerized order sets and screens and the like.”

Dr. Spaulding says the hospital’s current, antiquated system can be laborious to work with: “I can only do 50% of my orders on the system.” At the end of last year, Centura—the hospital’s parent health system—was preparing to implement a regional electronic medical record integrating CPOE and other applications.

“It is a gargantuan change,” he says. With rollout planned in phases, hospitalists at Penrose-St. Francis will lose access to CPOE for an estimated six to nine months, although the new CPOE system eventually will be accessed on a tablet PC.

Amid this stressful transition to new technology, the hospitalists have been trying to do the best they can with available resources, Dr. Spaulding notes. “We have come up with a paper-based Plan B for entering all of our orders until we get access to the new CPOE system,” he says. “We have been reminding everyone in the group how important it is to take care of each other, such as by putting in a PRN order set for every new patient, because we know we all will be taking our turn on-call.”

Arieh Rosenbaum, MD, hospitalist at California Pacific Medical Center (CPMC) in San Francisco, has for years been involved in technology issues at his hospital, which is developing a new electronic medical record with CPOE. It will replace a 15-year-old, DOS-based CPOE system he describes as “powerful but clunky.” However, CPMC’s parent, Sutter Health, is rolling out the new computer system gradually across its 40 Northern California facilities. It won’t reach CPMC until 2011.

“It’s an incredibly complex project,” Dr. Rosenbaum says. “To Sutter’s credit, they’re trying very hard to get physicians’ input, establishing structures for gathering feedback at the corporate and local levels. I am one of the physicians who will be involved at the local level, both building the clinical content and interface as well as gaining physicians’ acceptance and participation.”

Success depends on how the new system relates to physicians’ workflow. “Everybody knows the benefits of CPOE, but there are mitigating factors, such as what to do when the system crashes,” he says. “Hospitalists are the people who will be interacting with the new system the most. It’s our job to be leaders and to be aware that this is in our future.”

Head-On Approach

Timothy Hartzog, MD, a pediatric hospitalist and medical director of information technology/CPOE at Medical College of South Carolina (MUSC), Charleston, urges hospitalists to take CPOE seriously and view it as an opportunity.

“Implementation of CPOE, or electronic medical records, can be one of the most fundamental changes a hospital makes—affecting the workflow of everybody who works there,” he says. “As physicians, we each work a little differently. With the standardization imposed by CPOE, it’s going to make some physicians a little crazy, no matter how well it’s implemented.”

Dr. Hartzog encourages hospitalists to set aside any doubts they may have and get involved in creating workable CPOE solutions.

“Hospitalists don’t have to be experts in technology,” he stresses. “If you learned medicine, you can learn the technology—if you’re willing to put in some time, read a couple of books, take some training, and work with your IT people. Tackle CPOE head on—make sure your voice is heard. Be part of the build. But you need to have time dedicated for the IT project, and you need to do the work. If you are not present and if other people on the development group don’t know you and hear you speak, decisions will be made when you’re not in the room.”

For some physicians, Dr. Hartzog says, it could even be fun. “Especially if we can actually make the system work for us. We can actually create something that makes life better for our group.” TH

Larry Beresford is a regular contributor to The Hospitalist.

References

  1. Campbell EM, Sittig, DF, Ash JS, et al. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006 Sept-Oct;13(5):547-556.
  2. Connolly C. Cedars-Sinai doctors cling to pen and paper. The Washington Post, March 21, 2005:A1.

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