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.”