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The Right Pace for CPOE

Gienna Shaw, for HealthLeaders Media, July 13, 2011
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When CPOE went live, physicians wouldn’t be seeing the forms for the first time. Plus, instead of having to take the extra steps of printing, signing, and handing off the order, physicians had only to push one button to submit it.

WellStar is also using print-on-demand order sets.

Once an order set is complete, it is converted into HTML format and posted on the organization’s physician portal. The clinician logs on, selects the patient’s record, and the order set comes up on the page. About 85% of the orders are prepopulated.

The organization also added some rudimentary decision support to the print-on-demand orders. For example, the chest pain order set won’t let the physician print unless he or she has ordered aspirin and a beta-blocker or explained why not.

Starting physicians with a modified CPOE tool should aid with adoption, Morris says. When they flip the switch to “real” CPOE, physicians will no longer have to print the forms. Because there’s one less step in their process, physicians actually will perceive CPOE as an improvement in workflow—not a
small feat.

“The physicians are using them,” Morris says. “If we’re getting this kind of adoption now for print on demand, I’m very optimistic about CPOE adoption.”

After: Set expectations

The success or failure of CPOE implementation is more based on implementation than technology, Morris says. “If driven properly, an Impala can get you there as easily as a Cadillac.”

Metro Health, which has a mix of employed and independent physicians, set a “hard stop” date, after which no paper documentation—including orders and consult and discharge notes—was allowed (save for a few obvious exceptions, such as when a physician is in the midst of delivering CPR or another emergency intervention or is scrubbed in to a sterile procedure). The organization offers independent physicians access to the CPOE system, but the same rules apply.

The medical staff agreed to new recommendations from the physician IT group that were approved by the medical executive committee that mandate the use of CPOE—so physicians who choose not to comply cannot practice at the organization. That went a long way toward adoption.

About 87% of Metro Health orders are electronic. About half of the 13% of verbal orders fall into three exception categories, such as when the clinician is in the midst of an emergency intervention. The organization is working to “whittle down” the rest, Clegg says.

There were also some cultural issues to overcome. Some physicians kept asking nurses to take their orders even if they weren’t in an exception situation. That was not tolerated, Clegg says. Nurses have an obligation to say no—and if the doctor is still uncooperative, the nurse is supposed to direct him or her to Clegg or the CNO. And if the physician is in one of those “exception” situations and the nurse refuses to input orders, the physician is obligated to report the nurse. “It’s worked out quite well,” Clegg says. “If the docs want to complain, they can complain to me.”

The bottom line is that organizations can avoid complaints—and still pull off a big-bang implementation—if they take these steps before go-live. “We really tried to design a product that when it was turned on we knew it was going to work the way people wanted it to work,” Theal says.

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