Five Lessons on How to Get Physicians to Adopt CPOE

I often read or hear about "physician buy-in"—as I'm sure most of you do too—as the key component to successfully implementing many IT projects, including computerized physician order entry. While I agree that physicians need to join the effort for CPOE to be successful, I also think there is a lot more behind the successful implementations—like dogged persistence.

I recently spoke with Cynthia D. Burton, RN, who is the chief nursing officer and CPOE champion, if you will, at Rockcastle Regional Hospital and Respiratory Care Center in Mt. Vernon, KY, about her organization's switch to electronic health records and CPOE. Rockcastle, which had a completely paper clinical record, opted for a big bang approach in its switch to an EHR and went live with its CPOE system in November 2007. Today, the 26-bed acute-care facility has 100% of its orders entered through its CPOE system and 75% of those orders are entered directly by physicians. Yet, if given the choice today, there are still a handful of physicians who would jump at the chance to stop placing orders electronically, says Burton.

"Do they like it? No. Would they go back in a minute? Yes," she says, clarifying that that sentiment is solely for CPOE. The physicians would not want to go back to paper after using the electronic health record system and being able to access lab results with the click of a mouse, she says.

So how did Rockcastle get its physicians on board and more importantly using CPOE?

"We were going to do CPOE from the very beginning, so every time we talked about the record we constantly talked about how we are going to do this," Burton says. "We continued to say we could do it. I think it was just that constant positive discussion about it."

Here are five lessons Burton learned along the way.

Lesson 1: Sell the advantages. "We kept talking in a positive manner," says Burton, while acknowledging that, yes, it will be hard. Burton played up the fact that physicians would no longer have to look through paper charts for lab results, for example.

Lesson 2. Physicians don't like to train in groups. Rockcastle, which has about 25 physicians, including 12 primary-care doctors who are there most of the time, had a group training session with the physicians to show what the system would look like. Then the system arranged training sessions with no more than two physicians at a time. "They were more likely to ask questions or admit weaknesses when alone rather than in groups," says Burton.

Lesson 3. Provide support—especially early on in the process. Rockcastle identified three nurse champions to help physicians initially and that number grew to four. They were involved in physician training sessions so they could answer questions and assess the doctor's computer skills. "The nurses' job was to smooth the way for the physicians," says Burton. "Pick up questions and get them the answers that they needed." When the system went live the nurses were there around the clock for two weeks. For the first few days, if a doctor was using the system, there was a nurse at their elbow, says Burton. "When you start the process you have to have plenty of resources, so when physicians get on the computer there is someone right there to answer questions because it is frustrating if they can't get the assistance they need."

Lesson 4. Provide a private area for physicians to use the system. Rockcastle built a physicians lounge, complete with four computer terminals and a terminal for the PACS system so that doctors would have a private area to enter orders without being interrupted. "We also purchased small computers that they could use at home and that was a benefit that we sold them on because they could access records from home," says Burton.

Lesson 5. Keep the lines of communication open. The physicians at Rockcastle have a monthly meeting that every doctor attends—one of the perks of being a small hospital. Burton would typically sit in on that meeting on a quarterly basis. After the system went live in November, however, she started going every month to assist the doctors, answer questions, or make changes to the CPOE system. By the March, the comments changed from "we can't do this" to "can the system do this," says Burton, adding that that was when she knew she could stop going every month. "They reached the point where they were comfortable with it," she says.

Burton is very happy with her physicians' acceptance of CPOE. "We didn't have anyone pitching fits, stomping, leaving the building. They grumbled, but did it," she says. "We tried to be there and listen and reinforce that we could do it."