Monday, February 18, 2008

Provider Order Entry

Last week, I served on a panel to discuss the Massachusetts Technology Collaborative's release of its study about the benefits of Computerized Provider Order Entry (CPOE).

The study concluded that one in every 10 patients admitted to six Massachusetts community hospitals suffered serious and avoidable medication mistakes. This has created a new urgency for all hospitals in the state to install CPOE.

At BIDMC, we implemented CPOE in 2001 and have not had a handwritten order in most areas (we are just launching inpatient chemotherapy POE, planning NICU POE and discussing prep-Op holding area POE since these have very specialized workflows) , except for the 2 days of our network outage in 2002. Implementing CPOE is challenging and requires significant planning to do it right. Here's my top 10 lessons leanred about CPOE implementation based on 7 years of doing it.

1. Bad software, implemented badly, can cause bad results

You're probably familiar with the Cedars Sinai CPOE rollout failure and the Pediatrics article linking CPOE to increased mortality.

These studies are not about the failure of CPOE, they are about the failure to deliver software that meets clinician needs. Clinicians need easy to use, intuitive software that enhances their workflow. In the case of Cedars, the software was slow and cumbersome. The workflow was so confusing that nurses did not know when when orders were placed and asked doctors to place orders multiple times. In the case of the Pediatrics article, the software was archaic and challenging for physicians to use correctly. At BIDMC, we took a lesson from If you can order a DVD in one click, why should a renal dosed antibiotic, heparin or insulin be any different? We engineered a quick picks system that enables a doctor to click on a drug name, then have it dosed, interaction checked and routed to the pharmacy in one click. Pick the right patient from a dashboard, click the drug name, done. We've not seen any errors using web-based, intuitive software that automates a logical workflow.

2. CPOE is a platform not a product

Shortly after going live with CPOE, we established the Provider Order Entry Triage Committee (POET), to prioritize new development. Everyday we're asked to add new features that support new workflow, clinical resource management, research, and compliance requirements. Every change must be analyzed for its impact on clinicians. For example, if a new clinical trial requires that we capture the hair color of every patient on every order, we'll add hundreds of keystrokes to every provider's day. The POET committee ensures the right balance between safety, compliance, functionality, and clinician impact. Assume that your CPOE system will be very dynamic, with continuous revision of the decision support rules. CPOE Governance committees can

- Manage clinician expectations regarding their suggested changes to programs and the availability of resources to make the changes.

- Work with a clinical practice committee so that the CPOE committee does not bog down in adjudicating clinical issues, or creating a fix for one group of docs, only to find that another stakeholder group does not agree.

- Consider human factors to insure the learned responses hold true across applications-- e.g., if there is renal dose adjustment for one type of drug, does the adjustment happen for all renally excreted drugs?

- Anticipate and build in reports from POE-- topic, questions and recipient of report. Our data from the transfusion screen was extremely powerful for the Transfusion Committee to improve practice because we were able to capture overrides in monthly reports and target education where appropriate.

3. Clinicians will not go to training

Clinicians are time bankrupt. Requiring them to go to a half day CPOE training will cause resentment and will not result in much knowledge retention. The right way to train clinicians is in the field as they are using the system. When we rolled out CPOE, we staffed our nursing stations with roving IT professionals 24x7 for 6 weeks. As doctors entered orders, these trainers were available to help them with real patients, resulting in a successful first time ordering experience. You only have one chance to make a good first impression and having trainers elbow to elbow with clinicians is the best way to achieve a positive outcome.

4. Doctors will feel a loss of autonomy

Experienced clinicians note that medicine is art and science. Cookbook medicine which follows strict guidelines may not be personalized care. During implementation, some clinicians will feel a loss of autonomy as protocols, care paths and order sets replace handwritten orders. Our experience is that 85% of orders suggested by CPOE are accepted by clinicians without revision. Once clinicians realize they can create customized pick lists and that the computer provides value added decision support, the feelings of loss of autonomy disappear. It's important that the decision support be tuned just right - having thousands of rules that warn physicians about every potential minor side effect will cause 'cry wolf syndrome' - doctors will ignore the decision support. Having too few rules will make the doctors question the value add of the system. In our case, we've used a few hundred rules that seem to strike an appropriate balance.

5. Big Bang IT never works

Going live with CPOE across an entire hospital in one day would be a nightmare. The degree of training, communication and management of workflow change really requires a phased rollout. We picked logical clusters of related units to implement together i.e. medicine floors, surgical wards, related specialty floors, ICUs, the ED etc. This worked well because our staff could be present to train clinicians real time, coordinate additional hardware rollouts where needed to enhance workflow, and ensure any software issues were resolved rapidly. It did create some inconvenience during the transition. If a patient was transfered from a medicine service (on CPOE) to an Ortho service (not on CPOE) and back, the interns on the teams had to move the patient from electronic to paper to electronic workflows. This was a small price to pay for the 100% clinician acceptance of CPOE we achieved through a phased rollout.

6. CPOE must be a system created by the clinicians, not inflicted on them

One of the major problems with the Cedars Sinai rollout was that the administration created the software and then forced doctors to use it. Even worse, the administration planned to resell the software once the doctors had worked the bugs out. The doctors revolted and refused to use the system, which was perceived as a moneymaker for administrators. At BIDMC, we engaged key thought leaders from the medical executive committee, nursing, pharmacy, social work, lab, and radiology in the design of the system, so it was perceived as the clinician's system, not administration's system. When it went live, many doctors were eager to show off 'their system'. The Medical Executive Committee even voted to require use of the system as part of hospital practice, since it was widely perceived as improving safety without burdening the clinicians.

7. Many CPOE systems are a toolkit without rules

Many commercial CPOE systems are 'some assembly required'. They provide a container for rules, but do not come with an initial set. You can establish internal committees to build best practice rulesets, purchase rules from vendors such as Zynx or First Data Bank, or use rules others have created, such as ours.

8. CPOE decision support is only as good as the data available

Decision support depends upon accurate medical history. Safe drug dosing requires a current medication list, updated allergies, creatinine and other current labs, a problem list, and even genomic testing results. This means that all aspects of the hospital information system must be fully integrated into CPOE to achieve the best result. There is no such thing as a standalone CPOE system and it's best that CPOE be purchased as part of an integrated hospital information system.

9. Infrastructure must be reliable

Before CPOE, we could schedule downtimes on Sundays between 2am-4am for maintenance. After CPOE, no downtime is acceptable, since downtime implies that orders for medications, labs, radiology, transfer etc. cannot be placed. We've implemented redundant networks, redundant servers, clustered databases and even redundant data centers to ensure CPOE is available 24x7x365. A note to CIOs - implementing CPOE means that you'll now be carrying a pager to ensure real time response to any interruption of service.

10. Automating a bad process does not improve anything

When I was a resident, I was told that heparin should be dosed as a 5000 unit bolus then an infusion of 1500 units per hour for every patient. I was not taught about relating heparin dosing to body mass index, creatinine clearance or the presence of other medications. Unfortunately, it often took days to get the heparin dosing right because 5000/1500 is definitely not a one size fits all rule. Creating an automated CPOE order for 5000/1500 is not going to improve the safety or efficacy of heparin dosing. Implementing a new protocol for dosing based on evidence that includes diagnosis, labs, and body mass index will improve care. Our experience is that it is best to fix the process, then automated the fixed process. By doing this, no one can blame the software for the pain of adapting to the process change.

Our experience with CPOE over the past 7 years is that it has reduced medication error by 50%, it paid for itself within 2 years, and clinicians have embraced it. In 2008-2009 we're completing the bar coding for all our unit dose medications (including repackaging every dose of Tylenol in bar coded baggies) so we can scan the patient wrist band, scan the medication, and scan the nurse, achieving a completely automated medication administration record. Once this is complete, the last causes of medication error will be removed from our hospital and we hope to achieve a truly zero rate of adverse drug events.


Unknown said...


I appreciated your comments at the MTC event last week and have enjoyed reading your blog. As we prepare to go-live with CPOE in April, I will keep your 10 lessons in mind. I just wish that Meditech had as sophisticated CDS as your system does. I am also hopeful that Meditech will improve renal dosing to reduce key strokes for docs. How have your docs at Mt. Auburn found this to be?


Mike Coffey

John Halamka said...

Mt. Auburn physicians (and others) are hoping Meditech will continue to evolve their CPOE workflow so it is closer to the 'one click' BIDMC model. Meditech has made steps toward this by moving from their "one-size-fits-all" screen which allows you to order "anything" to context/medication appropriate prompting in their more recent versions. Based on Meditech's commitment and efforts to date, I'm confident we can work with them to bring this platform where it needs to go.

Ian Furst said...

We had a CPOE failure at our hospital due to "lack of user interest". In our clinic all of our IT initiatives have to pass two tests -- they must make the process more reliable and more lean. If it doesn't do either we don't roll it out. If it doesn't do one we prepare for an uphill battle. We've also had our mistakes along the way so I would add that anyone doing a rollout should have some hard and fast metrics to ensure the platform improves the process.

Leland Babitch said...

I must disgree with your comment about Big Bang. We launched CPOE at 8 hospitals in our system within 13 months with full CPOE and nursing documentation, and now are HIMSS Stage 6 across the board.

Clinovations said...


Loved the post but I want comment on a couple of the Top 10 lessons. I'm a family doc and I've spent the last 8 years supporting CPOE and complete EHR implementations and I've been really fortunate to be part of some very successful projects.

While I completely agree that physicians are "time bankrupt", I believe that physicians need training prior to a go-live. Ideally that training should be specialty specific, workflow focused and review relevant examples of order sets. The at-the-elbow support is critical and we've found that experienced, ideally clinical, resources work out best.

Also, I've been part of many big bang go-lives that included CPOE, physician documentation and results review at the same time. And while it's very dependent upon the vendor and the support resources that are available, it definitely can be done well. A great example of a successful big bang go-live at a community hospital system is Bon Secours Health System. John Kontor ( is their CMIO and I'm sure he'd love to share their experiences.

Trenor Williams