If you build it , they will come: the physician-friendly CPOE: not everything works as planned right out of the box. A Mississippi hospital customizes its electronic order entry system for maximum use by physiciansJohn Fitzpatrick
"If you build it, they will come," the famous line from the popular movie "Field of Dreams," has been the guiding principle behind efforts to implement computerized physician order entry (CPOE) at Forrest General Hospital (FGH), a 537-bed private community facility located in Hattiesburg, Miss. It also has been a lesson learned.
Origin of the "P" in CPOE
Patient safety is a top concern for all healthcare professionals and the primary reason for implementing CPOE. But doctors are reluctant to use CPOE. Why should this be, when the benefits of patient safety have been often quoted? A significant part of the reason is because doctors previously were not offered CPOE, but rather its predecessor, computerized order entry (COE).
What is the difference? The absence of the "P," for physician or providers, makes a telling statement about why CPOE has not been rapidly embraced by physicians even though its benefits are clear.
To understand physician reluctance to use CPOE, it is important to understand its history. COE was designed so that even the novice pharmacy technician or ward clerk could enter orders. In other words, it was designed based on the lowest common denominator, much the way a newspaper is written for consumers with an education level between eighth grade and tenth grade. The COE system was not arranged according to medical logic, but rather was an alphabetical system requiring a tremendous amount of scrolling and mouse clicking to place even a simple set of orders. Since pharmacy technicians and ward clerks receive little, if any, medical training, COE had to be set up in this manner.
Based on the reports of CPOE's benefits compared to COE by academic teaching centers, an increasing number of hospitals tried implementing CPOE in the most cost-effective manner: They tried not to change the software, but rather to change the user.
Two ominous problems arose. First, doctors were forced to use a system designed for people with minimal training who had fewer time constraints. Secondly, private physicians who perform their own ordering were now being pressured to use CPOE systems that had been studied in academic teaching hospitals by attending physicians with a team of juniors--residents, interns and students-who could absorb the brunt of the time-consuming nature of these systems. The probability of private physicians using a CPOE system remained small.
Motivating Physicians to Use CPOE
At FGH, we faced the problem of encouraging 360 physicians--95 percent of whom worked in private practice--to use CPOE on a daily basis.
Our first step was to ignore the current COE system and focus on how to build an optimal system for physicians. The "it" in "If you build it, they will come," became our focus. We wanted to build a CPOE system that doctors would want to use, not be forced to use. For many physicians, handwriting orders remains not only the preferred, but also the most efficient, method. To accomplish our objective, we had to create a more attractive alternative to handwriting orders. Such a move would require substantial time, resources and support.
In 1997, FGH replaced its homegrown legacy system with a comprehensive, longitudinal computer-based patient record, now Misys CPR. In 2001, FGH decided to move from COE to CPOE using the CPR's integrated COE functionality. After we spent months "shadowing" physicians using the COE system and collecting opinions from numerous doctors, the results were clear: Physicians would not use COE because, to them, it was fivefold more time-consuming than handwriting orders. In short, COE by itself was not attractive enough, even though doctors understood the potential patient safety benefits.
We halted the full-scale implementation of COE and rebuilt the system into a true CPOE application. By inserting the physician or provider back into the CPOE, the focus of the implementation enlarges to include not just electronic order transmittal, but utility of the software by physicians and usability of the system to physicians.
We had two primary directives: reduce the amount of time for ordering and increase functionality. By 2003, FGH's CPOE project team determined that the following software changes were necessary to reduce the amount of time required for electronic ordering:
Order sets. Order sets based on the latest evidence-based medicine were created. They allowed ordering by problems, as opposed to the simple alphabetical system. Also, they were arranged according to the major branches of medicine (internal medical, surgery, pediatrics, psychiatry), and further subdivided according to subspecialties (cardiology, neurology, etc.).
Ordering pages. Ordering pages were created to condense the information from multiple screens onto a single screen, and in the sequence they are normally ordered.
Duplicate sets. Order sets were duplicated to anticipate where physicians might look for them (e.g. community acquired pneumonia under Pulmonary and ID, or hypercalcemia under Renal and Endocrine/metabolic).
Frequent flyers. We realized the strength of the medical adage, "common things are common," because the 10 most frequently used order sets for each subspecialty usually cover more than 90 percent of their ordering. Because of this, we built "frequent flyer" lists for laboratory tests, radiology and medications. These common order sets minimized time-consuming system drill-down. As a result, for consultative services, physicians now routinely enter their orders faster online than on paper.
Formularies. In addition to "frequent flyer" medication lists, we give preferential placement to "formulary" medications. Not only does this reduce costs, but it also educates physicians about changes to the formulary, and decreases delays commonly caused by the pharmacy contacting the physician about changing the medication order from a non-formulary drug to one in the formulary.
Renal dosing. We improved medication ordering by including both normal and renal dosing regimens. Therefore, on the ordering screen we display the most recent creatinine and calculated glomerular filtration rate (GFR). We then suggest dose ranges based on GFR and dialysis modality (peritoneal dialysis, hemodialysis or continuous venovenous hemodialysis). This modification simplified medication ordering for patients with renal dysfunction, and it decreased renal consults.
Together, these modifications reduced the number of mouse clicks and scrolling required to complete orders, making online ordering time almost equal to the time required for handwritten orders.
To increase functionality, we also made the following changes:
* Created a graphical user interface (GUI) desktop;
* Linked the CPOE system to the hospital's CPR;
* Standardized order screens to minimize training;
* Established links on every page to the most popular medical references.
The result is an attractive and intuitive system that reduces both CPOE training and ordering time.
Placing links to such popular medical references as The New England Journal of Medicine, Up-To-Date, and Ovid greatly increases the system's appeal in two ways. First, questions that arise during the review of medical data can be easily addressed without leaving the patient's record. Secondly, physicians will use these resources even when they are not making rounds. Both of these factors are important for making the CPOE integral to the physician's life.
Where We Go From Here
We achieved our initial goal: an order entry system that physicians would need. Physicians--hospitalists, intensivists, nephrologists and infectious disease doctors--who had previously rejected the original version of CPOE at FGH now use it daily. In 2005, we expect to bring on board more specialties as the number of online order sets increases. Our ultimate goal is that all doctors will voluntarily use the system.
Even though we have a system that works well for physicians, we continue to look for ways to make it even more physician-friendly. One future improvement is to reduce the multiple clicks required to switch from one ordering screen to another. This underscores our firm belief that the number of mouse clicks is directly related to the amount of time it takes to order. We also want to display additional relevant information on problem-specific order sets.
Finally, a major key to our success is the close relationship with our vendor, Misys Healthcare Systems. FGH needed to improve its CPOE to increase physician use and the vendor needed to create a highly marketable product. This symbiotic relationship is a model for how medicine and business can work together to create a product far better than anything either could have achieved alone. We feel confident that our system is now a true CPOE system. We have built it, and they are coming.
John Fitzpatrick, M.D., is director of medical informatics at Forrest General Hospital, Hattiesburg, Miss. Contact him at email@example.com. Jason Soonju Koh is a fourth-year student at Harvard Medical School and vice president of Renesan Software, El Segundo, Calif. Contact him at firstname.lastname@example.org.
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