CPOE: It’s not a matter of if, but when, say the experts, so the time to prepare is now

Get involved in your hospital’s decision-making process

(Editors’ note: In this first part of a two-part series on computerized physician order entry [CPOE] we tell you how to plan for such a system. In next month’s issue, we’ll cover how to pick a CPOE that’s right for your ED and hospital.)

It’s going to come to every ED, warns Sarah Vogel, MD, FACEP, ED director at Albany (NY) Memorial Hospital. "You have two choices," Vogel says. "You can get proactively involved with [information systems] and administration and choose the best system for you, or you can hide under your protocols."

"It" is Computerized Physician Order Entry, or CPOE, which refers to computer-based systems for ordering diagnostic and treatment services, including medications. Some of these systems are ED-specific, while others are hospitalwide systems that incorporate an ED module.

Vogel is not alone in her belief that CPOE will one day be a part of every ED. "It’s definitely the future," says Brian Decker, RN, CEN, systems administrator and emergency preparedness coordinator in the ED at Robert Wood Johnson University Hospital in Hamilton, NJ.

And Brian F. Keaton, MD, FACEP, attending physician/emergency medicine informatics director at Summa Health System, Akron, OH, and president-elect of the American College of Emergency Physicians, is even more emphatic about the future of CPOE when he says, "There’s no question."

Several groups are pushing it as the best chance to improve quality and safety of care, especially in terms of medication errors, he says. The most prominent proponent is the Leapfrog Group, a Washington, DC-based health care safety organization, he says. The Joint Commission on Accreditation of Healthcare Organizations and the Centers for Medicare and Medicaid Services also are pushing CPOE, he says.

"The reality is if you want to get paid in the future, you will have to have these systems," Keaton says.

The potential benefits of CPOE are readily apparent. For one, because physicians directly enter their orders into a computer, the issue of poor handwriting is nonexistent. Since department secretaries no longer have to transcribe doctors’ orders, the potential for transcription errors also is eliminated. In addition, such systems can be programmed to provide alarms if an improper order has been entered.

Despite these clear benefits, sources tell ED Management that the adoption of CPOE can be fraught with pitfalls. The initial learning curve can be quite steep, physicians complain it does not save them time, and the first few months after going live can create problems the ED manager may never have anticipated.

Bumps in the road inevitable

As with any new computer system, it is inevitable that a new CPOE system will present challenges — some of which can be daunting.

"The initial learning curve was very steep, and it slowed us down significantly," says Vogel, whose facility is installing a hospitalwide system from Meditech in Westwood, MA, but is using the ED as its "guinea pig." They went live in November 2004. "It saves time for clerks who used to enter orders, but docs are doing things they would not have done previously," Vogel says.

The other challenge Vogel faced was per diem physicians. "It’s really tough for them to come in once or twice a month and remember the nuances of the system," she says.

Also using a Meditech system is Stamford (CT) Hospital, which went live a couple of months ago. "There’s resistance any time you have enormous change," notes Kristin Winbigler, administrative director of the ED. "We’ve worked hard to win the staff over." In order to do that, she says, coaching had to be tailored to individual needs. "Some staff needed a one-on-one approach," she adds.

Keaton, whose facility began implementation of its enterprisewide order entry system from Boca Raton, FL-based Eclipsys about four weeks ago, also notes frustrations because of the culture change. "The doctors had less trouble than the nurses, because many have been using computers for years, while nursing has gone from being pretty much paper-based," he observes.

There are potential kinks in the system that managers don’t think about ahead of time, Keaton warns. For example, his system uses fingerprint biometrics to identify users. So, if one physician user had been on a computer and left, but did not log off, the next physician user would have his order denied and would have to go back and sign in.

Then, there’s the whole issue of verbal orders, Keaton says. "It’s easy for me in a verbal order to say it was issued half an hour ago, but the computer has a hard time with me predating stuff, so you get into issues of when something really did happen," he says.

While training staff was time-consuming, Decker says it was not difficult at all — perhaps because of his experience as systems administrator. Another advantage he has was that the staff was already accustomed to using its IBEX Pulse Check system (from Picis, of Wakefield, MA).

By going through the implementation process, each of the managers learned valuable lessons about how to implement CPOE successfully.

"During the first three weeks of our go-live period, we had an extra nurse from the team on 24/7," says Winbigler. As with all CPOE systems, the manufacturer first trains a select group of staff, who then train the rest in-house. They were taken out of patient care flow and were called "super-users," she says.

"We knew no matter how much we trained, that when you go to a live situation you have problems," Winbigler notes. For example, many different screens need to be reviewed. "Perhaps you don’t remember where you need to indicate an assessment of oxygen units or whether something must be put in the notes," she says. "The super-users are there to provide support and assistance while the staff is still on a learning curve."

The facility also had a command center on-call for the first two weeks, manned by hospital information technology personnel.

"You also need to make sure you have enough computers for all the employees — not just nurses, but doctors, residents and attendings," adds Mary Nielsen, APRN, clinical educator for the Stamford ED.

One of the most impressive aspects of a CPOE system also can be one of the most challenging, notes Keaton. "If someone has a listed allergy for a medication, you can [program the system to] stop the process and avoid error," he explains. "But one of your key decisions is where to put the alarms."

In conversations with another facility manager who had implemented a system a year ago, Keaton learned that they had so many alarms programmed in their system that it "dragged the place to a stop," because the system required multiple clicks for so many medications. "You have to be very careful in how you implement this very valuable, strong feature," warns Keaton, who says that in his own ED, they decided not to turn on any alarms until the staff became more comfortable with the system.

Despite these challenges, users agree the benefits of CPOE are undeniable. The greatest benefit is patient safety, Decker says. "You can read the orders, the docs put in what they want, not what the secretary thinks they want, and you have an automatic cross-reference of drug allergies before the patient gets the medication," he says. "You can also program in your own order sets, so, for example, if you have an ankle, you can do an order set that says, X-ray, icepack, crutches, splint, ibuprofen,’" adds Vogel.

Sources/Resources

For more information on Computerized Physician Order Entry (CPOE) systems, contact:

  • Brian Decker, RN, CEN, Systems Administrator, Emergency Preparedness Coordinator, Emergency Department, Robert Wood Johnson University Hospital, One Hamilton Health Place, Hamilton, NJ 08690. Phone: (609) 584-2882. Fax: (609) 584-5919. E-mail: bdecker@rwjuhh.edu.
  • Brian F. Keaton, MD, FACEP, Attending Physician/Emergency Medicine Informatics Director, Summa Health System, 525 E. Market St., Akron, OH 44310. E-mail: bfkeaton@earthlink.net.
  • Sarah Vogel, MD, FACEP, Emergency Department Director, Albany Memorial Hospital, 600 Northern Blvd., Albany, NY 12204. Phone: (518) 417-3266.
  • Kristin Winbigler, Emergency Department Administrative Director, Mary Nielsen, APRN, Emergency Department Clinical Educator, Stamford (CT) Hospital. Phone: (203) 276-7598.

For a free CPOE evaluation tool and a free copy of the report, Computerized Physician Order Entry: A Look at the Vendor Marketplace and Getting Started, visit the Leapfrog Group’s web site at www.leapfroggroup.org/media/file/Leapfrog-CPOE_Guide.pdf.

For more information about CPOE products, contact:

  • Eclipsys Corp., 1750 Clint Moore Road, Boca Raton, FL 33487. Phone: (561) 322-4321. Fax: (561) 322-4320.
  • Medical Information Technology (Meditech), Meditech Circle, Westwood, MA 02090. Phone: (781) 821-3000. E-mail: info@meditech.com.
  • Picis, 100 Quannapowitt Parkway, Suite 405, Wakefield, MA 01880. Phone: (781) 557-3000. Fax: (781) 557-3140.