CPOE fails for many financial, IT and deep-seated cultural reasons – 4 primary:

1) Lack of “financial incentive” – Most MDs paid on volume, claim CPOE slows them down / lowers income – need more volume to offset lower reimbursement rates- worst fear (private focus groups) is “big brother” and loss of autonomy.

(never reconciling not supporting patient safety benefits, e.g. drug interaction, or other advantages for MDs, and hospitals, teams and patients)

2) Poorly -designed and -integrated EMRs – some “whining” a smokescreen, some legit. Original EMR user-friendly, sub second response time and integrated. Today, more GUI and “bells and whistles” but hard to describe some EMRs convoluted logic and “design”.

Unless hospitals demand more usable systems from vendors, it won’t happen. Design takes time and costs money, but can pay off. IT (vendors and hospitals) focus on “build” and are measured/incented by schedule, budget, not adoption or benefits realization.

3) Poor implementation strategies – lack of prerequisites

4) Lack of CEO or CMO “success strategy” – fear-based (some realistic) decisions about MD revolts or exodous. More hospitals now see higher risk in not mandating use.

I’ve been alone in many forums for years in recommending CPOE be in MD bylaws (”mandated”). We need carrots, but in the end, also a big stick. Voluntary “for the good of all” and small financial incentives haven’t worked.

Agree drug interaction key CDS but med orders complex and require allergy data (often collected by nurses first) to fire alerts and MDs need other clinical data, e.g. most recent vital signs, to know what to order.

I’m PRO-CPOE-, in timely, logical, incremenal steps with usable systems. Considering workflow doesn’t imply there aren’t solutions, I offered one that suport business and clinical goals. I’m not advocating either “whatever the docs want” or “slam in the software” approach.

MD resistance will die out as older MDs retire, with younger ones expecting automation. In the interim, IMHO we need to move forward, not let old guard hold us all back till they retire – rather lets bring them along with us, if possible.

As a longtime CPOE/EMR evangelist, I’m especially dismayed by lack of MD support. After courting MDs, for die hards suggest “we’ve done all we can and are sorry to lose you but to work here you have to use our systems.” More than ever it in best interest of MDs, hospital, care team and patients.

Thanks Tim for forum for lively discussion!
Ann

I say this having worked in a health system that has full CPOE for over 5 years as well as and eMAR/BCMA system in place for over 3 years. Having been the lead IT analyst on the medication portion of CPOE and the eMAR/BCMA implementation I can tell you first hand the resistance we faced. One major key to success was having strong management support and a physician champion we could let loose on any physician who was “resistant” to change. Most of those physicians can’t remember life without CPOE now.

Ms. Farrell is right to say we need to “examining physician workflow, decision making, cultural and change management needs, and foundational applications.” However, there are solutions to all these issues. She continues to say with key data, “physicians are forced to look for paper charts, call for information, chase nurses down, or make ordering decisions without important or current information.” Without a proper information system that is precisely what is physician is doing now. There will always be more data requested in a CPOE system, there will always be requests to change the way that data displays – but to hold off because of those reasons is self defeating. I know from experience: someone will always have a reason it cannot work.

Experience tells me that the journey to CPOE is a series of small steps and a few big ones. But every journey has to start with a single step. I’m not fond of the tack of the federal government forcing it to happen, but it does need to happen.

If properly implemented a CPOE system can not only bring the benefits of medication safety, but also safety in other clinical areas. It can also save money by avoiding duplicate testing. For example, not reordering a CT with contrast that a patient had a few days ago can save the kidneys and the cost of the test. It could also prevent lawsuits.

A dentist once told a friend of mine “only floss the teeth you want to keep.” It is similar, albeit an oversimplification, for CPOE: only use it on the patients you don’t want to harm.

If what you say is commonly true (and it sounds like it is), then systems at the bedside should focus almost entirely on making it easy to collect data in as much detail as the doc cares to – leaving deskside applications to focus on easy data access, presentation options, and robust analysis tools. Yes?

I’m new-ish to hospital IT… do you feel that this fundamental workflow difference is something we ITers have missed all along?

My read (and I am very experienced in this area) is that EPIC has less than great HIM applications and strategies, have only recently engaged an internal HIM resource. If not carefully strategized migrations like this could negatively impact HIM operations and even increase staffing.

HIM is a very complex, high volume envroinment that can easily be guided off the track into unproductive and more expensive practices by precipitous movements to a vendor that in reality does not have well established applciations in this area.

I’d love to hear from any sites or readers that can give guidance on their thoughts on this matter.