I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).
I wrote this piece in July 2006.
Hospitals Want Software to Do The Dirty Work of Changing Physician Behavior
By Mr. HIStalk
An editorial in the latest American Journal of Managed Care titled “Defending Computerized Physician Order Entry From Its Supporters” stresses that physician order entry (CPOE) and clinical decision support systems (DSS) are separate entities, despite popular perception. Ross Koppel, a sociologist and Penn professor, says that sloppy terminology has confused the respective benefits and shortcomings of CPOE and DSS.
Ross’s sociologist view is interesting. We’re expecting a lot from immature CPOE and DSS systems that most hospital executives can’t define, even when they’re plunking down hard-earned capital dollars to purchase them.
CPOE is a smart typewriter that, standing alone, has little ability to improve patient outcomes. It prevents transcription errors, although those seldom harm patients because they’re usually caught anyway. CPOE makes it easy to choose common order defaults instead of “winging it.”
Beyond that, the benefits (both clinical and financial) come from DSS, not CPOE. (I’ve often joked that hospitals could use e-mail as a poor man’s CPOE system – just let the doc free-text whatever he or she wants and send it to the appropriate department, thereby eliminating transcription and turnaround time errors for free.)
Commercially available DSS systems are, unfortunately, mostly frightfully immature, even more so than CPOE. Early adopters share war stories of nagging alerting, inflexible third-party rules, the inability to customize and personalize, and problems with performance-sapping rules engines incapable of delivering alerts of any more sophistication than the old hard-coded screen edits. No wonder doctors have been underwhelmed.
Still, the real problem is right down Ross’s alley. Hospitals usually buy CPOE and DSS because they’ve failed to control physician behavior otherwise — often euphemized as “reducing practice variation” or “practicing evidence-based medicine.” They want software to do the dirty work that they can’t or won’t: telling physicians that they’re wrong and demanding that they change. When docs don’t follow the electronic cookbook’s rules any better than the paper ones it replaced, systems and vendors are blamed.
I’ve been involved in two CPOE/DSS implementations, both involving large IDNs and well-known vendors. In both cases, hospital administrators ill-advisedly shot their patient safety technology wad on CPOE, confident that it would improve patient care better than any other investment (despite ample contradicting studies). Physician adoption was universal in one, minimal in the other, but one element was common: 90% of the expected DSS benefit never materialized. Pre-implementation enthusiasm gave way to the grim reality that the system wasn’t going to be much help in changing practice patterns. We purchased DSS, but implemented a smart typewriter.
No software contains a switch that turns resistant physicians into docile, rule-following sheep who make better decisions under the watchful eye of Big Brother’s can’t-miss medical guidelines. Displaying a few dumbed-down alerts won’t convince them they need to change. But if your hospital has already spent a few million on CPOE and DSS thinking that was the case, you’ve learned that already.
Maybe physicians will recognize the next generation of systems as their ally, not their enemy. After all, they want the best outcomes for their patients, too. Where they disagree is that we have the answer right now with these first-generation CPOE and DSS applications that we can’t even define.