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Apr 11 2011   10:14AM GMT

Ending 40 years of CPOE frustration

Posted by: Jenny Laurello
Computerized physician order entry, CPOE, KLAS

Guest post by Paul Brient, CEO, PatientKeeper Inc.

For 40 years, hospitals have been trying to shove computerized physician order entry (CPOE) down physicians’ throats, and for 40 years physician adoption has been abysmal. According to KLAS’s 2010 survey, less than one-sixth of U.S. hospitals are doing even a nominal amount of CPOE with commercial software, and less than six percent of hospitals have all their physicians using a CPOE system (most of these have lots of residents to help out).

One of the biggest reasons for the failure of most CPOE systems to date is that they were designed from the hospital perspective out to physicians, rather than from the physician’s perspective in to the hospital.  Most CPOE systems are modules of a hospital information system and, for the most part, force the vernacular and constructs of the hospital order processing infrastructure onto their physicians.  If you couple this with the fairly strict requirement that most of these systems impose to standardize all orders (rather than just evidence-driven ones), you can quickly get a system that requires physicians to spend more time ordering with CPOE than using paper.

Based on years of speaking with physicians about what they do and don’t like about technology, here’s what’s needed to make CPOE physician-friendly:

  • Order sets and order terminology must reflect the way physicians practice medicine and describe orders – Everyone would agree that practicing evidence-based medicine is important. Unfortunately, the majority of the orders in an evidence-based order set aren’t evidence driven. Most CPOE systems force hospitals to gather their physicians and develop a single “consensus based” order set. Modern software can do better. Why not allow physicians to take an evidence-based order set and tailor the non-evidence-based components to their practice? If a physician always has to add an order to an order set, why not add it automatically? If a physician never orders half of the non-evidence driven orders on the order set, why show them?
  • CPOE must save physicians time – Going from paper to a CPOE system is change.   Change is hard enough when the change benefits you (as we all know from our attempts at getting in shape, being better parents, etc.).   However, changing in a way that doesn’t benefit you, doesn’t save you time, and simply frustrates you, is a non-starter.  This kind of change characterizes some of the historical challenges of CPOE systems.  CPOE must save physicians time, and a meaningful amount of time.  Doing this requires that the very important clinical decision support must be implemented in a way that doesn’t drive physicians crazy and cause them to ignore/curse all CDS alerts and messages.
  • CPOE must support physicians who are responsible for their patients 24×7 and on the run – Making CPOE as easy to use on a smartphone or tablet as the rest of the world uses e-mail on these devices is critical to physician adoption and eliminating verbal orders.

And here are a couple of things hospitals need in a CPOE system:

  • CPOE should elegantly support hybrid paper/electronic processes (at least in the short term) – Going from zero percent CPOE to 100 percent CPOE in a day is crazy. A big bang approach is both difficult and dangerous. CPOE must work for hospitals as they transition from “all paper” to “all electronic” order entry. Hospitals need a practical way to immediately implement – or incrementally evolve toward – a full CPOE process from any starting point, and move at their own pace toward the goal of 100 percent adoption throughout the organization.
  • CPOE should be decoupled from a hospital information system – Most CPOE systems that exist today are modules of a hospital information system. That means when a hospital chooses the right system to run their hospital, they, by definition, have also chosen the system their physicians will have to use. Despite what the major HIS vendors would like the industry to believe, there is no magical reason why physicians have to enter orders in a system written by the same vendor that supplied the lab system, pharmacy system, radiology system, and nursing system in the hospital.

Incorporating these principals into the design of CPOE will result in software that is built from the physician’s perspective and that is amenable to hospitals. Inevitably this will lead to widespread voluntary adoption and sustained meaningful use of CPOE – and finally end 40 years of frustration.

PatientKeeper is a leader in physician healthcare information systems (HIS), with more than 27,000 active physician users today. Please visit for more information.

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VADOCTOR  |   Apr 12, 2011  11:13 AM (GMT)

The Veterans’ Affairs Hospitals have been essentially 100% CPOE for over 10 years. It is not difficult. Once physicians realize the efficiencies and advantages of CPOE and an integrated health record, even the most recidivists will adopt the paradigm. The orders are legible, timely and patient safety is enhanced. Yes, it takes more time, but less than the alternative of missed orders, incorrect orders and the legal and patient safety implications.


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