Safety Net Provider Describes ‘5 Stages of CPOE Implementation’

In 1969 Elisabeth Kübler-Ross, M.D., published her book “On Death and Dying,” in which she introduced her theory about five distinct stages of grief.

During a Dec. 14 webinar sponsored by the U.S. Health Resources and Services Administration, one provider borrowed the five stages concept and applied it to doing computerized physician order entry (CPOE) implementation in a safety net clinic setting.

David Simenson, M.D., associate medical director for health information technology at Golden Valley Health Centers in Merced, Calif., says that as with grieving, the first step on the road to CPOE with physicians is denial that it is even happening.  Typical comments: “This can't be happening, not in my office!” or “Maybe when I come back from vacation everything will be working smoothly.”

Simenson says anger comes next. Physicians say, “I don’t have time for this!”  Simenson says he often starts training sessions by asking how many of the physicians are angry about the change. When they raise their hands, he says, “I understand your pain, and starts to build a sense of rapport.

Once they get past anger, the next phase is bargaining, in which they ask if they can just have the paper chart for a while longer, or whether they can dictate into the EHR. Bargaining, he says, is followed by depression. “Now I’ll have to spend an hour every night finishing my notes at home,” physicians say.  But the final stage is acceptance, when physicians notice they like having their favorite prescriptions saved and that the order sets are a time saver.

If the process of implementation is painful, Simenson stresses the benefits of CPOE, using an example of clinical data about a typical diabetic patient, Mr. C. Before CPOE, all the electronic data Golden Valley had was:
• Mr. C., 47 yr M
• 250.00—DM2 without complication, not stated as uncontrolled.

“If you wanted to know anything else, you would have to crack open the paper charts," he says. Unknowns requiring manual review of paper
charts include:
• Date and value of last HbA1c, LDL, eGFR?
• Date of last comprehensive foot exam?
• Date of last retinal screen?
• Influenza vaccine, pneumococcal vaccine?
• Smoking status?

After Golden Valley implemented CPOE with decision support, here is what is available electronically:
• Date of latest lab: 8/2012
• HbA1c: 6.2
• LDL: 158
• eGFR: 114
• Albumin/creatinine ratio: 54
• Last dilated retinal exam was on: 10/2011
• Last comprehensive foot exam was on: 2/2012
• Date of most recent EKG: 10/2011
• Influenza vaccine: 10/05/12
• Former smoker

Golden Valley has written order sets so that with a few clicks, the physician can order the next tests Mr. C will need. It takes only a few seconds, Simenson says.

Golden Valley, a federally qualified health center system serving the Central Valley of California, is surpassing all thresholds for meaningful use measures relating to CPOE. “I want to give people encouragement that they can do this,” Simenson says. “Your support and medical staff can do it, and your patient population will benefit.”