Point of Failure

June 24, 2011
The case for implementing computer-based provider order entry (CPOE) is compelling. But despite being recognized and advocated as a tool to improve

The case for implementing computer-based provider order entry (CPOE) is compelling. But despite being recognized and advocated as a tool to improve patient care and safety, clinician (primarily physician) resistance has become a prominent impediment to full and effective CPOE implementation.

James FeldbaumThe commonly cited IT and software hurdles rarely are the real point of failure. The same CPOE software can be accepted and successfully implemented in one institution, and then be maligned and resisted in another. Clearly, physician/clinician behavioral barriers are at the root of most stalled implementations.

Getting to 100

KLAS surveys have documented the vast number of hospitals undertaking CPOE. Despite these numbers, there has not been a corresponding increase in institutions achieving greater than 50 percent CPOE acceptance. 100 percent CPOE should be the goal.

First, it is important to define what qualifies as “100 percent CPOE.” It is, in its most simplistic form, 100 percent of physicians placing their own orders electronically 100 percent of the time. Clearly, this goal is not achievable.

Karen FullerThere are some appropriate exceptions to CPOE, which must be spelled out in a healthcare system's policy. Common exceptions are emergency orders, phone orders — when the physician does not have access to a computer — verbal orders given during a procedure, medically approved protocol orders or all orders during system downtime. Policy will need to further define the requirements for use from outside the hospital if the hospital has implemented universal remote access for its staff. We define 100 percent CPOE as “all doctors placing all their orders under all prescribed conditions and in all appropriate settings as defined by CPOE policy.”

We wish to make the case for a mandate, the “M” word, in many institutions better known by the gentle euphemism “universal” order entry. With the appropriate preparation, such mandate can provide both the blueprint and the impetus for a successful rollout.

C-suite committment

CPOE by mandate requires first and foremost that it be a top priority with unwavering commitment by the highest level leadership. Physicians may threaten to take their patients to competing facilities, to sue the hospital, or in extreme cases make efforts to foment some sort of revolt. Some will test the administration's commitment to the bitter end, especially in cultures where physicians have always gotten their way. Ongoing education and counsel are necessary to help the entire C-suite (CEO, CNO, CMO, CIO, etc.) remain steadfast throughout the process.

Common behaviors of resistant physicians include, but are not limited to, abusing verbal orders by leaving the nursing unit to call in telephone orders; writing orders on scraps of paper slipped into charts (where they can easily be missed); smuggling in order sheets from non-activated units or simply coercing a favorite nurse to put in their orders for them. Nurses who take inappropriate verbal orders enable physician deviation from CPOE policy and can undermine implementation. A mandate can place nurses under increased pressure by non-compliant physicians. Nurses and unit staff should rehearse scripted responses to physician efforts to circumvent compliance. Unit staff must be supported by the administration during the difficult first stages of the mandate.

Change leadership

For the inexperienced, CPOE is not “time neutral,” and requiring busy physicians to alter their deeply engrained rounding workflow can be a painful proposition. With training, support and well-designed order sets, physicians can regain lost time and in many cases, create an electronic workflow that will be both effective and time saving. Mandated CPOE requires that the system being implemented be fast, user-friendly, reliable and stable before the go-live. Latency between clicks, dropped Wi-Fi signal, poor access to convenient devices, and unscheduled down-time are CPOE deal-killers. The IT and clinical implementation staff need to work together and be on the same timetable before the day of go-live. If the software being implemented is deemed not well designed after focus group testing to support clinician workflow, do not even think about mandated CPOE.

An aligned administrative and staff vision must be coupled with an achievable and reasonable scope based on an institution's culture of decision making and willingness to embrace change. Physician sponsorship, their participation in all elements of design and decision making, facilitated communication with clear feedback loops, and careful attention to clinical workflow processes must be established prior to mandating CPOE.

Since some resistance is inevitable, implementers must have in place policies, procedures and consequences to deal with non-compliance. It is a good idea to have the legal department review the CPOE policy before implementing. There should be clear delineation between CPOE non-compliance issues and those of disruptive behavior. Dealing with unprofessional behavior is not the responsibility of the CPOE implementation team and must be referred through appropriate staff channels.


Although we wish to make a case for a mandate, we are not advocating a “big bang” approach. Rarely will institutions have sufficient support resources to facilitate such a house-wide CPOE activation. Rather, we favor a sequential unit-by-unit or department-by-department mandated roll-out (the order based on readiness evaluations).

Prior to each area's activation, the early adopters and super-users must validate that the system's design will accommodate special unit/department workflow. Once a unit goes live, physician order sheets must be removed from the chart and 24/7 “at the elbow” clinical support be provided during and post activation.

We recommend daily briefings for a couple of weeks with the clinical staff on the go-live unit/department with ancillary department participation to review the issues discovered on the previous day. Sufficient resources must be assigned to problem solving and to correct deficiencies as they are discovered. The implementation team must be clinically driven and supported by IT leaders who are empowered to address and correct system and workflow issues as they become transparent. A successful rollout moves only at the speed of success but must maintain momentum. Do not be tied to an unrealistic schedule.

As indicated earlier, the critical role nursing plays in successful implementations is not to be underestimated. Nurses can be the glue that makes CPOE stick. Nursing leadership and staff must be advocates and competent users of CPOE. Mandatory training and competency must be achieved by each nurse prior to granting access to the system. Strategies such as “Adopt a Doc,” can provide physicians non-threatening one-on-one training and support by a trusted unit nurse and/or support team member enabling incremental learning at the time and point of CPOE.

We have found that these additional strategies can augment a smooth go-live:

  • A comprehensive community education/marketing campaign that emphasizes the institution's and staff's commitment to quality and safety through information technology. Don't undervalue the power of patient and community support for quality improvement.

  • Internal marketing that can include logos, posters, and ongoing educational sessions. Particularly helpful is a “countdown clock” that clearly reminds physicians of the beginning of the healthcare system's mandated roll out. Also effective are countdown reminders signaling the initiation of each unit/department activation.

  • Establishment of efficient feedback loops for system suggestions and enhancements that demonstrate the organization's commitment to support clinician needs. We suggest employing a dedicated e-mail or voicemail extension where physicians and nurses can make comments and suggestions at the point of discovery.

  • 24/7 unit based “at the elbow” support is compulsory for the first few weeks of each new unit/department activation. This must be followed by long-term 24/7 in-house clinical support.

CPOE brings to light many long standing workarounds that, while tolerated in the paper-based world, should not be permitted to be part of an electronic workflow. It is worth the extra effort to identify problematic practice patterns and make needed corrections prior to implementating CPOE. Another warning: CPOE can become the “scapegoat” for long-standing departmental inefficiencies and unrecognized, or ignored, deviations from hospital policy if not successfully remedied prior to implementation.

After consulting on multiple implementations, we have discovered that success breeds success. A conscientious effort to see that each unit's issues are assuaged before rolling-on makes each subsequent rollout faster and less problematic. Once critical mass is achieved, physicians begin to realize that CPOE is the way the healthcare system does business and resistant behaviors generally subside. Once resistance fades physicians begin to engage with the change and will become a valuable source of system and quality improvement.

A final note

The “M word” not only represents “mandate,” but also a “moral” imperative. Although the vision and mission of hospitals instituting CPOE clearly identifies it as a patient safety initiative, we find that vision and mission often get lost in the quagmire of implementation issues. The resulting failure to obtain full adoption results in the development of a hybrid system within a hospital whereby some doctors use CPOE and some don't. Some physicians continue to live in a paper world, others in an electronic one. In other words, technically adept physicians avail themselves of clinical decision support and tools that reduce errors and improve patient safety while others don't. To make matters worse, the maintenance of two separate record systems — one paper and one electronic — adds yet another source of medical errors.

Does this disparity in information and treatment rise to the level of a moral imperative? It does. How can a hospital that has committed significant human and financial resources to this inevitable initiative make adoption of this technology optional? Can it be acceptable to create two populations of patients who — unbeknownst to them — receive access to vastly different medical care?

As close observers of this phenomenon, it seems clear that hospitals and physicians must have the courage and commitment to mandate CPOE
. James Feldbaum, M.D, is physician consultant, CPOE, interoperability, and clinical transformation in Sarasota, Fla. Karen Fuller, R.N., is a consultant with IBM Healthlink Solutions, Clinical Transformation Services and is also based in Sarasota.

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