“The academic places have been doing it because they can and because they also see the benefits of it,” says Gerald Greeley, CIO of 229-bed Winchester Hospital (Winchester, Mass.). “But I think the community hospitals now, through payer incentives, are saying, ‘Hey, this is the right thing for us to be doing as well.’”

With the implementation of CPOE systems, however, come many factors, including added costs, the time required to train staff, and the need to assess an organization's wireless capabilities. CIOs like Greeley have found that infrastructure is an important element of a roll-out — not for CPOE itself, but to support all of the devices that clinicians utilize to document order entry.

In its research, KLAS found that CPOE is no longer limited to fixed desktops and hardwired sites; in fact, 94 percent of hospitals reported using either a combination of hardwired/wireless CPOE (67 percent) or wireless-only CPOE (27 percent). Whereas desktops used to be the most popular device, now computers on wheels, laptops, tablets and PDAs comprise 67 percent of the devices in use, states the report.

With so many more devices being deployed, it's becoming pivotal that facilities have a solid network in place, according to Jake Kretzing, senior partner at Greencastle Consulting (Malvern, Pa.). “The wireless component is not what CPOE in my experience has hinged on, but it does ride on that network itself,” he says.

At Winchester, which is currently in the midst of a roll-out of Westwood, Mass.-based Meditech's CPOE system, ensuring that a sufficient network is in place to accommodate devices and applications has played a significant part in the implementation, Greeley says.

“Infrastructure is hugely important,” he says. “We found that making more devices available to the physicians is a huge component of CPOE.”

Although at this stage, many physicians at Winchester prefer to document at the desktop — a situation that isn't rare in smaller, community hospitals — it is a trend that Greeley expects to change as tablets become more functional.

At Atlantic Health, a three-hospital, 1,585-bed system based in Morristown, N.J., determining what types of devices clinicians would be using played a key role in the planning process for CPOE.

“We planned the infrastructure at the same time that we were planning the entire program roll-out,” says Kretzing, who has served as a consultant in the implementation of the Horizon Expert Orders system from Atlanta-based McKesson. The system is currently live at Goryeb Children's Hospital (Morristown, N.J.) and in the pediatric unit at Overlook Hospital (Summit, N.J.). “We did a thorough assessment to understand where they are as an organization with regard to implementing CPOE, and part of that was finding out from each of the stakeholder groups what they find most concerning,” as well as what preferences clinicians had in terms of devices and applications.

For Linda Reed, R.N., vice president of information systems and CIO at Atlantic Health, making sure that the end users were involved and invested in every step of the process was a big priority. In addition to assigning a clinician excellence committee that had a significant stake in decision-making, Reed brought in Greencastle to perform a rigorous evaluation identifying clinicians' preferences and priorities in terms of mobility, remote capabilities and patient interactions. After reviewing the results, Atlantic Health opted to provide physicians with wall-mounted screens and CPUs in the hallways as well as medication carts with computers mounted on them.

“We worked with clinicians to get them involved, because change is so critical on the clinical side,” says Kretzing. “I told folks that you can control what it is that's delivered to you, but if you don't go out and vote, you can't complain about who gets elected.”

The bigger picture

Another reason for CIOs to consider infrastructure in CPOE roll-outs is that often, the system is implemented as part of a larger strategy. For Winchester, CPOE is just one of the steps in what Greeley calls “the total migration to an inpatient EMR,” along with nursing documentation and medication administration.

The CPOE implementation is also part of a larger plan at Atlantic Health, where remote physician order entry, clinical decision support and performance metrics analysis are also being phased in as part of the second stage of the roll-out. Right before CPOE was piloted, Atlantic Health began deploying AdminRx, a medication administration system from Alpharetta, Ga.-based McKesson; in order to support the roll-out, says Kretzing, a stronger infrastructure was needed. So as it happened, the wireless network from Cisco that was installed for medication administration was already in place when CPOE was introduced.

“They had installed the wireless technology for that particular project and CPOE rode on the coattails,” says Kretzing. “So as they were developing and rolling out AdminRx, we came right behind and worked on the CPOE implementation so that it was a complete closed-loop medication process.”

The network that was put in place to accommodate wireless carts and bar code scanners was also better able to support CPOE, says Reed; a decision that was carefully crafted by her team.

“When I got here, we really talked about our strategic plan and how do we get CPOE,” says Reed, who was hired as CIO in May of 2004 and had a strategy in place by September. “Some places go right to CPOE but they don't have the infrastructure in place. We didn't want to have that; we wanted to have more of a really automated, closed-loop type of system, so that what was generated from one system went into another system, not a piece of paper.”

Throughout the implementation, Atlantic Health's strategy has revolved around introducing technologies in what Kretzing calls a very incremental way. “They put the infrastructure in first to get nurses and pharmacy online with meds administration before we brought physicians online to start ordering electronically,” he says. This way, the organization was able to reduce medication cycle time and ensure that medication errors were identified and eliminated because the staff can verify it is the correct patient. “You can tell with CPOE if the patient has an allergic reaction to a certain type of medication or if they are taking another med that may have a reaction to that. So you're actually reducing your risk significantly.”

Atlantic's incremental roll-out started with upgrading to a more sophisticated pharmacy system that featured alerts, reminders and more advanced dosing. Because the pharmacy system feeds into administration, Reed says, the next step entailed automating paper-based medication administration records and installing bar coding at the point of care. Finally, the team looked at order entry as an endpoint and ensured that physicians could access the medication administration records online, enabling them to enter orders by computer instead of picking up a phone.

“What we were trying to do was put the process in place so that at the end of the day, all the other systems and all the information is at the physicians' fingertips,” says Reed. “CPOE was really the capstone to all the other things that we did.”

In Reed's experience, having a solid network in place was critical. “It made a big difference that infrastructure was dealt with before CPOE was introduced. By having all of that data already in place, our physicians can sign their charts online,” she says. “I think that's one thing we didn't appreciate until we got to the end — everything that we did fed right into this.”