Review of Lessons Learned from Computerized Provider Order Entry Implementation in Community Hospitals: a Qualitative Study
Simon, SR, Keohane, CA, Amato, M, Coffey, M, Cadet, B, Zimlichman, E, Bates, DW. Lessons learned from implementation of computerized order entry in 5 community hospitals: a qualitative study. BMC Medical informatics and Decision Making 2013; 13:67.
The consensus in the informatics community is that computerized physician order entry (CPOE) with clinical decision support (CDS) can improve patient safety.(1-4) Since the early adopters of CPOE have been academic institutions with their own internally developed programs, most of the studies of CPOE have been on those same institutions.(1) Consequently, community hospitals embarking on CPOE implementation with vendor developed systems will find limited guidance in the literature on peer institutions.(4) The same is true for literature evaluating the impact of CPOE implementation in community hospitals. Two recent studies have added to the body of literature about CPOE implementation and its impact in community hospitals. This paper will provide an overview of a study of CPOE implementation in community hospitals using vendor developed systems.
Simon et al conducted a qualitative study of five community hospitals in Massachusetts that had successfully implemented commercially-purchased CPOE.(4) The purpose of the study was to identify generalizable lessons that could guide other community hospitals during the implementation process. The authors used qualitative research methods/approach to characterize behaviors and attitudes of hospital personnel surrounding CPOE implementation into the following five domains that could be helpful to community hospitals engaging in CPOE implementation: governance, preparation, support, perceptions and consequences.
To gather data, researchers conducted in-depth interviews with hospital staff who were knowledgeable about the implementation process at their respective institutions.(4) The goal was to interview at least five members of staff, which would include one clinician who orders treatments using CPOE, a nurse or pharmacist who processes the orders, and an executive who oversaw the implementation. A total of 24 interviews were conducted: nine doctors, 12 nurses, and three pharmacists.
Researchers posit that the results of the study can be viewed as five lessons learned that provides a framework for community hospitals undertaking CPOE adoption. The five lessons are as follows:
The success of the CPOE implementation depends on how well the change is managed i.e. effective leadership. Researchers found that respondents thought it was essential for clinicians, pharmacists, and other staff directly affected by CPOE implementation to have a strong presence on the committee managing the change.(4) They can address workflow issues and liaise with their colleagues and the committee.
2.Preparation and advance planning
Preparing the institution for CPOE implementation is another key part of the process. It can take up to two years, and involves needs assessment, vendor selection, hardware and software purchase, and training. In planning staff training, allowances must be made for individualized training since technology/computer skill levels may vary.
3.Support at the elbow
On-going support or live help at the time of implementation is seen as essential. At the elbow help was provided by specially trained peer “superusers” at the community hospitals in the study.(4) The authors do not offer an assessment of peer “superusers” vs. outside “superusers”. However, they do note that the impact on staffing needs to be considered when deploying peer “superusers”.
Managing perceptions requires deft leadership, as well as “identifying and supporting a champion among each stakeholder group”.(4) Champions act as liaisons between stakeholders and institutional leadership. They can help allay stakeholders’ anxiety ensuring their concerns are addressed.
Institutions must address some of the unintended consequences of CPOE implementation. Retirement of senior nurses and physicians, “the transition of primary care doctors to using a hospitalist system” as well as, risks to patient safety were reported in this study.(4) Institutions that anticipate and discuss potential adverse effects have the opportunity not only to put measures in place to eliminate them but to also have more realistic expectations about initial outcomes.
The study reveals that successful CPOE implementation in community hospitals rely on the same key principles that has been shown to work in academic hospitals such as human, workflow, and systems integration.(2-3) Leadership, expressed as governance in the current study, is required at multiple levels to disseminate the reasons for CPOE, plan the transition, and keep the institution on message by cultivating champions on the clinical level to secure stakeholders’ buy-in.(3) Respondents in this study indicated that involvement of key stakeholders in the decision making, and a clinical champion who served as a liaison between the information systems department and physicians were essential to the success of the project.(4)
Training and support for front-line users have also been touted as crucial to the success of CPOE implementation.(1-3) Live help at the time of implementation is seen as critical not only to help users navigate the application, but also to the implementation team who will gain first-hand knowledge about what needs to be improved.3 Simon et al characterizes this stage of the implementation process as preparation and advanced planning, and support.(4) During the preparation and advanced planning phase, the staff’s training needs were assessed, and individualized tuition was offered in “pre-go-live”3 training. For example, basic computer training was provided to members of staff who needed it. The support phase entailed “at the elbow” during “go-live” period by specially trained peer users.
This study adds to body of literature about vendor CPOE implementation in community hospitals. The domains identified in this study—governance, preparation, support, perceptions, and consequences-- have been addressed in various ways in the existing body of literature on CPOE implementation.(1-3) This study’s value is in its specificity to community hospitals using commercial CPOE systems.
1. Ash, JS, McCormack, JL. Sittig, DF, Wright, A, McMullen, C, Bates, DW. Standard practices for computerized clinical decision support in community hospitals: a national survey. J Am Med Inform Assoc 2012; 19:980-87.
2.Ash, JS, Stavri, PZ, Dykstra, R, Fournier, L. Implementing computerized physician order entry: the importance of special people. Intl J of Medical Informatics 2003; 69:235-50.
3.Ash, JS, Stavri, PZ, Kuperman, GJ. A consensus statement on considerations for successful cope implementation. J Am Med Inform Assoc 2003; 10:229-34.
4.Simon, SR, Keohane, CA, Amato, M, Coffey, M, Cadet, B, Zimlichman, E, Bates, DW. Lessons learned from implementation of computerized order entry in 5 community hospitals: a qualitative study. BMC Medical informatics and Decision Making 2013; 13:67.
Submitted by Erleen Palmer