Using special people in a computerized physician order entry system implementation: Removing barriers to success
Environmental trends that put pressure on hospitals and outpatient practices to implement CPOE are focused mainly on cost and safety attributes. The CPOE application is part of a larger electronic health record (EHR) system. The application increases efficiency and accuracy by allowing a provider to enter an order for a medication, clinical laboratory or radiology test or procedure by using structured, electronic data. The application then transmits the order electronically within the EHR system to the appropriate department or individual so it can be carried out.
Some research has documented that CPOE threatens patient care, such as shifting synchronous to asynchronous communication that may deteriorate physician-nurse interactions and other work-flow efficiencies[2,3]. Despite these concerns, there is good evidence for CPOE implementation. Benefits of CPOE system adoption has been documented to include medical error reduction, access to clinical decision support systems, access to medical records and improved patient care[4,5,6]. These are common justifications for implementing CPOE in a hospital. However, adoption remains limited due partly to personal attitudes and behaviors, such as physician resistance or complete refusal to participate. Project champions who remove these barriers to successful implementation have been referred to by Ash as “special people.”
Barriers to Success
The decision to implement a CPOE system may mean a large capital investment and can take years of work before its completion. For a hospital to make the investment to implement a CPOE there must be a strong alignment between the institution and its physicians. This alignment is critical as, without it, there may be organizational trends that pose significant barriers to success. The organization must have vision and strong leadership to make the initial capital investment but also the investment in resources to carry the project through implementation, completion and maintenance. But many implementations fail or are never attempted because of much overlooked personnel issues such as insufficient leadership, negative physician attitudes and fragmented communication.
A hospital that has suffered previous implementation failures can affect the attitudes of the physician staff negatively. This type of experience may anchor the physician’s negative perception leading to a self-fulfilling prophecy and another implementation failure. Additionally, poor communication adds complexity and places the implementation at risk for failure. Without strong communication methods physicians will be unable to develop fully functioning project teams.
In a 2003 article by Ash she describes how “special people” can increase the likelihood of a successful CPOE implementation. These talented people are already part of the organization and have unique management characteristics. Special people understand that they are in the position break down barriers to implementation success. They are often people who are charismatic with high emotional intelligence and they understand when to be tough or empathetic. Their credentials vary from physicians, nurses and pharmacists to non-clinical project managers and analysts. What is common among them is they can live in multiple worlds7. They understand the technical challenges of health information technology systems as well as user experience needs.
Special people fall into two basic groups: Leaders and Bridgers. Leaders are executive sponsors of an implementation who possess excellent social skills and emotional intelligence. Bridgers are generally non-physician personnel such as project managers, clinical informatics specialists and analysts. Since there are many stakeholders in a CPOE implementation each with their own goals, special people can align their incentives and attitudes through building multidisciplinary trust. Leaders can provide motivation and project context to promote improved attitudes while Bridgers promote adequate training, support and inclusive project planning and management. These combined elements are considered critical for implementation success5.
Successful implementation relies on an organization’s attention to more than the technical challenges of a CPOE system, but the behavioral and emotional needs of the users’ of that system. Change is a difficult process and there are few people who are comfortable with it. Change threatens an individual’s concept of what is stable and predictable and one’s behavioral response is generally negative. Implementing a CPOE system brings this very change to an organization and barriers are continually presented.
Countering these barriers requires the participation of our special people. It is important that the organization recognizes these people, nurtures their talents and takes full advantage of their ability to remove the threats and barriers to a successful implementation.
1. Sittig DF, Krall M, Kaalaas-Sittig J, Ash JS. Emotional aspects of computer-based provider order entry: a qualitative study. J Am Med Inform Assoc. 2005 Sep-Oct;12(5):561-7.
2. Poon EG, Blumenthal D, Jaggi T, Honour MM, Bates DW, Kaushal R. Overcoming the barriers to the implementing computerized physician order entry systems in US hospitals: perspectives from senior management. AMIA Annu Symp Proc. 2003:975.
3. Pelayo S, Beuscart-Zephir M. Organizational considerations for the implementation of a computerized physician order entry. Stud Health Technol Inform. 2010; 157:112-7.
4. Aarts J, Ash J, Berg M. Extending the understanding of computerized physician order entry: implications for professional collaboration, workflow and quality of care. Int J Med Inform. 2007 Jun;76 Suppl 1:S4-13.
5. Ash JS, Fournier L, Stavri PZ, Dykstra R. Principles for a successful computerized physician order entry implementation. AMIA Annu Symp Proc. 2003:36-40.
6. Ash JS, Stavri PZ, Kuperman GJ. A consensus statement on considerations for a successful CPOE implementation. J Am Med Inform Assoc. 2003 May-Jun;10(3):229-34.
7. Ash JS, Stavri PZ, Dykstra R, Fournier L. A consensus statement on considerations for a successful CPOE implementation. J Am Med Inform Assoc. 2003 May-Jun;10(3):229-34.
8. Bartos CE, Butler BS, Penrod LE, Fridsma DB, Crowley RS. Negative CPOE attitudes correlate with diminished power in the workplace. AMIA Annu Symp Proc. 2008; Nov 6:36-40.
Submitted by Joe Fazio, RPh, MHA