CPOE for the Smaller Set

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Community, rural, and even county hospitals have found ways to master healthcare's toughest technology.

By any measure, computerized physician order entry is healthcare's elusive technology. According to the 2008 HIMSS Analytics survey of clinical IT, just 2.1% of U.S. hospitals have automated order entry, and even fewer have completely automated the rest of the medication food chain, from processing in pharmacy to bedside administration by the nurse. The notable examples of CPOE occur in large, well-heeled academic medical centers, where IT resources and support (and perhaps an employed physician group) figure in.

CPOE, however, is not for the big guys only. Looking to achieve the same goals of the AMCs, a handful of smaller hospitals have deployed the technology. Although they encountered familiar hurdles, some community, rural, and county hospitals have managed to bring their largely independent physicians on board with the technology. Three of their stories follow.

Name: Riverview Hospital
Location: Noblesville, IN
Type of facility: County-owned
The community hospital deployed CPOE in its busy emergency department in August 2006. Part of a hospitalwide IT makeover, the order entry component is part of a clinical information system from QuadraMed. CPOE is available in other departments, but only in the ED do physicians enter their own orders, explains Joy Barrett, RN. Part of the IS staff, Barrett serves as clinical information systems manager at the 137-staffed-bed facility, which handles about 30,000 annual ED visits. Aware of the hurdles of implementing order entry, Riverview opted to deploy the technology in the ED first because physicians there—part of a contracted group—were clamoring for it, Barrett says.

"Everywhere else they worked, they did CPOE," she says. "And we needed a pilot anyway for the rest of the hospital."

Riverview no longer processes any orders with paper in its ED, Barrett adds, ticking off a list of automated tasks that includes X-rays, medications, labs, procedures, and consults. After an initial fervor for CPOE, several ED physicians began sidestepping direct entry of orders by placing them verbally. Barrett turned to the chief medical and chief nursing officers for help in encouraging all ED physicians to use the CPOE system. In tandem, the CMO and CNO established a rule that verbal orders could only be given in code situations. As a result, direct physician entry returned to previous levels.

Now that order entry has taken hold in the ED, Riverview is looking to expand the technology to its inpatient areas. Pending completion of a database upgrade, the transition will begin later this year or in 2009. To facilitate the transition, Riverview has created a storehouse of order sets based on its old paper forms. Any electronic sets, however, are vetted by a physician committee. Another physician committee, staffed by the CMO, will weigh in on the more difficult issue of when and where to begin implementing CPOE. Barrett figures that Riverview will explore starting with its hospitalists or perhaps in obstetrics. Either way, it's important that the medical staff maintain ownership over the technology, she says.

"We're a non-teaching community hospital, so we don't have many carrots to dangle," she says. "We never kid ourselves that patients follow physicians, and so we value them."

Name: Decatur Memorial Hospital
Location: Decatur, IL
Type of facility: Independent community hospital
The 160-staffed-bed community hospital began its CPOE journey in spring 2006, deploying McKesson technology that, at first, was used by nurses and unit secretaries acting as traditional scribes for physicians. That July, Decatur began transitioning to direct physician order entry, moving department by department over a nine-month period. Today, 100% of all orders made during inpatient rounding are placed directly by physicians, says Michael Zia, MD, vice president of medical affairs and quality.

"If the physician leaves the hospital, we still accept phone orders," he says. "We have the capacity to enter orders remotely, but if it is after hours, it is not practical to tell the physician to enter their orders while they are home in bed."

Zia says the technology has boosted patient safety, if for no other reason than solving the legibility problem. About 160 physicians are regular users of the system, he adds. The biggest obstacle the rural hospital faced in transitioning to electronic orders was building the datasets of drugs that physicians would encounter.

"We have some 6,000 drugs on the formulary and wanted to avoid asking for redundant information," he recalls.

For example, if a medication is only available as a tablet, the system should not ask about administering it as a liquid. Such unnecessary steps will alienate physician users, he says. "Each click is an issue. You can't buy software for $1 million and have 25% adoption."

Now that the medical staff is comfortable with the system, Decatur is looking to expand its clinical decision support features. The hospital may add software that integrates clinical and genetic information, applying an algorithm to suggest whether a drug might be effective or a test will be valuable.

"We want the computer to be a resource to guide better care," Zia says. "CPOE is not just a way to make sure orders are legible and complete."

Name: Citizens Memorial Healthcare
Location: Bolivar, MO
Type of facility: Independent rural hospital
For physicians at 74-staffed-bed Citizens Memorial, CPOE is an old hat. A real front runner in the technology, the rural hospital deployed order entry in 2003. The technology was part of a documentation overhaul in which the hospital abandoned paper charts and adopted clinical IT, primarily from MediTech.

Order entry was adopted in a step-wise manner, recalls Cindi Lockhart, IS clinical application specialist. First, physicians were taught how to use the electronic medical record to look up labs and sign charts electronically. Then Citizens Memorial introduced procedure ordering using the new technology.

"It is much easier than complex medication ordering," she explains.

During this time, the hospital worked to ensure that the adjoining pharmacy system was ready to accept medication orders electronically. That effort proved cumbersome, as Citizens wound up rewriting the pharmacy "dictionary," a database that controls how and what information appears. Initially, the pharmacists wanted to use the system to measure inventory, she explains. That meant, however, that physicians would see every type of pill available when first entering the system.

"If physicians see everything, they get overwhelmed," she says. Citizens streamlined the system to minimize the number of options presented to physician users.

Another boost to physician adoption was the creation of a special "orders room" in a central location.

"As a rural hospital, we are physically smaller," Lockhart says. "So we built a room near our med-surg unit, and that became the place to go to do order entry. The physicians said they didn't want to carry a computer with them."

As staff go-to expert on how the system works, Lockhart still maintains a presence in the orders room during busy morning hours.

"Physicians are not going to pick up the phone and call when they need something," she says. "You need to keep the lines of communication open when they are there."

—Gary Baldwin

Diplomacy 101

Group training with physicians won't work, says Cindi Lockhart, IS clinical application specialist at Citizens Memorial Healthcare in Bolivar, MO. Charged with teaching the medical staff a new EMR system, Lockhart set up group training classes.

"Physicians won't say, ‘I don't know how to use a mouse' in front of their colleagues," she observes. Lockhart quickly switched to one-on-one training. "A few physicians are absolutely scared to death of CPOE and a few are just opposed to it," she says. "We are asking them to do the job the secretary once did. I just would emphasize quality and safety. I never told them the technology was going to save them time."

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