Published in the December 2006 issue of Today’s Hospitalist
Computerized physician order entry (CPOE) may rank high on the list of patient safety targets being set by national organizations, but it’s yet to be embraced by most hospitals and physicians. CPOE systems have gone live in as few as 10 percent of U.S. hospitals, for example, and interest in the technology among most physicians remains low.
But according to a new study of physicians’ attitudes toward CPOE, physicians may be more willing to use the technology than they are letting on. The key, researchers say, lies in giving physicians a reason to overcome the barriers to using CPOE systems.
When researchers surveyed a group of attending physicians using a CPOE system at two Massachusetts hospitals, they weren’t terribly surprised to find that only 22 percent of them thought that the system supported their workflow. What did come as a surprise, however, was the number of physicians who persevered and used the system anyway.
Despite their abysmal assessment of the system design, 42 percent of the physicians in the study were categorized as “high users,” which meant that they entered at least 80 percent of their orders electronically. Thirty-two percent were low users, relying on CPOE for 20 percent or less of their orders, while 26 percent fell in between.
According to Peter K. Lindenauer, MD, a hospitalist and lead author of the study, the findings point to the fact that CPOE vendors have a long way to go to make systems more user-friendly.
But the results also provide a valuable window into what makes physicians willing to embrace new technology.
“You have to give physicians a reason to get past the discomfort,” says Dr. Lindenauer, medical director of clinical and quality informatics at Baystate Medical Center in Springfield, Mass., one of the hospitals included in the study. “If you tell them the reason is to provide the safest possible care, you’ll increase your chances of success.”
In addition to surveying physician use and attitudes of CPOE systems at Baystate, where housestaff help care for only one-half of the inpatients, researchers also looked at attendings at Franklin Medical Center, a rural community hospital. That makes the study, which was published in the July/August 2006 issue of Journal of Hospital Medicine, the first to examine CPOE use in the community setting.
Dr. Lindenauer spoke with Today’s Hospitalist about the study and about hospitalists’ unique role in implementing CPOE.
Your study was the first to look at CPOE in a community hospital. Why is that important?
The majority of care provided in the U.S. is provided at small community hospitals by physicians working without housestaff.
But most of the research and development on CPOE has taken place at a few well-known academic medical centers that have designed and built systems themselves. That doesn’t tell us what CPOE is like in the real world, and it won’t help us make a dent in patient safety.
What were the most surprising findings?
That doctors’ age or the number of years they’d been practicing at an institution had very little bearing on whether they were high users.
Hospital leaders are often concerned that older physicians “whatever “older” is, 40 or 50 “will have a hard time adopting new technology. We found that low-user physicians weren’t any older than high users, nor did we see any gender phenomenon. It turns out that the conventional wisdom isn’t true.
What factors were associated with higher usage?
We did find a correlation between use and physicians who had trained in hospitals that used CPOE. That argues for how important it is to include CPOE in training programs.
But the strongest association was with beliefs about order entry. Physicians who bought into the concept that CPOE was safer and led to higher quality were more likely to use the system. That’s probably the most useful finding for hospital leaders.
Because CPOE represents a very dramatic change in how physicians do their work, you really need to make the quality and safety case for CPOE when you’re rolling it out.
What were some objections from physicians?
Some physicians complain that “it’s a secretary’s job to place orders.” That ignores the fact that clinical decision support is most valuable when it’s provided to the person making decisions, not to transcriptionists.
Even our high users thought the system didn’t support their workflow. But they dealt with the discomfort because they believe this is the right thing to do for patients.
You found that usage rates varied among specialties. Who were your high users?
At our institution, anesthesiologists and surgeons have tended to embrace CPOE more than internists because surgical care is often very protocol-driven. A cardiac surgeon can open up a postoperative cardiac surgery order set that has more than 100 orders in it, click OK and place all those orders at once.
Internists, especially general internists, have tended not to rely as much on order sets. They may use a generalized admission order set or one for pneumonia, but they frequently have to enter individual orders to address comorbidities like concomitant dementia or a urinary infection. Ordering outside of order sets is often slow and can be an incentive to not use the system.
How do you get around that?
One solution we’re working on here is linking order sets. You might have a general medicine admission care set that would link to three or four other sets. That’s one way to try to meet the needs of a complex, multisystem patient often seen on a general medical service.
What implications does specialty usage have for CPOE design?
You need to understand the different work styles of physicians in different specialties. When placing orders, hospitalists’ workday and workflow are very different from surgeons doing elective surgeries who can place some orders days or even weeks before the patient arrives.
A hospitalist is typically placing orders after patients have been admitted from the ER, so a good general admission care set is invaluable. It needs to cover common diagnostic studies, common medications and general care measures such as DVT prophylaxis and immunization.
In addition, condition-specific care sets can increase adherence to quality of care measures, so order sets are critical. They need to be owned and championed at a departmental and usually a divisional level.
Where did hospitalists stand in terms of usage?
We looked at all the internists together and didn’t break out hospitalist data in the published report. But anecdotally, our hospitalists had the highest rate of order entry use of all the physician groups in the hospital.
Physicians who are casual or infrequent visitors to the hospital find it extremely hard to stay on top of these systems. By virtue of their day-in, day-out use of these systems, hospitalists, on the other hand, tend to embrace CPOE very quickly.
You expect CPOE implementation to expand. What’s driving that change?
National organizations, including the Leapfrog Group and the Institute of Medicine, have made CPOE a big part of their patient safety agenda. For hospitals, the biggest motivator is to provide decision support to physicians.
We didn’t address decision support in the study because the CPOE system we had at the time was too old to have rules and alerts. But we have since installed a system with decision support, so we’re measuring the number of drug errors we’re avoiding through the use of alerts on drug allergies, drug-drug interactions and dose-range checking.
There is still very limited evidence on the benefits of decision support, but its promise is enticing hospitals to embark on the next wave of CPOE rollouts.
How should hospitalists be involved in those rollouts?
Hospitalists can play two vital roles in CPOE. First, they are in the best position to be the physician champions of CPOE because of their moral authority within the hospital, based on the amount of time they spend there and the number of patients they see.
Second, they need to be intimately involved in system design and the development of order sets, as well as of decision-support rules and alerts. They need to make sure that any system meets the quality, safety and efficiency goals that hospitalists tend to be held accountable for.
Phyllis Maguire is Executive Editor of Today’s Hospitalist.