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2/24/2014
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CPOE Stragglers: One Hospital's Fix

Computerized physician order entry is mandated by law but some doctors still resist. Christus Health provides CPOE input assistants until docs see the value.

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When Christus Health implemented CPOE as part of its EHR initiative, the hospital chain didn't require all doctors replace traditional paper orders with the new computerized system. However, it made the capability available to all physicians -- and most hospitalists, surgeons, and other medical staff were relatively fast to adapt to the computerized system, said Dr. Luke Webster, vice president and chief medical information officer at Christus Health.

"We implemented very aggressively, very quickly... but we did not mandate use. What we found, unsurprisingly, was physicians used CPOE in varying degrees of compliance. Some absolutely refused to use the order-entry system," he said, during a presentation at HIMSS14 in Orlando, on February 24.

With the exception of its children's hospital, all Christus's hospitals' CPOE systems now perform at 78% across the Texas region, said Dr. George Gellert, regional CMIO at Christus Health in Santa Rosa. Those least likely to use the CPOE are low-frequency users (LFUs) -- typically private or community doctors, many of whom have privileges at several hospitals and therefore must learn multiple EHRs and CPOEs, said Webster.

[How to keep patients happy while they're waiting? Read 10 Waiting Room Apps That Engage Patients. ]

Forcing these doctors to use the Christus CPOE might encourage them to work with competitors situated literally a courtyard away. Yet maintaining a mixture of paper and computerized physician orders was confusing and prone to error, mistakes that could jeopardize patient health and safety, he said.

A team came up with six considerations that would allow LFUs to avoid CPOEs while helping the hospital advance its adoption of CPOE. Options included having a hospitalist enter orders while the LFU doctor stood by or using a mid-level practitioner to enter the doctor's orders while the doctor gave them verbally. Less costly approaches included using a dedicated nurse supervisor or unit clerks. Or hiring and training a dedicated CPOE staff, or using college students.

Despite offering a menu of options to avoid a one-size-fits-all solution, Christus Health managers opted to hire a dedicated CPOE staff to work, at the elbow, with LFU physicians, Gellert said. In addition to entering these doctors' orders, the CPOE staff are demonstrating the system's ease of use, answering physicians' questions about CPOE, and ultimately will see their positions end as doctors realize the benefit and inevitability of these systems, he said.

"We really don't regard this as necessarily a permanent investment," added Webster. "Once a good number of physicians see how easy CPOE is to navigate and once they save their favorite order sets, they'll become independent users. In a few years, only one third [of today's LFUs] will need at-the-elbow help. We estimate 12% to 15% are these low frequency users so it's a good, significant part of the overall community."

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Alison Diana has written about technology and business for more than 20 years. She was editor, contributors, at Internet Evolution; editor-in-chief of 21st Century IT; and managing editor, sections, at CRN. She has also written for eWeek, Baseline Magazine, Redmond Channel ... View Full Bio

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Alison_Diana
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Alison_Diana,
User Rank: Author
2/28/2014 | 9:20:43 AM
Re: How do you pull that support?
Those are great points -- and it will be interesting to see how Christus' pilot works out and addresses those areas. Judging by HIMSS14 attendees, many of the physicians at the conference were proud of their technological astuteness and their leading edge adoption of tools like CPOE within their organization. 

Hospitals are in a bind when they're working with referring physicians, especially hospitals in competitive areas where doctors can choose where to send patients. They don't want to force these doctors to use their system if a competing provider isn't doing the same. So if hospital A and B mandate CPOE but hospital C doesn't, then C could be at an advantage in the case of the X% of doctors who don't or won't use CPOE. Hopefully that percentage will drop over time -- but right now, it's an issue! In non-competitive areas where there's only one hospital or hospitals that have only on-staff doctors, it's less of a challenge since the hospital can mandate the use of CPOE.
Alison_Diana
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Alison_Diana,
User Rank: Author
2/28/2014 | 9:17:01 AM
Re: Using College Students
In Christus' case, they decided against using college students but I'd think this would be a viable approach for some healthcare providers. Seems a win-win: Students build relationships and get experience in a more clnical setting and those physicians unwilling to learn a CPOE can still help their organizations meet the requirement. And the costs would be lower, I'd imagine, than hiring full-time or part-time clerical staff. Of course, one negative is turnover.
Lorna Garey
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Lorna Garey,
User Rank: Author
2/24/2014 | 4:51:42 PM
How do you pull that support?
"ultimately will see their positions end as doctors realize the benefit and inevitability of these systems, he said."

That's an optimistic assessment! Can you picture a doctor voluntarily giving up that support? Moreover, do you see a danger that early adopers who played by the rules now feel slighted? If the "punishment" for refusing to use a new system is getting an assistant, that doesn't bode well for the next tech rollout.
Gary_EL
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Gary_EL,
User Rank: Ninja
2/24/2014 | 4:36:55 PM
Using College Students
What a great idea! Aspiring med students will do almost anything to pick up brownie points that might tip the balance in their favor. Doctors are the most incredibly busy people, especially now that more and more individuals are getting access to the system thanks to the recent positive changes brought about by President Obama. It will take many tears to bring up the supply of MDs to the point now needed. In the LOOOONG run, CPOE will free up a lot of doctor time, but for now, anything that will get the system over the hump is of immense value.
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