The long and winding road to computerized physician order entry: massive, 8-year project to bring CPOE to Thomas Jefferson University Hospital is nearly complete

Physician Executive, March-April, 2004 by Jonathan Gottlied

Founded in 1825, Thomas Jefferson University Hospital is a 932-bed multi-facility hospital located in downtown Philadelphia that admits more than 40,000 patients a year and cares for over 80,000 patients annually in its emergency department.

Throughout the 1970s and '80s Jefferson developed--largely in-house--a variety of information systems that remained in the background from the clinician's perspective. Paper charts, written orders, printed laboratory reports and consultations remained virtually unchanged over the preceding decades.

By 1996, Thomas Jefferson University (TJU) and Thomas Jefferson University Hospital (TJUH) reached a watershed in their approach to information systems. A steering committee with broad representation across the hospital and university recommended scrapping the home-grown custom designed systems that supported admission, discharge and transfer (ADT), laboratory results reporting and other functions, and replacing it with an off-the-shelf commercial system.

Because the hospital had never installed a computer order system of any kind, the committee also recommended taking the bold leap of bypassing a generic order system and implementing a computerized physician order entry system (CPOE).

Furthermore, they believed strongly from the outset that in order to reap the benefits of this approach, CPOE would have to be mandatory for every patient and every physician. Eight years later, Jefferson is in the final months of realizing this goal.

Why CPOE?

In the early 1990s, the great information technology juggernaut was in full swing. Daily newspapers published charts showing the geometric rise of Web sites, which in turn boasted of their volume of "hits." Microsoft launched an aggressive and comprehensive strategy that encompassed operating systems, business applications, Internet browsers and more. E-mail was moving from an office-based to a global entity with the advent of AOL and the iconic "you've got mail" reaching deep into popular culture.

Physicians were, if not all early adopters, at least conversant with information technology. On one level, physician innovators had helped develop computed tomography, computer-assisted interpretation of electrocardiograms and pulmonary function tests and other applications. In general, physicians had completely abandoned manual searching through the index medicus in favor of "MedLine," "Grateful Med" and other online programs. They demonstrated that if information technology were convenient and helpful, they would use it

At Jefferson University Hospital, the aging mainframe systems that had so well supported the business functions of the hospital for so long were at the end of their useful life expectancy, and the institution was at a crossroads with respect to information technology.

One path led to the replacement of current functionality, perhaps with client-server architecture to supplant older technology. A second approach involved changing the model of hospital information systems at Jefferson from a primarily financial, administrative and clerical one to one that put clinical information and processes first.

Perhaps the weight that tipped the scales was the admonition from the information technology consultant (engaged by administrative leadership to guide the institution through the process): that physicians, through the order sheet, controlled up to 70 percent of the cost of medical care.

Information systems provided, for the first time in history, a potential to intervene, standardize, direct and constrain the physician order on an institutional scale. If a clinical information system could also offer the physician a perceived benefit in patient care and practice, then there would be a double benefit: relationships with the community physicians could be strengthened without incurring the cost of purchasing practices, and unnecessarily costly ordering behaviors could be curtailed.

These were the two driving forces that led the institution toward a potentially risky undertaking, one that had a tarnished and inconsistent record of success: the complete transition from paper to electronic ordering.

There was a third consideration: Jefferson's success could provide a competitive advantage.

Laying the groundwork

Clearly, strong leadership for the project from the CEO of the hospital and the dean of the medical college was an absolute prerequisite for success. They recognized that this was a huge project that required reassignment of major responsibilities, one that would not succeed with the usual project plan and assignment to an implementation team. Existing staff needed to devote the majority of their effort over several years to the project, and new employees with novel skill sets would need to be recruited.

From the outset, the ground rules were clear. Far beyond simple automation of existing procedures, the mandate was to assess the current state of clinical processes (registration, results reporting, patient education, etc.) and then utilize information technology to support their redesign.