If you build it , they will come: the physician-friendly CPOE: not everything works as planned right out of the box. A Mississippi hospital customizes its electronic order entry system for maximum use by physicians

Health Management Technology, Jan, 2005 by John Fitzpatrick, Jason Soonju Koh

"If you build it, they will come," the famous line from the popular movie "Field of Dreams," has been the guiding principle behind efforts to implement computerized physician order entry (CPOE) at Forrest General Hospital (FGH), a 537-bed private community facility located in Hattiesburg, Miss. It also has been a lesson learned.

Origin of the "P" in CPOE

Patient safety is a top concern for all healthcare professionals and the primary reason for implementing CPOE. But doctors are reluctant to use CPOE. Why should this be, when the benefits of patient safety have been often quoted? A significant part of the reason is because doctors previously were not offered CPOE, but rather its predecessor, computerized order entry (COE).

What is the difference? The absence of the "P," for physician or providers, makes a telling statement about why CPOE has not been rapidly embraced by physicians even though its benefits are clear.

To understand physician reluctance to use CPOE, it is important to understand its history. COE was designed so that even the novice pharmacy technician or ward clerk could enter orders. In other words, it was designed based on the lowest common denominator, much the way a newspaper is written for consumers with an education level between eighth grade and tenth grade. The COE system was not arranged according to medical logic, but rather was an alphabetical system requiring a tremendous amount of scrolling and mouse clicking to place even a simple set of orders. Since pharmacy technicians and ward clerks receive little, if any, medical training, COE had to be set up in this manner.

Based on the reports of CPOE's benefits compared to COE by academic teaching centers, an increasing number of hospitals tried implementing CPOE in the most cost-effective manner: They tried not to change the software, but rather to change the user.

Two ominous problems arose. First, doctors were forced to use a system designed for people with minimal training who had fewer time constraints. Secondly, private physicians who perform their own ordering were now being pressured to use CPOE systems that had been studied in academic teaching hospitals by attending physicians with a team of juniors--residents, interns and students-who could absorb the brunt of the time-consuming nature of these systems. The probability of private physicians using a CPOE system remained small.

Motivating Physicians to Use CPOE

At FGH, we faced the problem of encouraging 360 physicians--95 percent of whom worked in private practice--to use CPOE on a daily basis.

Our first step was to ignore the current COE system and focus on how to build an optimal system for physicians. The "it" in "If you build it, they will come," became our focus. We wanted to build a CPOE system that doctors would want to use, not be forced to use. For many physicians, handwriting orders remains not only the preferred, but also the most efficient, method. To accomplish our objective, we had to create a more attractive alternative to handwriting orders. Such a move would require substantial time, resources and support.

In 1997, FGH replaced its homegrown legacy system with a comprehensive, longitudinal computer-based patient record, now Misys CPR. In 2001, FGH decided to move from COE to CPOE using the CPR's integrated COE functionality. After we spent months "shadowing" physicians using the COE system and collecting opinions from numerous doctors, the results were clear: Physicians would not use COE because, to them, it was fivefold more time-consuming than handwriting orders. In short, COE by itself was not attractive enough, even though doctors understood the potential patient safety benefits.

We halted the full-scale implementation of COE and rebuilt the system into a true CPOE application. By inserting the physician or provider back into the CPOE, the focus of the implementation enlarges to include not just electronic order transmittal, but utility of the software by physicians and usability of the system to physicians.

Physician-driven Modifications

We had two primary directives: reduce the amount of time for ordering and increase functionality. By 2003, FGH's CPOE project team determined that the following software changes were necessary to reduce the amount of time required for electronic ordering:

Order sets. Order sets based on the latest evidence-based medicine were created. They allowed ordering by problems, as opposed to the simple alphabetical system. Also, they were arranged according to the major branches of medicine (internal medical, surgery, pediatrics, psychiatry), and further subdivided according to subspecialties (cardiology, neurology, etc.).

Ordering pages. Ordering pages were created to condense the information from multiple screens onto a single screen, and in the sequence they are normally ordered.

Duplicate sets. Order sets were duplicated to anticipate where physicians might look for them (e.g. community acquired pneumonia under Pulmonary and ID, or hypercalcemia under Renal and Endocrine/metabolic).