Getting the physician on board with CPOE

The hardest part of installing a CPOE (computerized physician order entry) system may be getting the physicians to use it. A hospital can have chosen good software and hardware and may have all the technology in place, but no system will work until physicians start to use it.

Getting physicians on board with any electronic record system with CPOE has been difficult in many places, said Bruce Berg, M.D., dean of the Florida State University College of Medicine at Sarasota. Berg was previously chief medical information officer at Sarasota Memorial Hospital. There, he oversaw one of the earliest hospital installations of a CPOE system. Hospitals must move to automated record systems, he said, because it is safer for patients, faster, and more secure.

It takes a combination of rewards and punishments to get some physicians to use any type of automated data entry system, Berg noted. At Sarasota, this involved continual efforts by the implementation team. Other businesses have long since moved to computerized or automated ordering systems, he observed. "Here we are in 2005, and we're still talking about physician adoption of an electronic medical record," he noted at the recent Healthcare Information and Management Systems Society (HIMSS) meeting in Dallas.

When the new CPOE system came to Sarasota Memorial Hospital, about half the physicians there really liked it and used it all the time and about half swore they'd never touch it no matter what, said David Jungst, Pharm.D., manager of patient care services for the hospital's pharmacy.

The best way to get past resistance from individual physicians is to get strong support from the hospital administration, Berg advised. One way to do this is to couch the argument in terms of patient safety and security, which has been a topic of public debate for several years. Then, Sarasota divided physicians into two groups: those who would immediately adopt the new technology and those who would probably adopt it only if forced. Most of the doctors in this last group were nearing retirement, but not all of them were old, Berg noted.

The implementation team then held lectures and tutorials to bring all physicians up to speed on computers in general and the new system specifically. Physicians in each specialty who were comfortable with CPOE were recruited to talk to their colleagues, discuss their concerns, and get them more comfortable with the technology. A system of awards and rewards was set up to recognize physicians who used the system correctly.

But still some physicians were resistant and asked to opt out of CPOE. Some physicians snuck order sheets onto the floors, and others made notes on scraps of paper. Some physicians threw tantrums. Physicians who did not start using CPOE were faced with levels of correction that increased in severity, Berg said. "You can't just have a physician who refuses and not have a subsequent action," he explained.

Physicians who did not use the system after a certain date were referred to the hospital's Patient Safety Officer (who was Berg at the time) and, in worst cases, were referred to the hospital's VP of medical affairs. There were some exceptions allowed for CPOE. Orders could be phoned in from outside the hospital or from another floor, Berg said. Verbal orders could be made during emergencies, he added. "Those are legitimate exceptions."

The CPOE system in place at Sarasota is Eclipsys' Sunrise Medical Manager. Physicians can access the system from wherever they are. Although remote access to the system was not originally available, it became a powerful selling point when it was. The system is pretty reliable and has back-up procedures built into it, but it has gone down, said Amy Giovino, Pharm.D., formulary coordinator at Sarasota Memorial Hospital. "That is one of our least favorite things."

Both Jungst and Giovino praised Berg's work on bringing the entire hospital on board with the new system. "Every place that wants to do this needs a Bruce Berg. You need a physician champion to spearhead the program," Jungst said.

Valerie DeBenedette is a writer based in New York.