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Fear Factor: CPOE Implementation

February 29, 2012
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Some change management tips to weather stressful implementations

A nursing symposium session at HIMSS12 made me think back about my magazine’s recent website redesign and transition to a new content management system (the ‘other’ CMS). The HIMSS12 session, "Transitioning From a 'Best of Breed' to a Single Vendor EHR With CPOE," brought up some great points about change management within organizations and how best to guide people through what can be at times an emotional EHR transition.

Last week, Willa Fields, R.N., professor at the San Diego State School of Nursing and program manager at Sharp Grossmont Hospital, spoke about her organization’s transition from older disparate EHRs to a new comprehensive one. Sharp Grossmont Hospital, a 536-bed Magnet designated acute care hospital in San Diego, had been computerized in every department for more than two decades and had best of breed systems for many departments. In October 2010 the hospital underwent a Big Bang implementation for the existing radiology, order entry, pharmacy, laboratory, ED, documentation, and health information management applications, which were converted to a one vendor solution.

Know the Organization’s Culture
Fields noted in her presentation that CPOE was strongly encouraged, but not mandatory. “It’s really important to understand the culture of the organization in which you’re going live,” she said. “The medical executive committee would not make CPOE mandatory, nor did they make education mandatory.” Users didn’t have to have education to get a user name and password, but were strongly encouraged to attend training sessions.

In the end a total of 3,101 staff were trained, which included 1,625 nurses. After surveying nurses after the go-live, Fields found out that many emotions, especially fear—fear of missing an order or not knowing where to put things—drove nurses to seek out training. One surveyed nurse, said “I really am afraid that I am going to make a mistake, and that I’ve been a nurse for 43 years, and I have had a stellar career, I’ve never been in trouble for anything, and I fear being in trouble with this system.”

I can totally understand this ‘fear factor,’ as a lot of what drove my questions to learn how to use our new website was definitely fear-driven. Granted, if I made a mistake it didn’t impact someone’s life; however a mistake could affect HCI’s reputation if my article didn’t appear correctly on the website, and it could impact whether or not it reaches our busy readers. So to assuage my fears, I asked many questions about how to get content on the website; how to format it correctly and input relevant images; and what buttons to push to allow content to appear in the correct locations.

Clinicians Teaching Clinicians
Another lesson learned from Sharp Grossmont Hospital was the impact of having the right teachers in place to guide the implementation. The trainers for Sharp Grossmont’s implementation were actually not clinicians. “The trainers were not clinical, and the person teaching knew nothing about nursing,” said Fields. “So, I strongly encourage you to make sure you have clinical people, who understand nursing workflow, nursing process, and nursing care, doing the classes.”

Thinking back to the HCI’s CMS transition, it was really helpful during that time that our Editorial Director Charlene Marietti became a super-user on the new CMS and was there to answer all of our implementation related questions as it related to editorial concerns, instead of us just lobbing questions right at the developers, who had to manage sales, marketing, as well as editorial needs.

Some other recommendations Fields pointed out during her presentation:

  • train, train, train
  • practice, practice, practice
  • have nurses do the training and go-live support
  • involve staff nurses in the design of the system
  • increase staffing during go-live
  • possibly take a phased approach to implantation

And finally, Field’s advice to “be prepared for an EHR change to be emotional” and “savor the positive,” is certainly good advice. There were a few moments during our website transition where a few overlooked steps in categorizing content came back to haunt us, but we accomplished  everything by pitching in as a team to get it done. After a while, I realized that “this too shall pass,” which certainly helped to mitigate the negative feelings at the time.




Another fear, is what happens when the hospital becomes accustom to CPOE and then has to deal with a planned or unplanned downtime of the CPOE system. Will they remember how to hand write orders? What about complex order sets? Yikes! Every Hospital and entity with CPOE should have a downtime system and downtime plan in place. And downtime solutions from what I have seen are not equal. A superior solution should withstand a system and/or network downtime and be near real time with data, making it ready to use immediately (no data synchronization time required).

Order Sets can be printed and included in CPOE downtime kit to be used in downtimes. even if it doesn't exist we can live without the order sets. The more crucial issue here is the order list if the hospital policy does not obligate keeping a printed order list. and if it obligates it, how frequent it should be reprinted.