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CPOE and the Doc Dilemma

February 24, 2010
by Frank Poggio
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One CEO explores the challenge of how to get more independent physicians to utilize CPOE

Recent industry surveys find that a very small percentage of physicians are using CPOE at the bedside. ARRA's proposed meaningful use criteria states at least 10 percent of orders must be input via CPOE or the hospital will get dinged, which brings up the decade old question as to why MD Luddites refuse to use this great technology.

How did we get here, and what can be done to increase physician usage? To understand the core issues, we need to view things from the eyes of a typical community doctor.

Before CPOE:

Mr(s). Doc stands at Ms. Patient's bedside flips through the paper chart, scribbles a couple of orders (while conversing with the patient) then pats the patient on the shoulder and says, “You're doing fine; this new medication should help; see you tomorrow.” It all takes about one minute.

The unit clerk or nurse then transcribes the order(s) into a computer system (hopefully). Mr. Doc sees about 10 or 15 more patients at the hospital then gets in his car and drives to the office.

While in his car he gets a call from the nurse reviewing his order. The nurse says that Ms. Patient had trouble swallowing the night before, and asks if they can change the med route from oral to injection. He says it's fine.

In his office an hour later after seeing four patients and while waiting for the next, he quickly checks his e-mail. He sees one from the hospital pharmacist saying that the med ordered for Ms. Patient is no longer available as an injectable, and asks if they can substitute another brand. The Pharmacist lists three alternatives with revised doses. The Doc responds “OK, go with number two.”

At this point the order is now ‘complete.’ How long did it take? An industrial engineer would say the combined time for the physician, nurse, pharmacist, and unit clerk, with phone tag and conversation probably took about 15 minutes. But if you ask the doc he would say ‘less than a minute,’ basically the time it took to scribble the order in the chart. In his mind the time in his car does not count (it's downtime anyway) and responding to e-mails is part of his usual office routine.

It gets even more onerous if the patient has complications, there are medication/diagnostic conflicts, or multiple overlapping orders are involved. In each situation they get chased down, sorted out and preliminarily resolved by hospital staff, who then communicate with the physician to reach final order approval. But in the end it's still only a minute for the physician.

After CPOE:

At Ms. Patient's bedside he picks up his notebook, or iPod, or BlackBerry, or similar, and enters the same med order. Maybe not as fast as scribbling on paper, but not too bad.

Assuming response times are instantaneous (could be a big assumption), the system comes back and displays assessment information about the swallowing problem. The system suggests he change the med route (this is a really advanced system!). He isn't sure about this, so he scrolls back into the EMR and sees where the late shift nurse made a note about swallowing difficulty, so he cancels/changes the original order and requests an injection.

Red flags go up again when he gets a message from the Rx system that this med is no longer available (or recommended) as an injectable. The system then shows him a list of three alternatives (after a slight delay, of course). He picks one, cancels then re-enters the new order, changes the dosage, then signs off, and now he's done, except for patting the patient on the shoulder and saying, “see you tomorrow.” Total time: five or six minutes.

As noted earlier, if the situation involves more complex cases or multiple orders even more of his time gets eaten up.

How much time did it take nursing and pharmacy to complete this order request? Zero, or near zero.

If he sees 15 patients and each one takes an additional four minutes more, to him that's 60 minutes extra effort. But the hospital “saves” the hour. We all can agree it is better patient care, but who's paying for it? One hour of his time is equal to four or five patients in his office, maybe $300 to $500 in billings. If this happens two or three times a week, it quickly becomes real money and nobody is paying him a salary to hang around.

So, from where Mr. Doc sits, CPOE is great for the hospital and hopefully delivers better patient care, but he's carrying the lion's share of the time cost, and to an independent practitioner - time is money.

Where CPOE works and why

If you look under the covers at why CPOE has worked in the Mayo, Kaisers and Cleveland Clinic, it's because the attending physicians are part ‘owners’ of the hospital. They get paid a salary and bonus based on the performance of their practice, and the performance of the hospital and all owned facilities. They readily accept that less support staff will save the hospital money. But they also understand how it will result in a monetary benefit for them and improve patient care, which can lead to even more patient referrals and more revenues.

In military facilities it's even simpler. The Colonel says to get it done and the MD captain says “Yes, sir!” In regard to the VA system, a recent Wall Street Journal report dated Oct. 27, 3009 entitled “The Digital Pioneer” by Jane Zhang, stated:

To be sure, the VA's health care system isn't a perfect roadmap for the industry - since the agency is in a unique position. The VA … employs the doctors … which makes it easier to mandate performance standards. The VA has an incentive to keep patients healthier because it takes care of veterans for life and sicker patients eat up the VA's budget faster.


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Dr. Garrison,
Congratualions on your achievement. As you state it was no small task.
As I note in the article there are many quallity reasons to do CPOE and legibilty is surely one of them.
But even still, a person could hand print an order faster than most Ipod or similar tools particularly if it is a complex order.

If we ever could change the warped financial incentives there could be alot more like Salem, Or. and alot faster then 3yr implementations.
Keep up the good work.

Interesting article
I am the CMIO at Salem Hospital in Salem Oregon, we have an ALL volunteer medical staff (some hospitalists, NO residents)
We started on our EMR journey in 2003, implemented Epic 2006 and just got over the CPOM hump last month.

I had a steering committee of 11 physicians and took 6 months of weekly meeting to come up with our messaging and came to the conclusion that the reason we needed to transform the order entry process is for our patients due to legibility problems.

This has worked, I agree with your concern of the financial model for healthcare but disagree that we as physicians need to change our habit of making our illegible handwriting somebody elses problem.