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Point of Failure

June 1, 2007
by James Feldbaum, M.D. and Karen Fuller, R.N.
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Getting physicians on board with CPOE can be a battle, but is one well worth the fight

The case for implementing computer-based provider order entry (CPOE) is compelling. But despite being recognized and advocated as a tool to improve patient care and safety, clinician (primarily physician) resistance has become a prominent impediment to full and effective CPOE implementation.

James feldbaum, m.d.

James Feldbaum

The commonly cited IT and software hurdles rarely are the real point of failure. The same CPOE software can be accepted and successfully implemented in one institution, and then be maligned and resisted in another. Clearly, physician/clinician behavioral barriers are at the root of most stalled implementations.

Getting to 100

KLAS surveys have documented the vast number of hospitals undertaking CPOE. Despite these numbers, there has not been a corresponding increase in institutions achieving greater than 50 percent CPOE acceptance. 100 percent CPOE should be the goal.

First, it is important to define what qualifies as “100 percent CPOE.” It is, in its most simplistic form, 100 percent of physicians placing their own orders electronically 100 percent of the time. Clearly, this goal is not achievable.

Karen fuller, r.n.

Karen Fuller

There are some appropriate exceptions to CPOE, which must be spelled out in a healthcare system's policy. Common exceptions are emergency orders, phone orders — when the physician does not have access to a computer — verbal orders given during a procedure, medically approved protocol orders or all orders during system downtime. Policy will need to further define the requirements for use from outside the hospital if the hospital has implemented universal remote access for its staff. We define 100 percent CPOE as “all doctors placing all their orders under all prescribed conditions and in all appropriate settings as defined by CPOE policy.”

We wish to make the case for a mandate, the “M” word, in many institutions better known by the gentle euphemism “universal” order entry. With the appropriate preparation, such mandate can provide both the blueprint and the impetus for a successful rollout.

C-suite committment

CPOE by mandate requires first and foremost that it be a top priority with unwavering commitment by the highest level leadership. Physicians may threaten to take their patients to competing facilities, to sue the hospital, or in extreme cases make efforts to foment some sort of revolt. Some will test the administration's commitment to the bitter end, especially in cultures where physicians have always gotten their way. Ongoing education and counsel are necessary to help the entire C-suite (CEO, CNO, CMO, CIO, etc.) remain steadfast throughout the process.

Common behaviors of resistant physicians include, but are not limited to, abusing verbal orders by leaving the nursing unit to call in telephone orders; writing orders on scraps of paper slipped into charts (where they can easily be missed); smuggling in order sheets from non-activated units or simply coercing a favorite nurse to put in their orders for them. Nurses who take inappropriate verbal orders enable physician deviation from CPOE policy and can undermine implementation. A mandate can place nurses under increased pressure by non-compliant physicians. Nurses and unit staff should rehearse scripted responses to physician efforts to circumvent compliance. Unit staff must be supported by the administration during the difficult first stages of the mandate.

Change leadership

For the inexperienced, CPOE is not “time neutral,” and requiring busy physicians to alter their deeply engrained rounding workflow can be a painful proposition. With training, support and well-designed order sets, physicians can regain lost time and in many cases, create an electronic workflow that will be both effective and time saving. Mandated CPOE requires that the system being implemented be fast, user-friendly, reliable and stable before the go-live. Latency between clicks, dropped Wi-Fi signal, poor access to convenient devices, and unscheduled down-time are CPOE deal-killers. The IT and clinical implementation staff need to work together and be on the same timetable before the day of go-live. If the software being implemented is deemed not well designed after focus group testing to support clinician workflow, do not even think about mandated CPOE.

An aligned administrative and staff vision must be coupled with an achievable and reasonable scope based on an institution's culture of decision making and willingness to embrace change. Physician sponsorship, their participation in all elements of design and decision making, facilitated communication with clear feedback loops, and careful attention to clinical workflow processes must be established prior to mandating CPOE.

Since some resistance is inevitable, implementers must have in place policies, procedures and consequences to deal with non-compliance. It is a good idea to have the legal department review the CPOE policy before implementing. There should be clear delineation between CPOE non-compliance issues and those of disruptive behavior. Dealing with unprofessional behavior is not the responsibility of the CPOE implementation team and must be referred through appropriate staff channels.


Although we wish to make a case for a mandate, we are not advocating a “big bang” approach. Rarely will institutions have sufficient support resources to facilitate such a house-wide CPOE activation. Rather, we favor a sequential unit-by-unit or department-by-department mandated roll-out (the order based on readiness evaluations).


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