The use of computer physician order entry (CPOE) systems in the hospital setting is gaining serious momentum. According to a report published in 2008 by Orem, Utah-based KLAS, nearly 10 percent of hospitals are currently doing some level of CPOE, compared with just 3.5 percent five years earlier. Among larger hospitals, the numbers are even higher, with 17.5 percent on CPOE and many more organizations planning to implement the technology.
The trend, however, isn't only impacting large health systems. As more states begin to pass mandates requiring hospitals to adopt CPOE by a certain date (Massachusetts has set a deadline of 2012), industry experts predict that a growing number of community hospitals will look to the technology to reduce medication errors and take advantage of incentives, as well as to comply with legislation.
“The academic places have been doing it because they can and because they also see the benefits of it,” says Gerald Greeley, CIO of 229-bed Winchester Hospital (Winchester, Mass.). “But I think the community hospitals now, through payer incentives, are saying, ‘Hey, this is the right thing for us to be doing as well.’”
With the implementation of CPOE systems, however, come many factors, including added costs, the time required to train staff, and the need to assess an organization's wireless capabilities. CIOs like Greeley have found that infrastructure is an important element of a roll-out — not for CPOE itself, but to support all of the devices that clinicians utilize to document order entry.
In its research, KLAS found that CPOE is no longer limited to fixed desktops and hardwired sites; in fact, 94 percent of hospitals reported using either a combination of hardwired/wireless CPOE (67 percent) or wireless-only CPOE (27 percent). Whereas desktops used to be the most popular device, now computers on wheels, laptops, tablets and PDAs comprise 67 percent of the devices in use, states the report.
With so many more devices being deployed, it's becoming pivotal that facilities have a solid network in place, according to Jake Kretzing, senior partner at Greencastle Consulting (Malvern, Pa.). “The wireless component is not what CPOE in my experience has hinged on, but it does ride on that network itself,” he says.
At Winchester, which is currently in the midst of a roll-out of Westwood, Mass.-based Meditech's CPOE system, ensuring that a sufficient network is in place to accommodate devices and applications has played a significant part in the implementation, Greeley says.
“Infrastructure is hugely important,” he says. “We found that making more devices available to the physicians is a huge component of CPOE.”
Although at this stage, many physicians at Winchester prefer to document at the desktop — a situation that isn't rare in smaller, community hospitals — it is a trend that Greeley expects to change as tablets become more functional.
And when the tide does change, Winchester will be ready. “We expect to have quite a wide spectrum once physicians have seen the devices and what they can do,” he says. “Putting as many devices as possible in there is a challenge, but I think it's one that everyone needs to recognize.”
At Atlantic Health, a three-hospital, 1,585-bed system based in Morristown, N.J., determining what types of devices clinicians would be using played a key role in the planning process for CPOE.
“We planned the infrastructure at the same time that we were planning the entire program roll-out,” says Kretzing, who has served as a consultant in the implementation of the Horizon Expert Orders system from Atlanta-based McKesson. The system is currently live at Goryeb Children's Hospital (Morristown, N.J.) and in the pediatric unit at Overlook Hospital (Summit, N.J.). “We did a thorough assessment to understand where they are as an organization with regard to implementing CPOE, and part of that was finding out from each of the stakeholder groups what they find most concerning,” as well as what preferences clinicians had in terms of devices and applications.
For Linda Reed, R.N., vice president of information systems and CIO at Atlantic Health, making sure that the end users were involved and invested in every step of the process was a big priority. In addition to assigning a clinician excellence committee that had a significant stake in decision-making, Reed brought in Greencastle to perform a rigorous evaluation identifying clinicians' preferences and priorities in terms of mobility, remote capabilities and patient interactions. After reviewing the results, Atlantic Health opted to provide physicians with wall-mounted screens and CPUs in the hallways as well as medication carts with computers mounted on them.
“We worked with clinicians to get them involved, because change is so critical on the clinical side,” says Kretzing. “I told folks that you can control what it is that's delivered to you, but if you don't go out and vote, you can't complain about who gets elected.”
The bigger picture
Another reason for CIOs to consider infrastructure in CPOE roll-outs is that often, the system is implemented as part of a larger strategy. For Winchester, CPOE is just one of the steps in what Greeley calls “the total migration to an inpatient EMR,” along with nursing documentation and medication administration.
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