Case Examples of CPOE Implementation Problems: Case Examples of CPOE Implementation Problems David W. Bates, Medical Director of Clinical and Quality Analysis, Partners Healthcare Chief, Division of General Medicine, Brigham and Women’s Hospital NHS Masterclass, London, 2007


Introduction: Introduction Can have problems with implementation of any clinical system CPOE in the inpatient setting has especially large impact on care and is particularly challenging Still, many of the lessons learned are generic


University of Virginia: University of Virginia Hospital attempted to introduce mandatory CPOE in 1988 Introduction went badly Although some technical issues, many were social Challenged basic institutional assumptions Forced people to modify established routines Time issues substantial Most physicians spent andlt;1 hour/day Some on busy services spent andgt;4 hours/day Massaro T, Academic Medicine, 1993


Key Problems at UVA: Key Problems at UVA Administrative and clinical leadership were insufficiently aware of how big a change this would be Were taken by surprise Insufficient forewarning to providers Initial response to severely stressed providers was that 'they had to live with it' Some users may need special help Application required too many screens


Cedars-Sinai CPOE Implementation: Cedars-Sinai CPOE Implementation One of the leading hospitals in U.S. Deep experience with IT, and talent, especially ICU Many providers—about 700 physicians on the private staff Care for many of the wealthiest patients in Beverly Hills area Co-developed own CPOE application with a small vendor Did billing also from application Had extensive preparation


Results of Implementation: Results of Implementation Implementation failed Application had to be turned off, even though it was working Physicians complained bitterly Said that too much unnecessary decision support was being displayed Was slow Didn’t fit workflow


Some Key Decisions : Some Key Decisions Drug-drug interactions were set up as 0-1, so that they had to be all on, or off Couldn’t change how many were displayed Physicians felt far too many were being shown Leadership told team they would fix problems as they went, while leaving system live


Post-Mortem Analysis: Post-Mortem Analysis If Cedars could fail, anyone can Tremendous resources, great team At the same time, several key decisions probably should have been made differently Environment very challenging with so many private staff physicians They will do again, and will be successful next time Highly desirable to avoid a failure like this


University of Pennsylvania: Unintended Consequences: University of Pennsylvania: Unintended Consequences Koppel et al evaluated on a commercial CPOE application at U Penn and asked users about their impressions about the system Found many situations in which 'a leading CPOE system facilitated medication error risks' Often took many screens to do things Needed views not available Others including Ash have also reported on this Koppel, JAMA, 2005


Issues with the Koppel Study: Issues with the Koppel Study Didn’t actually count errors or adverse events Said that other studies focused only on advantages—not accurate CPOE application studied was an old one Nonetheless, paper has stimulated valuable debate and identified key points Need change systems after implementation Software alone is insufficient Bates DW, J Biomed Inform 2005


University of Pittsburgh PediatricsStudy: University of Pittsburgh Pediatrics Study Studied children transported in for special care Mortality rate increased from 2.8% to 6.3% (OR=3.3) after introduction of a commercial CPOE application Study design was before-after Other changes were made at same time as CPOE was implemented Overall mortality wasn’t reported Han, Pediatrics 2005


Introduction of CPOE: Introduction of CPOE CPOE was introduced very rapidly—over 6 days! After implementation, order entry wasn’t allowed until the patient had actually entered hospital and been logged into system After CPOE implementation, all drugs including vasoactive agents were moved to central pharmacy Pharmacy couldn’t process medication orders until after they were activated Many order sets weren’t available initially Result was substantial delays in care delivery


Comments on Han Study: Comments on Han Study Study was very weak methodologically Another group reported decreased ADE rate but used approach so weak that should be completely discounted Nonetheless, increase in mortality rate was very large and of obvious concern Introducing substantial delays in this group could easily have caused Organization broke many of the rules for implementation Essential for other organizations to handle sociotechnical aspects better Phibbs et al, Pediatrics 2005


Ten Pitfalls: Preparation: Ten Pitfalls: Preparation Don’t recognize how big a change this truly is Expensive Huge process change! Failure to sufficiently engage both administrative and clinical leadership Failure to do necessary preparation with key stakeholders Often takes 2 years to have all the key groups meet


Ten Pitfalls: Implementation: Ten Pitfalls: Implementation Going too fast early on—e.g. turning on whole hospital at once Trying to fix previously existing policy problems at the time you implement Easy to get stuck Turning on too much decision support early on Much better to phase in


Ten Pitfalls: After Implementation: Ten Pitfalls: After Implementation Failure to provide users an easy mechanism for reporting on-going problems Failure to make sufficient changes to application Failure to devote sufficient resources to making changes to the application Won’t get value Insufficient support for the underlying system Keeping network up to speed Having enough terminals


Conclusions: Conclusions Leadership is pivotal at all stages Have to educate, engage both the clinical and management leadership Many of the problems observed are generic, though CPOE is an especially large change Will discuss keys to success in next discussion