Expert Panel Discussion on The Road to CPOE
If you are an academic medical center with residents and employed physicians, you will have an easier effort than convincing independent physicians because CPOE will take more physician time--about five minutes per patient).
Regarding nonacademic medical centers, it’s crucial to get nursing staff involved early and engaged often. Nurse workflows are also dramatically changed.
Edward, I’m glad you brought up the importance of physician productivity. One of the main reasons for physician resistance to CPOE adoption is the perception that physician productivity will be hurt--at least during a transitional period.
You indicate that CPOE takes an extra five minutes per patient from the physician. The Fall 2008 edition of the Journal of Healthcare Information Management featured a time motion study that examined the productivity of 19 physicians at United Hospital, a 426-bed hospital in the Twin Cities--part of Allina Hospitals and Clinics. The study looked at the impact of EMR and CPOE implementation on physician efficiency. Physician rounding times were measured. They measured pre-rounding times (information gathering, information review, seeing the patient) and post-rounding time (writing notes, placing orders, communication with other providers). The study found a statistically significant reduction in time spent on rounding by physicians per patient. The largest reduction was in the pre-rounding activities and was attributed to the fact that the providers had to spend less time looking for charts or patient information from disparate systems. There was also evidence of a declining trend in average time for the post-rounding activities (which includes order entry), but that decline alone was not statistically significant.
This seems right to me--that CPOE in isolation may slow the physician down, especially during a transitional period. But when you look at the broader physician workflow including chart review and documentation, the physician will become more efficient with CPOE and EMR.
Again, as you point out, the details of system design including mouse clicks and all related workflow is relevant. This highlights the importance of analysis of the current state physician workflow, design of a new workflow, piloting to confirm the new workflow and system configuration, and good training that includes not only software functions but workflow.
I advise colleagues to clear everything else off their calendars to support the project. It’s also important to ensure they have the right collection of technical talent--and enough of them. Another key component is developing a really solid communication plan for end- users and make sure structure is in place for timely communications among all the different types of technical and clinical staff who are needed to complete a project of this scale.