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Considerations for a Successful CPOE Implementation
Funded by a research grant from
the National Library of
Medicine, the 2001 Menucha Consensus Conference
succeeded in its goals of identifying and agreeing on a list of considerations
for successful implementation, as well as outlining a set of issues that fostered debate
within the group and deserve further exploration. A list of ten high level considerations
(which includes 36 sub-considerations) was generated and is presented here for
the benefit of those thinking about implementing CPOE.
For a .PDF
document of this material, click here. Comments, questions, requests for print copies of this document
and other feedback may be sent to Joan Ash, Ph.D.
or by mail to the address at the left.
The 2001 Menucha Conference Considerations:
- Motivation for Implementing POE
- Foundations Needed Prior to Implementing POE
- Costs
- Integration/Workflow/Health Care Processes
- Value to Users/Decision Support Systems
- Vision/Leadership/People
- Technical Considerations
- Management of Program/Strategies/Processes from Concept to Implementation
- Training/Support/Help at the Elbow
- Learning/Evaluation/Improvement
Consideration #1:
Motivation for Implementing POE
Motivation: consider what is motivating you and others in your organization to think about implementing POE.
1. Environment:
A. Regulations: Are you predicting that POE will be required
for your organization at some time in the future? For example, in the state of California, hospitals and surgical clinics
must have a plan for adopting technology to reduce medical errors by January 1, 2002 and have implemented POE by January 1, 2005.
B. Labor shortages: Will you have enough nursing and ancillary support personnel to staff clinical
services? POE can save clinician time through streamlined processes.
C. Other pressure: Do you sense other environmental pressure? The Institute of Medicine report To
Err is Human, insurance company demand, the Leapfrog
Group representing healthcare purchasers, and consumer demand all represent
other pressures.
2. Workflow issues:
A. Administrative needs: Are administrators pressing for POE
implementation? Administrative needs may include response to the above environmental
pressures plus billing, quality assurance, and accreditation needs.
B. Clinical needs: Are clinicians pressing for POE implementation? Clinician needs may include the desire to apply information technology
to improve patient care.
C. Efficiency needs: Is there pressure to improve efficiency? These needs may include lowering costs and/or increasing revenue.
End Consideration #1
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Consideration #2:
Foundations Needed Prior to Implementing POE
There are several necessary but not sufficient conditions that must be in place before one should consider implementing
POE. These are:
1. Vision: Is there an overall vision for the organization that would allow staff to embrace the concept of POE?
2. Leadership: Is there top-level leadership commitment that would
provide unwavering support for POE? Institutions per se cannot really commit; ultimately, it is people who commit.
3. Resources: Does the organization have adequate resources?
A. Infrastructure: Is the technical network infrastructure appropriate?
B. People: Is the staff available and ready?
4. Trust: Does the clinical staff trust administrative staff?
5. Learning organization: Is there a mental model throughout the organization
that values feedback, change, quality, and continuous learning?
6. Sense of urgency: Is there a compelling sense of urgency about
implementing POE?
7. Vendor Readiness:
A. Quality: Are you satisfied with the quality of the product? Consider the quality and maturity
of the product and service offered by the vendor. Are sites similar to yours using the product as you plan to use it?
B. Stability: Have you considered the long term stability of the vendor in making your selection?
C. Relationship: Can you put time and effort into forging a productive two-way relationship
with the vendor? The vendor is your partner and helpmate in this endeavor.
D. Innovation: Is this vendor likely to have more useful products over time than other vendors? Consider
the speed with which the vendor is improving its product.
E. Flexibility: How flexible is the vendor? Is the vendor able to integrate its systems with your existing suite
of applications?
F. Reliability: How reliable is the vendor in meeting deadlines and delivering high-quality code?
8. Maturity: Can the organization be considered mature and stable?
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Consideration #3:
Costs
1. Consider several economic aspects concerning the decision to
implement POE:
A. Timing: Can you take a long term view? Financial benefits may not be realized for
a long time and expenses short term may be significant. In the long term, the purpose of POE is to help patients.
B. Total cost of ownership: Can you afford additional costs beyond
those of hardware and software?
C. Productivity: Can you afford a temporary loss of productivity? Consider that there will be a loss of productivity during training
so that staff can take time to become comfortable with the new system; patient loads may need to be reduced or staffing increased.
2. Dollars and cents considerations:
A. Plan: Do you have a good financial plan? Consider that by having a good financial plan, you will be ready to
evaluate and address unexpected situations. The plan might take a broader view and look at other projects that may compete for money, time, and other
resources.
B. Dedicated funds: Are there funds put aside for POE? Consider the level of adequate financial backing needed and assure
that it remains dedicated to the project at hand.
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Consideration #4:
Integration/Workflow/Health Care Processes
1. Time is of paramount importance to clinicians and there are several
facets of it to be carefully considered:
A. Response time: Is it good enough? Consider how fast the system’s response time should be for it to be
tolerable to clinicians.
B. Ordering time: Is it time neutral? Weigh the tradeoffs so that the time spent entering an order is worth
it or is at least time-neutral for the clinician. These tradeoffs might be easier access to information, ordering from multiple locations, and fewer
calls about legibility.
C. Communication time: Will it be increased or decreased? Consider whether more (or less) total time will be spent gathering
data and communicating using computerized POE rather than today’s method.
2. Workflow issues also need careful consideration:
A. Process: Has the impact of POE on the work process been considered? POE needs to be seen as part of one’s job, it must be integrated into
the individual’s workflow and that of the order communication process necessary for the execution of orders, and used for all orders.
B. Work will change: Is it understood that work will change as a result of POE? POE may cause a redistribution of work and changes in the communication
and decision-making process, so people’s work will change. Users need to visualize this change.
C. Strategy: Is there an organization-wide change strategy? These workflow changes can be seen as a part of larger strategy of
process change, an institutional strategy.
3. Integration must be planned carefully as well:
A. Scope: Will all orders be done using POE? Consider the scope of POE to include the whole range of orders.
B. Retrieval: Is information retrieval easy? Retrieval of other information such as medical records and medical
literature needs to be integrated seamlessly into the workflow.
C. Embedding POE: How well does POE fit with other systems? POE needs to be embedded into other systems like the electronic medical
record.
4. Readiness for integrating POE into the clinical workflow must
be considered:
A. Readiness: Are the users ready for POE? Consider the level of physician readiness for POE and the communication
and planning needed to increase readiness. At the same time, consider nursing readiness and staffing issues, plus the readiness of those who will receive
orders generated by POE.
5. Other related considerations include:
A. Paper: Have you decided how much paper can actually be eliminated
in the process? Consider the role of paper and where in the ordering process its use might be tolerated.
B. Other projects: What are other high priority projects? Consider other projects with which POE will compete, both technology
and other resource intensive projects.
C. Fostering use of POE: Is there a plan for promoting usage? Will the project be mandatory for all medical staff? Hybrid situations introduce frustrations and higher operating costs.
Consider mechanisms you might be able to put in place to facilitate and incent physicians to use the system.
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Consideration #5:
Value to Users/Decision Support Systems
1. Consider the following high-level decisions related to providing value for clinicians:
A. Benefit: How will clinicians benefit? The user must derive visible benefit in terms of improved workflow
and a perception of “doing a better job” for the patient. The benefit of patient safety is a more intellectual and somewhat removed concept.
B. Results: Have you implemented results review before POE? Experience with results reporting prepares users for POE.
C. Analyze needs: Have you done a needs analysis? Analyze user needs carefully; do not just give people what they ask for.
D. Communication: Have you considered the impact of POE on communication flow? Consider that POE decreases face-to-face communication.
E. Involvement: Is there a plan for involving physicians? Physician involvement is needed from the start and throughout the process.
2. Being able to provide decision support is an important benefit
of computerized POE. The following issues need consideration:
A. Content determination and maintenance: Is there a plan for
ongoing decision making about decision support content? Consider putting a process in place to determine the kind of decision
support that should be implemented and how to oversee and maintain it.
B. Efficiency: Will decision support improve efficiency? Consider how to implement decision support in such a way that physician
efficiency can be improved. Examples are the use of order sets and therapies based on diagnoses.
C. Alerts: Will you provide alerts? There is value to POE even without alerts and reminders. Decision
support can help the clinician to make faster and more confident decisions;
offering constrained choices is a form of decision support. Alerts can become
noise and aggravate users. Drug-drug interactions and drug allergies alerts
are useful and fairly easy to obtain.
D. Readiness: Are users ready for decision support linked to
POE? Consider decision support when assessing readiness for POE.
3. Other considerations concerning value to users:
A. Perception of efficiency: What is in it for the individual
physician? There needs to be a clinician perception that the software makes the
physician more efficient.
B. Technology: Is the proposed technology far enough advanced?
C. Benefit: Are benefits for clinicians easy to see and describe? Demonstrable benefits are needed for continued sustained use.
D. Education: Is there a plan for educating as well as training users? Educate users about the limitations of POE as well as its capabilities.
E. Patient care: Are there clear benefits for patient care? Emphasize that POE is for the good of the patient, not the bill.
F. Order sets: Is there a plan to implement order sets? Order sets provide local control as well as perceived benefit.
G. Intentions: Is the system designed so that the clinician easily understands the status of an order? Make sure the system does what the user intended.
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Consideration #6:
Vision/Leadership/People
Effective leadership is needed at several levels in the organization: at the executive level to get funding,
at the clinical level to get champions and buy-in, and at the project manager
level to make practical, effective, and useful decisions. Both the leadership
and software need to be flexible enough to be able to make modifications that
address identified concerns and problem. The leaders may or may not be the
same person. A shared vision needs to underscore work at all levels.
1. Consider the existence of a shared vision:
A. Shared vision: Is there a shared vision regarding the purpose
of POE to improve patient
care and are there stated goals for fulfilling the purpose? Do physicians
regularly play a role in strategic planning and IT decisions?
B. Communication: Are there physician leaders and champions
who can effectively communicate the shared vision? Is there ability at all
levels to communicate the vision and articulate tangible objectives?
C. Current state: Are there enough people who feel that the current
state is intolerable and that change is needed?
2. Considerations at the highest level in the organization:
A. Commitment: Is there real and visible financial and administrative
commitment by leadership at the chief executive officer level?
B. Persistence: Does the leadership exhibit persistence in striving
toward ultimate project goals?
C. Trust: Is there a sense of trust, credibility, and communication
between the administration, implementation team, and clinician users?
D. Strength: Is the leader someone who can make a decision on
his or her own if strategies for reaching consensus fail?
E. Function: Can the leader differentiate between POE functionalities
that clinicians want and those that they need for patient care?
F. Urgency: Does the leader sense a level of urgency, from either
external or internal motivators, about implementing POE such that it is a top priority?
G. Style: Does top leadership understand its own leadership style?
Leadership does not need to be charismatic: different leadership styles can be equally effective.
H. Value clinicians: Does leadership have faith in, value, and
depend on individual clinicians in the organization to make implementation succeed?
3. Considerations at the clinical leadership level:
A. Ability: How well do leadership skills fit different phases
of implementation? The clinical information technology leadership must have the ability
to use the management style appropriate for needs at different stages of the
project.
B. Pre-implementation: develop a vision, get funding, identify
individuals who will be key for the implementation, elicit involvement from
these key people, and exhibit other strategic and tactical planning skills.
C. Implementation: hire staff, deploy staff where and when most
needed, keep up the spirit of the staff doing the work, and use other communication,
publicity, and personnel management skills.
D. Post-implementation: establish the maintenance phase, create
an environment for ongoing system improvement, and provide management systems
for the long term.
E. Attributes: How well do leadership attributes fit the task? This leader must have clinical credibility (be respected by physician
peers), be persistent, consistent, accountable, and thick-skinned.
F. Realism: How realistic a view does the leader have? This leader must maintain an organizational anticipation and excitement
for the project without overselling it and creating unrealistic expectations.
G. Educator: Can the leader educate administrators? The leader must be good at educating executives and keeping them up
to speed.
H. Feedback: Will leaders listen to constructive feedback? The decision makers need to come to user feedback sessions. They
need to actively solicit negative as well as positive feedback and respond
to it in a timely, demonstrable fashion. Identified problems must be addressed
expeditiously.
I. Golden rule: Does leadership follow the golden rule? This person should remember the golden rule when dealing with people:
do unto others as the leader would have done to himself or herself.
J. Teamwork: Does the leader foster teamwork? The person should be able to form a great team, foster clinician involvement,
and be viewed as an advocate by clinicians.
4. Clinician or physician level champions and project leaders:
A. Clinical skills: Are they clinically trained? At least one leader at this level needs to be a clinical person, but
not necessarily a physician. This should be a paid person with visibility
who is at least partially excused from competing clinical duties.
B. Involvement: How heavily involved in implementation should
the clinical champions be? The clinician leader(s) may not be at the top of the project leadership
hierarchy, but a clinician must be involved at a visible and influential level.
C. Technical knowledge: What is the leader’s level of technical
knowledge? At least one of the clinical project leaders must have enough technical
knowledge to be able to challenge technical staff and vendors.
D. Sympathy: Is the leader sympathetic? Leaders need to be charismatic and clinically credible but not necessarily
technically trained. It is most important that these individuals be seen
as understanding of and sympathetic to the needs of clinicians.
E. Opinion leaders: Are there other opinion leaders identified? The effective clinician leader will enlist the assistance of both
senior credible champions and people perceived to be technical opinion leaders.
F. Role: Is there one identifiable top leader in this group? There must be only one clinical project leader; the roles and duties
of the clinician leader must be clearly delineated.
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Consideration #7:
Technical Considerations
1. Strategic level considerations:
A. Security: Is there a security plan? Data backup and disaster recovery are significant considerations for
mid-level managers and higher. While downtime may be necessary for data backup,
it should be minimal to cause the least disruption to clinical workflow.
B.Customization: How customizable is the system? Consideration needs to be given to the amount and level of customization
allowed by a particular POE system. It should be customizable by an analyst
to accommodate variations in workflow and procedures from department to department,
unit to unit, and shift to shift.
C. Replacement: What are special considerations for replacing
older systems? There are special considerations for replacing present POE systems:
even sophisticated users may have difficulty adjusting to a new system that
may not meet workflow needs as well as the older already customized system.
D. Data: Is there assurance of high level data quality? Accurate and reliable data must be maintained at the highest possible
level to ensure clinician acceptance.
E. Connections: Can the POE system interface with existing and
planned systems? Interfacing capability among systems from different vendors is important.
Interface engines or hubs and HL7
protocols need consideration.
F. Access: Has a risk analysis been done? Security of access and confidentiality issues must be seriously considered,
especially with impending enforcement of
HIPAA
regulations. A risk analysis should be done. Advantages and disadvantages
of a single sign-on need consideration.
G. Remote access: Is there a need for access from remote locations
such as home, nursing home, etc.? If this is needed, does the vendor support this capability?
H. Infrastructure: Is the network infrastructure stable?
2. User considerations:
A. Escapes: Are there escape routes for frustrated users? Consider establishing escape mechanisms for nonstandard, unusual,
and complex orders. An example is allowing a section in the interface for plain free-text typing.
B. Interface: How easy to use is the interface? There needs to be a consistent user interface which is intuitive,
easy to navigate, and efficient. This should include a logical flow from
one screen to the next.
C. Time: How time consuming is the system from the user point
of view? A new POE system will likely tax a clinician’s time or be time neutral
and, at the least, it needs to be secure, fast, and reliable.
D. Clerical tasks: Will users view it as clerical work? Consideration should be given to how the rationale for a new system
is communicated so that clinicians do not perceive it as clerical work.
3. Flexibility in task completion:
A. Style: Can the system fit different work styles? Because individual work styles differ, consider allowing multiple
ways to do the same thing. For example, keyboard equivalents for mouse actions
help accommodate differing work styles .
B. Customization: Can users customize some things themselves? In addition to allowing systems analysts to modify the system, there
should be options for users to customize screens as well.
C. Decision support: Has the addition of decision support been
carefully considered? Carefully consider decision support to avoid overloading the clinician
with messages. One approach to this is to allow tuning of a drug interaction alert to account for the severity of the interaction.
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Consideration #8:
Management of Project or Program/Strategies/Processes from Concept to Implementation
1. Highest level considerations:
A. Impact: Have you carefully considered the impact on workflow? Too narrow a concept of implementation can derail the project. Realize
that re-engineering the order entry process will impact other clinical and
ancillary processes.
B. Strategy: Is there an overall strategy for improving care? POE needs to be part of a larger strategy to improve patient care.
C. Management: Are people issues carefully considered? Sound project management during implementation and ongoing program
management post-implementation must be planned with people issues in mind.
D. Scope: Is there a defined scope to the project? An emphasis of sound project management is management of the scope
of the project.
E. Treatment of others: Do you adhere to the golden rule? Remember the golden rule: do unto others as you would have them do
unto you.
F. Detail: Are plans detailed enough but not overly so? Perfection is the enemy of the good; do not allow exaggerated attention
to details to jeopardize the overall implementation goal. Keep it simple;
strive for excellence, not perfection.
G. Goals: Are there clear and measurable goals?
H. Communication: Is there a plan for constant communication
with users and implementation staff?
I. Expectations: Are expectations reasonable and achievable and
do they also maintain excitement for the project?
J. Relationships: Have you anticipated significant changes in
clinical relationships and planned accordingly?
K. Ambition: Have you carefully considered how ambitious your
goals can realistically be? Without disciplined project management, outside influences may force
a project implementation pace that is too ambitious.
L. Consensus: Can you balance consensus with directive leadership? Too much emphasis on consensus will slow project implementation; too
directive an approach can decrease user involvement.
M. Downtime: Have the implications of downtime been considered
and procedures been established?
2. Mid-level considerations:
A. Consultant expertise: How will consultants be used? Weigh the need for internal expertise vs. consultants; avoid becoming
too dependent on outside consultants by developing internal expertise.
B. Critical mass: Will you be ready for the important moment? Recognize that a critical window of opportunity will arrive where
a critical mass of users is using the system. It is vital that the implementation
team capitalize on this important moment.
C. Long term view: Can leaders adopt a long term view? The administration and information technology team need to take a
long term view of POE implementation.
D. Early objectives: Have you identified early wins? Categorize implementation objectives as easy, hard, or hardest to
implement; start where early success is expected. Consider gaining an early
victory by making results reporting available early.
E. Vendor: How carefully have you chosen a vendor? Choose an experienced vendor with care. Realize that the implementation’s
success may depend on cooperation, if not synergy, with the vendor. Expect
and depend on a long term relationship with the people in the vendor organization.
F. Clinicians: Is there a plan for involving clinicians? Allow interested (and encourage uninterested) clinicians from all
specialties to participate in product selection and local customization efforts.
Turn ardent opponents into ardent supporters; convince the skeptics and curmudgeons.
G. Users: Have you considered all clinical users? Carefully consider that the P in POE can stand for professional, physician,
provider, or practitioner. Realize that the POE function will have impacts
on organizational workflow beyond order entry alone and that other functions
such as results reporting will also be impacted.
3. Lower level considerations:
A. Workarounds: Are workarounds available? Provide simple workarounds for occasional users such as a text entry
option, but provide some mechanism by which all users may improve their skills
so that dependency on the workaround does not develop.
B. People: Are variations in people’s ways of doing things being
considered? People engineering needs to be concurrent with software engineering:
realize that workflow redesign and attitude maintenance may be required with
POE implementation.
C. Metrics: How good are your metrics? To do good project management, you must have specific metrics; it
is vital to know what is working and what elements must be improved. Have
“before” as well as “after” metrics.
4. Roles:
A. Accountability: Who is accountable for what? Assign and expect personal accountability for all project tasks.
B. Clinician: Is there clinical involvement at the leadership level? There must be a clinician representation within the project leadership.
Recognize that providers play a pivotal role in the implementation’s ultimate success.
C. Champions: Have champions been identified? Clinician champions have to be identified early and supported and
relieved of some other duties.
D. Leader: Is there an identified clinical leader? There is need for a strong leader with a foot in both the clinical
and technical camps, possibly someone with medical informatics training.
5. Localization:
A. Modification: Can you modify the system on site? You need to be able to do some modification at the institutional level.
B. Customization: Can users customize some things themselves? For a fast win, allow more individual customization.
C. Balance: Have you considered the balance between customization
and standardization? Consider how local modifications affect vendor upgrade paths. Too
many local modifications may make it difficult to implement the vendor upgrade,
as the upgrade may not support the modifications. Even if it does support
the modifications, each modification will slow down the ability to upgrade.
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Consideration #9:
Training/Support/Help at the Elbow
Considerations for training and support include the concept of “help at the elbow.” This means ongoing, readily
available help.
1. Support:
A. Help: Is there a plan to provide help at the elbow? Provide help at the elbow: skilled support staff available all the
time during implementation and much of the time post-implementation; err
on the side of too much user support.
B. Training: Is there a training plan for support staff? Train as support staff high quality, patient, thick-skinned support
people who have good people and communication skills and can teach others to use the application.
C. Translators: Can support staff act as translators? Support staff should be able to translate between the clinical and
technical realms.
D. Online help: Are there provisions for online help? Also provide different mechanisms for help such as online help in
addition to on site help.
E. Help Desk: Does the Help Desk operate 24 x 7? Is it staffed
by experienced technical support personnel? Are the processes and tools mature?
2. Training methods:
A. Training: Will users train users? During implementation, consider using successful users to train the
next set of users.
B. Tools: Will multiple training methods be used? Provide multiple learning tools and methods, including computer based
training.
C. Plan: Is there an initial plan? Plan to provide sufficient initial training, erring on the side of
too much training.
D. Updates: Will there be updates? Consider providing ongoing updates that also go back and reiterate
prior information.
E. Monitoring: Is there provision for monitoring proficiency? Consider monitoring proficiency and having continuous retraining to
make sure that physicians are using systems effectively.
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Consideration #10:
Learning/Evaluation/Improvement
POE implementation is an ongoing effort that benefits from continuous improvement. It is important that mechanisms
for feedback and modification of the system be in place.
1. Higher level considerations:
A. Problems: How will problems be addressed? Consider carefully planning a process for problem identification and
problem resolution involving the users.
B. Feedback: What is the formal evaluation plan? As formal evaluation takes place, feed results of the evaluation back
to the users so that they can gauge responsiveness.
C. Testing: How will you test the system? Think about how you test whether it is good enough to go.
D. Continuous improvement: How will you continuously improve the system? Understand that you are never done: continuous improvement is needed.
E. Learning: How will your organization learn? Be a learning organization: learn from evaluations.
F. Revisiting: Is there a plan to revisit decisions? Revisit strategic decisions on a regular basis.
G. Continued Training: Is there provision for regular training sessions (e.g., brown bag lunches)?
2. Strategies:
A. Response: Is there a process for responding to problems? Provide a quick response to system flaws.
B. Escapes: Is there an escape mechanism? Provide an escape mechanisms such as free text entry: it can be a
great source of feedback, allowing you to see how to improve the system.
C. Test: How will the system be tested? Have moonlighting house staff test the system. Have adequate integrated
testing.
D. Pilot: How will pilots be conducted? Pilot software in small groups and improve it if necessary before
rollout.
E. Mentoring: Is there a mentoring system? Set in place a buddy or mentoring system so that clinicians can share
their expertise in developing order sets and templates and exchange tips.
End Consideration #10/Document
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