Workflow Issues

Unintended adverse consequences relating to workflow may be avoided by considering the following questions.

Project Management

Integration/Workflow Vision/Leadership/People

Foundations Technical Considerations Value to Users Learning/ Evaluation Motivation ... ...

Project Management Considerations: 26%

• Are expectations reasonable, achievable, clearly communicated, and do they also maintain excitement for the project?
• Are people issues carefully considered?
• Are plans detailed enough but not overly so?
• Are the important variations in people’s ways of doing things being considered? People engineering needs to be concurrent with software engineering.
• Are workarounds available?
• Have you carefully considered how ambitious your goals can realistically be? Is there a defined scope to the project? Sound project management will emphasize scope.
• Have you carefully considered the impact on workflow?
• Have you considered all clinical users?
• How carefully have you chosen a vendor?
• How good are your metrics (i.e. information about system function)?
• How wisely or optimally will consultants be used?
• Is there a plan for constant communication between users and management?
• Is there a plan for involving clinicians?
• Is there an overall strategy for improving care? Can leaders adopt a long term view?
• Is there clinical involvement at the leadership level? Have champions been identified? Is there an identified clinical leader?

Integration/Workflow/Healthcare Processes Considerations: 18%

• Are the users ready for POE?
• Has the impact of POE on the work process been considered?
• How well does POE fit with other systems? POE needs to be embedded into other systems like the electronic medical record.
• Is it understood that work will change as a result of POE?
• Is ordering time neutral?
• Is response time good enough? Consider how fast the system’s response time should be for it to be tolerable to clinicians.
• 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
• Is there an organization-wide change strategy?
• What are other high priority projects?
• Will time to communicate be increased or decreased?

Vision/Leadership/People Considerations: 16%

• Can the leader differentiate between POE functionalities that clinicians want and those that they need for patient care?
• Does leadership have faith in, value, and depend on individual clinicians in the organization to make implementation succeed?
• Does the leader sense a level of urgency, from either external or internal motivators, about implementing POE such that it is a top priority?
• Does top leadership understand its own leadership style? Leadership does not need to be charismatic: different leadership styles can be equally effective.
• How well do leadership skills fit different phases of implementation? Pre-implementation: has leadership developed a vision, gotten funding, identified individuals who will be key for the implementation, elicited involvement from these key people, etc.
• Is the leader someone who can make a decision on his or her own if strategies for reaching consensus fail?

Considerations for Proper Foundations: 11%

• Are you satisfied with the quality of the product?
• Can the organization be considered mature and stable?
• Is the staff available and ready?
• Is there a compelling sense of urgency about implementing POE?
• Is there an overall vision for the organization that would allow staff to embrace the concept of POE?
• 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.

Technical Considerations: 10%

• Are there escape routes for frustrated users?
• Can the POE system interface with existing and planned systems?
• Can the system fit different work styles?
• Can users customize some things themselves?
• Does the vendor support and institution permit this capability?
• Has the addition of decision support been carefully considered?
• How customizable is the system? Can you modify it on site? Have you considered the balance between customization and standardization?
• How easy to use is the interface?
• How time consuming is the system from the user point of view?

Considerations for Value to Users/Including Decision Support Systems: 8%

• Have you considered appropriate implementation, use, and levels of alerts?
• Have you done a needs analysis?
• Is the proposed technology far enough advanced?
• Is the system designed so that the clinician easily understands the status of an order?
• Is there a plan for involving physicians?
• Will decision support improve efficiency?

Considerations for Learning and Evalutation: 5%

• Have you considered how problems will be addressed? Is there a process for responding to problems? Provide a quick response to system flaws.
• How will you continuously improve the system? Understand that you are never done: continuous improvement is needed. s there a plan to revisit decisions? Revisit strategic decisions on a regular basis. How will pilots be conducted?
• How will your organization learn? Be a learning organization: learn from evaluations. Is there a mentoring system? Set in place a buddy or mentoring system so that clinicians can share their expertise.

Considerations on Motivation: 4%

• 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.
• 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.
• Is there pressure to improve efficiency? These needs may include lowering costs and/or increasing revenue.
• Will you have enough nursing and ancillary support personnel to staff clinical services? POE can save clinician time through streamlined processes.

Considerations for Training and Support: 1%

• Can support staff act as translators? Support staff should be able to translate between the clinical and technical realms.
• Is there provision for monitoring proficiency?
• Will multiple training methods/learning styles be used?

Cost Considerations: < 1%

• 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.

New Kinds of Errors

Introduction of new kinds of medical errors may be avoided by considering the following questions.

Project Management

Vision/Leadership/People Foundations

Learning/ Evaluation Value to Users Technical Integration/ Workflow Motivation

Project Management Considerations: 30%

• Are expectations reasonable, achievable, clearly communicated, and do they also maintain excitement for the project?
• Are plans detailed enough but not overly so?
• Have the implications of downtime been considered and procedures been established?
• Have you carefully considered how ambitious your goals can realistically be? Is there a defined scope to the project? Sound project management will emphasize scope.
• Have you considered all clinical users?
• How carefully have you chosen a vendor?
• How good are your metrics (i.e. information about system function)?
• How wisely or optimally will consultants be used?
• Is there a plan for constant communication between users and management?
• Is there a plan for involving clinicians?
• Is there an overall strategy for improving care? Can leaders adopt a long term view?
• Is there clinical involvement at the leadership level? Have champions been identified? Is there an identified clinical leader?

Vision/Leadership/People Considerations: 16%

• Can the leader differentiate between POE functionalities that clinicians want and those that they need for patient care?
• Does the leader sense a level of urgency, from either external or internal motivators, about implementing POE such that it is a top priority?
• Does top leadership understand its own leadership style? Leadership does not need to be charismatic: different leadership styles can be equally effective.
• How well do leadership skills fit different phases of implementation? Pre-implementation: has leadership developed a vision, gotten funding, identified individuals who will be key for the implementation, elicited involvement from these key people, etc.
• Is the leader someone who can make a decision on his or her own if strategies for reaching consensus fail?

Considerations for Proper Foundations: 14%

• Are you satisfied with the quality of the product?
• Can the organization be considered mature and stable?
• Is the staff available and ready?
• Is there a compelling sense of urgency about implementing POE?
• Is there an overall vision for the organization that would allow staff to embrace the concept of POE?
• 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.

Considerations for Learning and Evalutation: 11%

• Have you considered how problems will be addressed? Is there a process for responding to problems? Provide a quick response to system flaws.
• How will you test the system? How will the system be tested? Have moonlighting house staff test the system. Have adequate integrated testing.
• How will your organization learn? Be a learning organization: learn from evaluations. Is there a mentoring system? Set in place a buddy or mentoring system so that clinicians can share their expertise
• What is the formal evaluation plan? 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.

Considerations for Value to Users/Including Decision Support Systems: 10%

• Have you considered appropriate implementation, use, and levels of alerts?
• Have you implemented results review before POE?
• Is the proposed technology far enough advanced?
• Is the system designed so that the clinician easily understands the status of an order?
• Is there a plan for ongoing decision making about decision support content?
• Is there a plan to implement order sets?
• Will decision support improve efficiency?

Technical Considerations: 8%

• Can the POE system interface with existing and planned systems?
• Can the system fit different work styles?
• Has the addition of decision support been carefully considered?
• How easy to use is the interface?
• Is there assurance of high level data quality?

Integration/Workflow/Healthcare Processes Considerations: 7%

• How well does POE fit with other systems? POE needs to be embedded into other systems like the electronic medical record.
• Is information retrieval easy?
• 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.
• What are other high priority projects?
• Will all orders be done using POE?

Considerations on Motivation: 5%

• 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.
• Is there pressure to improve efficiency? These needs may include lowering costs and/or increasing revenue.

Communication Issues

Unintended adverse consequences related to communication may be avoided by considering the following questions.

Project Management

Vision/Leadership/People Foundations

Technical Integration/ Workflow Learning/ Evaluation Value to Users Motivation

Project Management Considerations: 35%

• Are expectations reasonable, achievable, clearly communicated, and do they also maintain excitement for the project?
• Are plans detailed enough but not overly so?
• Have you anticipated significant changes in clinical relationships and planned accordingly?
• Have you carefully considered how ambitious your goals can realistically be? Is there a defined scope to the project? Sound project management will emphasize scope.
• Have you considered all clinical users?
• How carefully have you chosen a vendor?
• How good are your metrics (i.e. information about system function)?
• How wisely or optimally will consultants be used?
• Is there a plan for constant communication between users and management?
• Is there a plan for involving clinicians?
• Is there an overall strategy for improving care? Can leaders adopt a long term view?
• Is there clinical involvement at the leadership level? Have champions been identified? Is there an identified clinical leader?

Vision/Leadership/People Considerations: 19%

• Can the leader differentiate between POE functionalities that clinicians want and those that they need for patient care?
• Does the leader sense a level of urgency, from either external or internal motivators, about implementing POE such that it is a top priority?
• Does top leadership understand its own leadership style? Leadership does not need to be charismatic: different leadership styles can be equally effective.
• How well do leadership skills fit different phases of implementation? Pre-implementation: has leadership developed a vision, gotten funding, identified individuals who will be key for the implementation, elicited involvement from these key people, etc.
• Is the leader someone who can make a decision on his or her own if strategies for reaching consensus fail?

Considerations for Proper Foundations: 16%

• Can the organization be considered mature and stable?
• Is the staff available and ready?
• Is there a compelling sense of urgency about implementing POE?
• Is there an overall vision for the organization that would allow staff to embrace the concept of POE?
• 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.

Technical Considerations: 8%

• Can the POE system interface with existing and planned systems?
• Can the system fit different work styles?
• Does the vendor support and institution permit this capability?
• Has the addition of decision support been carefully considered?
• Is there assurance of high level data quality?

Integration/Workflow/Healthcare Processes Considerations: 6%

• 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.
• What are other high priority projects?

Considerations for Learning and Evaluation: 6%

• Have you considered how problems will be addressed? Is there a process for responding to problems? Provide a quick response to system flaws.
• How will your organization learn? Be a learning organization: learn from evaluations. Is there a mentoring system? Set in place a buddy or mentoring system so that clinicians can share their expertise

Considerations on Motivation: 6%

• 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.
• Is there pressure to improve efficiency? These needs may include lowering costs and/or increasing revenue.

Considerations for Value to Users/Including Decision Support Systems: 4%

• Have you considered the impact of POE on communication flow?
• Is there a plan for involving physicians?

More Work/New Work

Unintended adverse consequences in the form of more work or new work may be avoided by considering the following questions.

Project Management Vision/Leadership/People

Foundations Integration/ Workflow

Value to Users Technical Motivation Learning/ Evaluation costs ...

Project Management Considerations: 24%

• Are expectations reasonable, achievable, clearly communicated, and do they also maintain excitement for the project?
• Are plans detailed enough but not overly so?
• Are workarounds available?
• Have you carefully considered how ambitious your goals can realistically be? Is there a defined scope to the project? Sound project management will emphasize scope.
• Have you considered all clinical users?
• How carefully have you chosen a vendor?
• How good are your metrics (i.e. information about system function)?
• How wisely or optimally will consultants be used?
• Is there a plan for constant communication between users and management?
• Is there a plan for involving clinicians?
• Is there an overall strategy for improving care? Can leaders adopt a long term view?
• Is there clinical involvement at the leadership level? Have champions been identified? Is there an identified clinical leader?

Vision/Leadership/People Considerations: 22%

• Can the leader differentiate between POE functionalities that clinicians want and those that they need for patient care?
• Does leadership have faith in, value, and depend on individual clinicians in the organization to make implementation succeed?
• Does the leader sense a level of urgency, from either external or internal motivators, about implementing POE such that it is a top priority?
• Does top leadership understand its own leadership style? Leadership does not need to be charismatic: different leadership styles can be equally effective.
• How well do leadership skills fit different phases of implementation? Pre-implementation: has leadership developed a vision, gotten funding, identified individuals who will be key for the implementation, elicited involvement from these key people, etc.
• Is the leader someone who can make a decision on his or her own if strategies for reaching consensus fail?

Considerations for Proper Foundations: 12%

• Are you satisfied with the quality of the product?
• Can the organization be considered mature and stable?
• How flexible is the vendor? Is the vendor able to integrate its systems with your existing suite of applications?
• Is the staff available and ready?
• Is there a compelling sense of urgency about implementing POE?
• Is there an overall vision for the organization that would allow staff to embrace the concept of POE?
• 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.
• Is this vendor likely to have more useful products over time than other vendors?

Integration/Workflow/Healthcare Processes Considerations: 12%

• Has the impact of POE on the work process been considered?
• Is information retrieval easy?
• Is it understood that work will change as a result 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.
• Is there an organization-wide change strategy?
• What are other high priority projects?
• Will all orders be done using POE?

Considerations for Value to Users/Inclusing Decision Support Systems: 10%

• Are users ready for decision support linked to POE?
• Have you implemented results review before POE?
• Is the proposed technology far enough advanced?
• Is there a plan for involving physicians?
• Is there a plan to implement order sets?
• Will decision support improve efficiency?

Technical Considerations: 7%

• Can the POE system interface with existing and planned systems?
• Can the system fit different work styles?
• Can users customize some things themselves?
• Has the addition of decision support been carefully considered?
• How customizable is the system? Can you modify it on site? Have you considered the balance between customization and standardization?
• How easy to use is the interface?
• How time consuming is the system from the user point of view?

Considerations on Motivation: 6%

• Are clinicians pressing for POE implementation? Clinician needs may include the desire to apply information technology to improve patient care.
• 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.
• Is there pressure to improve efficiency? These needs may include lowering costs and/or increasing revenue.

Considerations for Learning and Evaluation: 4%

• Have you considered how problems will be addressed? Is there a process for responding to problems? Provide a quick response to system flaws.
• How will you continuously improve the system? Understand that you are never done: continuous improvement is needed. s there a plan to revisit decisions? Revisit strategic decisions on a regular basis. How will pilots be conducted?
• How will your organization learn? Be a learning organization: learn from evaluations. Is there a mentoring system? Set in place a buddy or mentoring system so that clinicians can share their expertise.

Cost Considerations: 2%

• 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.

Considerations for Training and Support: 1%

• Is there a plan to provide help at the elbow?
• 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. "Train the trainers."
• Is there an initial plan? Plan to provide sufficient initial training, erring on the side of too much training.

Never-ending System Demands

Never-ending system demands may be avoided by considering the following questions.

Project Management

Vision/Leadership/ People Foundations

Technical Considerations Costs Training/Support Motivation Learning/ Evaluation Integration/ Workflow

Project Management Considerations: 27%

• Are expectations reasonable, achievable, clearly communicated, and do they also maintain excitement for the project?
• Are plans detailed enough but not overly so?
• Are there clear and measurable goals?
• Have you carefully considered how ambitious your goals can realistically be? Is there a defined scope to the project? Sound project management will emphasize scope.
• Have you considered all clinical users?
• How carefully have you chosen a vendor?
• How good are your metrics (i.e. information about system function)?
• How wisely or optimally will consultants be used?
• Is there a plan for constant communication between users and management?
• Is there a plan for involving clinicians?
• Is there an overall strategy for improving care? Can leaders adopt a long term view?
• Is there clinical involvement at the leadership level? Have champions been identified? Is there an identified clinical leader?
• Will you be ready for the important moment when a critical mass of users is using the system?

Vision/Leadership/People Considerations: 19%

• Can the leader differentiate between POE functionalities that clinicians want and those that they need for patient care?
• Does the leader sense a level of urgency, from either external or internal motivators, about implementing POE such that it is a top priority?
• Does the leadership exhibit persistence in striving toward ultimate project goals?
• Does top leadership understand its own leadership style? Leadership does not need to be charismatic: different leadership styles can be equally effective.
• How well do leadership skills fit different phases of implementation? Pre-implementation: has leadership developed a vision, gotten funding, identified individuals who will be key for the implementation, elicited involvement from these key people, etc.
• Is the leader someone who can make a decision on his or her own if strategies for reaching consensus fail?
• Is there real and visible financial and administrative commitment by leadership at the chief executive officer level?

Considerations for Proper Foundations: 12%

• Can the organization be considered mature and stable?
• Can you put time and effort into forging a productive two-way relationship with the vendor?
• How flexible is the vendor? Is the vendor able to integrate its systems with your existing suite of applications?
• Is the staff available and ready?
• Is there a compelling sense of urgency about implementing POE?
• Is there a mental model throughout the organization that values feedback, change, quality, and continuous learning?
• Is there an overall vision for the organization that would allow staff to embrace the concept of POE?
• 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.

Technical Considerations: 10%

• Can the POE system interface with existing and planned systems?
• Can users customize some things themselves?
• Has the addition of decision support been carefully considered?
• How customizable is the system? Can you modify it on site? Have you considered the balance between customization and standardization?
• How easy to use is the interface?
• Is there assurance of high level data quality?
• What are special considerations for replacing older systems?

Cost Considerations: 8%

• 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.
• Can you afford additional costs beyond those of hardware and software?
• 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.
• 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.

Considerations for Training and Support: 7%

• Are there provisions for online help?
• Can support staff act as translators? Support staff should be able to translate between the clinical and technical realms.
• Does the Help Desk operate 24 x 7?
• Is there a plan to provide help at the elbow?
• 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. "Train the trainers."
• Is there an initial plan? Plan to provide sufficient initial training, erring on the side of too much training.
• Is there provision for monitoring proficiency?
• Will multiple training methods/learning styles be used?
• Will there be updates?
• Will users train users?

Considerations on Motivation: 6%

• Are administrators pressing for POE implementation? Administrative needs may include response to the above environmental pressures plus billing, quality assurance, and accreditation needs.
• 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.
• 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.
• Is there pressure to improve efficiency? These needs may include lowering costs and/or increasing revenue.

Considerations for Learning and Evaluation: 6%

• Have you considered how problems will be addressed? Is there a process for responding to problems? Provide a quick response to system flaws.
• How will you continuously improve the system? Understand that you are never done: continuous improvement is needed. s there a plan to revisit decisions? Revisit strategic decisions on a regular basis. How will pilots be conducted?
• How will you test the system? How will the system be tested? Have moonlighting house staff test the system. Have adequate integrated testing.
• How will your organization learn? Be a learning organization: learn from evaluations. Is there a mentoring system? Set in place a buddy or mentoring system so that clinicians can share their expertise.
• Is there provision for regular training sessions (e.g., brown bag lunches)?

Integration/Workflow/Healthcare Processes Considerations: 4%

• 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.
• What are other high priority projects?

Power Issues

Unintended adverse consequences related to the organizational power structure may be avoided by considering the following questions.

Project Management

Vision/Leadership/ People

Foundations Technical Learning/ Evaluation Value to Users Motivation Integration/ Workflow

Project Management Considerations: 34%

• Are expectations reasonable, achievable, clearly communicated, and do they also maintain excitement for the project?
• Are people issues carefully considered?
• Are plans detailed enough but not overly so?
• Are there clear and measurable goals?
• Are workarounds available?
• Can you balance consensus with directive leadership?
• Have you anticipated significant changes in clinical relationships and planned accordingly?
• Have you carefully considered how ambitious your goals can realistically be? Is there a defined scope to the project? Sound project management will emphasize scope.
• Have you considered all clinical users?
• Have you identified early wins?
• How carefully have you chosen a vendor?
• How good are your metrics (i.e. information about system function)?
• How wisely or optimally will consultants be used?
• Is there a plan for constant communication between users and management?
• Is there a plan for involving clinicians?
• Is there an overall strategy for improving care? Can leaders adopt a long term view?
• Is there clinical involvement at the leadership level? Have champions been identified? Is there an identified clinical leader?

Vision/Leadership/People Considerations: 26%

• Are there enough people who feel that the current state is intolerable and that change is needed?
• 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?
• Can the leader differentiate between POE functionalities that clinicians want and those that they need for patient care?
• Does leadership have faith in, value, and depend on individual clinicians in the organization to make implementation succeed?
• Does the leader sense a level of urgency, from either external or internal motivators, about implementing POE such that it is a top priority?
• Does top leadership understand its own leadership style? Leadership does not need to be charismatic: different leadership styles can be equally effective.
• How well do leadership skills fit different phases of implementation? Pre-implementation: has leadership developed a vision, gotten funding, identified individuals who will be key for the implementation, elicited involvement from these key people, etc.
• Is the leader someone who can make a decision on his or her own if strategies for reaching consensus fail?
• Is there a sense of trust, credibility, and communication between the administration, implementation team, and clinician users?
• 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?

Considerations for Proper Foundations: 11%

• Can the organization be considered mature and stable?
• Does the clinical staff trust administrative staff?
• Is the staff available and ready?
• Is there a compelling sense of urgency about implementing POE?
• Is there an overall vision for the organization that would allow staff to embrace the concept of POE?
• 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.

Technical Considerations: 8%

• Can the POE system interface with existing and planned systems?
• Can users customize some things themselves?
• Has the addition of decision support been carefully considered?
• How customizable is the system? Can you modify it on site? Have you considered the balance between customization and standardization?
• Will users view it as clerical work?

Considerations for Learning and Evaluation: 6%

• Have you considered how problems will be addressed? Is there a process for responding to problems? Provide a quick response to system flaws.
• How will your organization learn? Be a learning organization: learn from evaluations. Is there a mentoring system? Set in place a buddy or mentoring system so that clinicians can share their expertise.
• What is the formal evaluation plan? 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.

Considerations for Value to Users/Including Decision Support Systems: 6%

• Are users ready for decision support linked to POE?
• Have you considered appropriate implementation, use, and levels of alerts?
• Is there a plan for involving physicians?
• Is there a plan for ongoing decision making about decision support content?
• Is there clear clinician perception of benefits for patient care?

Considerations on Motivation: 5%

• Are clinicians pressing for POE implementation? Clinician needs may include the desire to apply information technology to improve patient care.
• 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.
• Is there pressure to improve efficiency? These needs may include lowering costs and/or increasing revenue.

Integration/Workflow/Healthcare Processes Considerations: 4%

• 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.
• What are other high priority projects?

Overdependence on Technology

Overdependence on the CPOE system may be avoided by considering the following questions.

Project Management

Foundations Vision/Leadership/People

Technical Learning/ Evaluation Motivation Integration/ Workflow Training Value to Users

Project Management Considerations: 34%

• Are expectations reasonable, achievable, clearly communicated, and do they also maintain excitement for the project?
• Are plans detailed enough but not overly so?
• Have the implications of downtime been considered and procedures been established?
• Have you carefully considered how ambitious your goals can realistically be? Is there a defined scope to the project? Sound project management will emphasize scope.
• Have you considered all clinical users?
• How carefully have you chosen a vendor?
• How good are your metrics (i.e. information about system function)?
• How wisely or optimally will consultants be used?
• Is there a plan for constant communication between users and management?
• Is there a plan for involving clinicians?
• Is there an overall strategy for improving care? Can leaders adopt a long term view?
• Is there clinical involvement at the leadership level? Have champions been identified? Is there an identified clinical leader?

Considerations for Proper Foundations: 20%

• Can the organization be considered mature and stable?
• Have you considered the long term stability of the vendor?
• How reliable is the vendor in meeting deadlines and delivering high-quality code?
• Is the staff available and ready?
• Is there a compelling sense of urgency about implementing POE?
• Is there an overall vision for the organization that would allow staff to embrace the concept of POE?
• 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.

Vision/Leadership/People Considerations: 15%

• Can the leader differentiate between POE functionalities that clinicians want and those that they need for patient care?
• Does the leader sense a level of urgency, from either external or internal motivators, about implementing POE such that it is a top priority?
• Does top leadership understand its own leadership style? Leadership does not need to be charismatic: different leadership styles can be equally effective.
• How well do leadership skills fit different phases of implementation? Pre-implementation: has leadership developed a vision, gotten funding, identified individuals who will be key for the implementation, elicited involvement from these key people, etc.
• Is the leader someone who can make a decision on his or her own if strategies for reaching consensus fail?

Technical Considerations: 8%

• Can the POE system interface with existing and planned systems?
• Has the addition of decision support been carefully considered?
• Is the network infrastructure stable?
• What are special considerations for replacing older systems?

Considerations for Learning and Evaluation: 7%

• Have you considered how problems will be addressed? Is there a process for responding to problems? Provide a quick response to system flaws.
• How will your organization learn? Be a learning organization: learn from evaluations. Is there a mentoring system? Set in place a buddy or mentoring system so that clinicians can share their expertise.
• What is the formal evaluation plan? 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.

Considerations on Motivation: 6%

• 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.
• Is there pressure to improve efficiency? These needs may include lowering costs and/or increasing revenue.

Integration/Workflow/Heathcare Processes Considerations: 6%

• 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.
• What are other high priority projects?

Considerations for Value to Users/Including Decision Support Systems: 3%

• Do users have relaistic expectations? Plan for educating users.
• Have you done a needs analysis?
• Is the system designed so that the clinician easily understands the status of an order?

Considerations for Training and Support: 2%

• Can support staff act as translators? Support staff should be able to translate between the clinical and technical realms.
• Is there an initial plan? Plan to provide sufficient initial training, erring on the side of too much training.

Emotions

Unintended adverse emotional responses to CPOE implementation may be avoided by considering the following questions.

Project Management

Vision/Leadership/ People Integration/ Workflow

Foundations Learning/ Evaluation Motivation Technical Value to Users Training/ Support ...

Project Management Considerations: 30%

• Are expectations reasonable, achievable, clearly communicated, and do they also maintain excitement for the project?
• Are people issues carefully considered?
• Are plans detailed enough but not overly so?
• Are workarounds available?
• Can you balance consensus with directive leadership?
• Do you adhere to the golden rule?
• Have the implications of downtime been considered and procedures been established?
• Have you anticipated significant changes in clinical relationships and planned accordingly?
• Have you carefully considered how ambitious your goals can realistically be? Is there a defined scope to the project? Sound project management will emphasize scope.
• Have you considered all clinical users?
• Have you identified early wins?
• How carefully have you chosen a vendor?
• How good are your metrics (i.e. information about system function)?
• How wisely or optimally will consultants be used?
• Is there a plan for constant communication between users and management?
• Is there a plan for involving clinicians?
• Is there an overall strategy for improving care? Can leaders adopt a long term view?
• Is there clinical involvement at the leadership level? Have champions been identified? Is there an identified clinical leader?

Vision/Leadership/People Considerations: 16%

• Can the leader differentiate between POE functionalities that clinicians want and those that they need for patient care?
• Does leadership have faith in, value, and depend on individual clinicians in the organization to make implementation succeed?
• Does the leader sense a level of urgency, from either external or internal motivators, about implementing POE such that it is a top priority?
• Does top leadership understand its own leadership style? Leadership does not need to be charismatic: different leadership styles can be equally effective.
• How well do leadership skills fit different phases of implementation? Pre-implementation: has leadership developed a vision, gotten funding, identified individuals who will be key for the implementation, elicited involvement from these key people, etc.
• Is the leader someone who can make a decision on his or her own if strategies for reaching consensus fail?
• Is there a sense of trust, credibility, and communication between the administration, implementation team, and clinician users?

Integration/Workflow/Healthcare Processes Considerations: 13%

• Are the users ready for POE?
• Is ordering time neutral?
• Is response time good enough? Consider how fast the system’s response time should be for it to be tolerable to clinicians.
• 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.
• What are other high priority projects?
• Will time to communicate be increased or decreased?

Considerations for Proper Foundations: 11%

• Can the organization be considered mature and stable?
• Is the staff available and ready?
• Is there a compelling sense of urgency about implementing POE?
• Is there an overall vision for the organization that would allow staff to embrace the concept of POE?
• 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.

Considerations for Learning and Evaluation: 5%

• Have you considered how problems will be addressed? Is there a process for responding to problems? Provide a quick response to system flaws.
• How will your organization learn? Be a learning organization: learn from evaluations. Is there a mentoring system? Set in place a buddy or mentoring system so that clinicians can share their expertise.
• What is the formal evaluation plan? 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.

Considerations on Motivation: 5%

• 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.
• 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.
• Is there pressure to improve efficiency? These needs may include lowering costs and/or increasing revenue.
• Will you have enough nursing and ancillary support personnel to staff clinical services? POE can save clinician time through streamlined processes.

Technical Considerations: 5%

• Can the POE system interface with existing and planned systems?
• Has the addition of decision support been carefully considered?
• Is the network infrastructure stable?
• Is there a security plan? Has a risk analysis been done?
• Will users view it as clerical work?

Considerations for Value to Users/Including Decision Support Systems: 3%

• Are users ready for decision support linked to POE?
• Do users have relaistic expectations? Plan for educating users.
• Have you considered appropriate implementation, use, and levels of alerts?
• How will clinicians benefit?
• Is the system designed so that the clinician easily understands the status of an order?
• Is there a plan for involving physicians?
• Is there clear clinician perception of benefits for patient care?

Considerations for Training and Support: 2%

• Does the Help Desk operate 24 x 7?
• Is there a plan to provide help at the elbow?
• 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. "Train the trainers."

Cost Considerations: 1%

• 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.

Paper Persistence

Unintended adverse consequences related to the use of paper may be avoided by considering the following questions.

Project Management

Foundations Vision/Leadership/People

Integration/ Workflow Motivation Technical Learning/ Evaluation Value to Users

Project Management Considerations: 35%

• Are expectations reasonable, achievable, clearly communicated, and do they also maintain excitement for the project?
• Are plans detailed enough but not overly so?
• Have you carefully considered how ambitious your goals can realistically be? Is there a defined scope to the project? Sound project management will emphasize scope.
• Have you considered all clinical users?
• How carefully have you chosen a vendor?
• How good are your metrics (i.e. information about system function)?
• How wisely or optimally will consultants be used?
• Is there a plan for constant communication between users and management?
• Is there a plan for involving clinicians?
• Is there an overall strategy for improving care? Can leaders adopt a long term view?
• Is there clinical involvement at the leadership level? Have champions been identified? Is there an identified clinical leader?

Considerations for Proper Foundations: 16%

• Can the organization be considered mature and stable?
• Is the staff available and ready?
• Is there a compelling sense of urgency about implementing POE?
• Is there an overall vision for the organization that would allow staff to embrace the concept of POE?
• 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.

Vision/Leadership/People Considerations: 16%

• Can the leader differentiate between POE functionalities that clinicians want and those that they need for patient care?
• Does the leader sense a level of urgency, from either external or internal motivators, about implementing POE such that it is a top priority?
• Does top leadership understand its own leadership style? Leadership does not need to be charismatic: different leadership styles can be equally effective.
• How well do leadership skills fit different phases of implementation? Pre-implementation: has leadership developed a vision, gotten funding, identified individuals who will be key for the implementation, elicited involvement from these key people, etc.
• Is the leader someone who can make a decision on his or her own if strategies for reaching consensus fail?

Integration/Workflow/Healthcare Processes Considerations: 10%

• Have you decided how much paper can actually be eliminated in the process?
• 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.
• What are other high priority projects?

Considerations on Motivation: 6%

• 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.
• Is there pressure to improve efficiency? These needs may include lowering costs and/or increasing revenue.

Technical Considerations: 6%

• Can the POE system interface with existing and planned systems?
• Has the addition of decision support been carefully considered?
• What are special considerations for replacing older systems?

Considerations for Learning and Evaluation: 6%

• Have you considered how problems will be addressed? Is there a process for responding to problems? Provide a quick response to system flaws.
• How will your organization learn? Be a learning organization: learn from evaluations. Is there a mentoring system? Set in place a buddy or mentoring system so that clinicians can share their expertise.

Considerations for Value to Users/Including Decision Support Systems: 3%

• Have you implemented results review before POE?
• Is the proposed technology far enough advanced?