Principles for a Successful CPOE Implementation

Computer Technology Principles

1.  Time Concerns

From the user's viewpoint, the most important CPOE consideration is that it shouldn't take any extra time to use.

2.  Technology / Meeting Information Needs

There are several technical details to consider as part of a CPOE implementation. These include strategic considerations, user considerations, and task completion flexibility as well as the quality of the application, from customizability to user friendliness.

3.  Integration of Multiple Systems

From a technology viewpoint, integration of different systems was desired by users for ease of use and timesavings. They wanted seamless access to different systems through CPOE and they wanted CPOE to be integrated into their workflow so that it did not disrupt their work.

4.  Understanding the Financial Costs

Financial considerations cannot be underestimated: they include not only the cost of hardware and software, but all the costs associated with system implementation. In addition, they must include training and support costs, ongoing maintenance expenses, as well as any hidden costs related to decreased productivity in each unit as CPOE is initially rolled out.

Personal Principles

5.  Value to Users and Tradeoffs

While there are benefits to using CPOE, there are also liabilities. The downsides always involve the time it takes compared to the old way of doing things and the perceived or actual rigidity of the new systems. The upsides usually involve remote entry of orders, legibility and groupings of orders that are often entered together. Useful aspects of the system often include decision support as well.

6.  Essential People

There are two large categories of people who are essential to the successful implementation of CPOE. The first group is the leaders. These include both administrative leaders and clinical leaders. Administrative leaders need to be at the highest levels of the organization, at the chief executive officer or presidential level. Clinical leaders include the chief medical officer and, in academic centers, the department chairs. The Chief Medical Information Officer, an informatician, is a key player who can make or break a system implementation. Opinion leaders, who are respected clinical experts, and champions, who are enthusiastic about the system itself, are also critical.

The second essential group, are the talented people who speak the languages of both medicine and technology. These are the staff members who can train, support, and make changes in the system.

7.  Training and Support

Help "at the elbow" at the time of implementation is a very important part of implementation. In addition to the symbolic importance of supporting the users by being present while they are first using the application, intensive support at "go-live" allows the implementation team to directly experience what is and is not working well. Most successful implementations have had more post-go-live support than pre-go-live training. Most sites have had 24/7 support for several weeks after go-live.

Organizational Principles

8.  Strong Organizational Foundation

A successful implementation depends on the existence of a firm foundation in organizational terms. Much of this foundation involves aspects of organizational culture that cannot be quickly changed once a decision is made to implement CPOE. If the right organizational culture is not in place, CPOE should not be considered. Top-level commitment from administration, both moral support and financial, is mandatory, as is a high level of trust between administration and clinicians. There must be a realistic vision about CPOE and a readiness on everyone's part to implement it. Leadership must be open to feedback. Both the organization and the vendor need a high degree of stability.

9.  Collaborative Project Management

A theme that emerged from the field data was "collaboration and trust." This is because one of the most important aspects of project management related to CPOE is teamwork and being able to pull different groups of people together. The groups include multidisciplinary teams of clinicians, leaders, and technology staff. An important component of the project management process, in addition to managing resources and timelines, is assuring that team members treat one another with respect.

10.  Good Communication / Careful Use of Language

The appropriate uses of language and communication are critical to CPOE implementation success. Collaboration can be improved or undermined, depending on how carefully individuals choose their words. Because multiple clinical disciplines and information technology and administrative groups are involved in CPOE, a common vocabulary with common understanding is needed.

11.  Improvement Through Evaluation and Learning

CPOE 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. The organization should be able to learn from the CPOE implementation project. Environmental Principles

12.  Understanding Motivations and Context

It is important to consider the motivation for implementing CPOE because often pressure from outside the hospital or a desire for increased efficiency will motivate administration to want it, but clinicians may remain unmotivated. If, on the other hand, clinicians are highly motivated because they would like decision support capabilities readily available through CPOE, the likelihood of success is greater.

Context involves attributes of the institution such as geography, the era during which the system is installed, the kind of unit where it is being implemented, and the types of individuals involved. For example, a Silicon Valley hospital might want to be perceived as being on the cutting edge of technology, the era of managed care may pit administrators against physicians, and emergency room personnel may feel CPOE is inappropriate in acute situations. Motivation and context must be analyzed prior to discussions of implementation so that barriers can be assessed.

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