Since 1997 the Physician Order Entry Team (POET) in the Department of Biomedical Informatics and Clinical Epidemiology at OHSU has been using qualitative techniques to study the implementation of CPOE systems in various healthcare settings. Through surveys, conferences with experts, and fieldwork consisting of semi-structured interviews, focus groups and observation, POET has gathered thousands of pages of transcripts and notes on CPOE implementation. Analysis of this data has produced detailed descriptions of factors related to CPOE success and insight into the implementation process. Further research by POET has examined the unintended consequences, both positive and negative, of CPOE implementation. Below this research has been divided into three sections with brief descriptions and references for each:

Considerations and Issues to Explore Before CPOE Implementation

A consensus conference of invited experts was held in May of 2001 at the Menucha retreat center near Portland, Oregon. Thirteen people representing administrative, vendor, clinician, and technology roles discussed success factors for CPOE implementation over a two-day period. The conference succeeded in identifying and agreeing on a list of considerations for successful CPOE implementation, as well as outlining a set of issues that fostered debate within the group and deserve further exploration. These considerations and issues can be found here.


  1. 2001 Menucha Conference
    May 10 and 11, 2001
    Menucha Conference Center
    Portland, Oregon
  1. Ash JS, Stavri PZ, Kuperman GJ. A consensus statement on considerations for a successful CPOE implementation. J Am Med Inform Assoc 2003;10(3):229-234. PubMed Full-Text

Factors for a Successful CPOE Implementation

Fieldwork was conducted at four sites between 1998 and 2003: The University of Virginia, the Veterans Affairs Puget Sound Health Care System, El Camino Hospital in Mountain View, CA and Kaiser Permanente Northwest. Oral history interviews focused on past events and captured the dynamics of implementation issues over time. Focus groups were used either to take a snapshot picture of CPOE use, by house staff for example, or to review the history of CPOE implementation at the facility. Observation was done to verify interview data and gain the current view. Because we wanted to study multiple perspectives, we interviewed and shadowed not just physicians, but also nurses, pharmacists, information technology staff, administrators, and others. Subject selection involved identification of representatives of varying roles and perspectives, including skeptics. Analysis of the combined data from the 2001 Menucha Conference and fieldwork at four sites using CPOE ultimately generated 12 principles for successful CPOE implementation [5]. You can find these principles here.


  1. Sittig DF, Krall MA, Dykstra RH, Russell A, Chin HL. A Survey of Factors Affecting Clinician Acceptance of Clinical Decision Support. BMC Med Inform Decis Mak. 2006 Feb 1;6(1):6. PubMed Full-Text
  2. Ash JS, Bates DW. Factors and forces affecting EHR system adoption: report of a 2004 ACMI discussion. J Am Med Inform Assoc. 2005 Jan-Feb;12(1):8-12. PubMed Full-Text
  3. Stavri PZ, Ash JS. Does failure breed success: narrative analysis of stories about computerized provider order entry. Int J Med Inform. 2003 Dec;72(1-3):9-15. PubMed Full-Text
  4. Ash JS, Stavri PZ, Dykstra R, Fournier L. Implementing computerized physician order entry: the importance of special people. Int J Med Inf 2003;69(2-3):235-50. PubMed Full-Text
  5. Ash JS, Stavri PZ, Fournier L, Dykstra R. Principles for a successful computerized physician order entry implementation. AMIA Annu Symp Proc. 2003;:36-40. PubMed Full-Text

Unintended Consequences of CPOE Implementation

Over the course of their studies POET had learned about various unintended adverse consequences of CPOE. This was a rather startling revelation at a time when CPOE was being touted as the "leap" that hospitals should take in the interest of patient safety. With funding from the U.S. National Library of Medicine, POET has been able to conduct an in-depth study over the past three years, utilizing both qualitative and quantitative methods to discover more about these unintended consequences (UCs) of CPOE. Data were gathered via two expert panel conferences, fieldwork at a total of six sites (one outpatient and five primarily inpatient), and a national telephone survey of all CPOE sites in the U.S. The aims were to identify types of UCs and strategies for preventing, managing or overcoming them, and to provide tools to help implementers address them. Descriptions of the types of UCs observed can be found here.


  1. 2006 Menucha Conference
    May 4 and 5, 2006
    Menucha Conference Center

    Portland, Oregon

  2. 2004 Menucha Conference
    April 8 and 9, 2004
    Menucha Conference Center

    Portland, Oregon

  3. Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006 Sep-Oct;13(5):547-56. PubMed Full-Text
  4. Sittig DF, Ash JS, Zhang J, Osheroff JA, Shabot MM. Lessons from "Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system". Pediatrics. 2006 Aug;118(2):797-801. PubMed Full-Text
  5. Aarts J, Ash J, Berg M. Extending the understanding of computerized physician order entry: Implications for professional collaboration, workflow and quality of care. Int J Med Inform. 2006 Jun 22; PubMed Full-Text
  6. Ash JS, Sittig DF, Dykstra RH, Guappone K, Carpenter JD, Seshadri V. Categorizing the unintended sociotechnical consequences of computerized provider order entry. Int J Med Inform. 2006 Jun 20; PubMed Full-Text
  7. Smith DH, Perrin N, Feldstein A, Yang X, Kuang D, Simon SR, Sittig DF, Platt R, Soumerai SB. The impact of prescribing safety alerts for elderly persons in an electronic medical record: an interrupted time series evaluation. Arch Intern Med. 2006 May 22;166(10):1098-104. PubMed Full-Text
  8. Ash JS, Berg M, Coeira E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004 Mar-Apr;11(2):104-12. PubMed Full-Text
  9. Dykstra R. Computerized physician order entry and communication: reciprocal impacts. Proceedings / AMIA Annual Symposium. 2002:230-4. PubMed Full-Text