CPOE systems

[ozzie]

Computer physician order entry systems anyone have comment thoughts etc
I am doing some research for a client and I am looking for the gotcha's.. the bad things, where it can go wrong

thanks

[Kursk]

Too many alerts (click fatigue, get ignored or anger users)
Not having order sets already established (crucial to speed)
Not getting MD involvement from the start (Cedars anyone?)
Not having 24-7 support at the start
Inadequate training schedule
Not enough devices (no queing allowed!)
Not having different types of devices (COWs, wireless, PCs)
Not having administrative buy in
Looking for hard ROI
Response time is crucial. Good studies show good systems are time neutral. That is about the best you can hope for.
CPOE is the top of a pyramid as true decision support requires realtime interfaces to lab, radiology, ADT, etc. Orders touch and receive input from every provider and system in the hospital. Rushing to CPOE without a firm foundation leads to chaos.

[hirschr]

CPOE requires a very fast, reliable system. NO downtime, no waiting for decision support tools to act. We may be finally getting there.
The biggest inpediment is the huge egos of physicians. Most think that they can do things better than computers so if it slows them down 1 second, it's not worth it. "It's all the other doctors that kill those 100,000 medical error patients, not me."

[ozzie]

The biggest inpediment is the huge egos of physicians. Most think that they can do things better than computers so if it slows them down 1 second, it's not worth it. "It's all the other doctors that kill those 100,000 medical error patients, not me."
Ok so we want preemptive solutions as long as it does not pre empt the physician..LOL

[ozzie]

I am looking at solutions under a group home scenario. So I would guess that much decision support is going to be hybrid to start..
Paper chart then over time digital. Also I am looking at intergrating a bar code system to track the meds from pharmacy to PAT..

The MAR system for the aides has to go.. LOL

[Kursk]

The biggest inpediment is the huge egos of physicians. Most think that they can do things better than computers so if it slows them down 1 second, it's not worth it. "It's all the other doctors that kill those 100,000 medical error patients, not me."

Thanks for the bashing, as if we don't get enough from everyone else.

This is an overgeneralization and is inaccurate. It dismisses the complexity of the order process and the required integration of every currently unconnected system in the hospital. It minimizes the outrageous implementation and recurent operational costs to CDOs ( in a period of intense financial stress), the relative inexperience of the vendor market, and the lack of useful standards. Clinical information systems are not the same as accounting, order entry or ERP programs. Orders can include absolutely anything (unrestricted domain) and start with a blank piece of paper. Logical relationships to other systems and decision support is fuzzy at best. Many vendors have gone out of business trying to leverage their "expertise" in medicine obtained from billing/PM/lab reporting side of the house while making a foray into clinical systems, only to have their capital drain away as they chase the undreamed of complexities inherent in CPOE.

Physicians will use well designed software. There is no excuse for poor performance of software. If software is bad it will not be used.

Saying that physicians are the major problem in the process makes doctors the convenient scape goat for the press, the government, insurers and vendors. Everybody loves a simple answer to a very complex question. It doesn't mean its the right or even a useful answer.

[ozzie]

I know your are right Kursk and until systems can fix themselves the idea of fixing a human to me is just a pipe dream..
I am not so sure that even systems can be built as I have seem so many times over the years where the human just aha's and gotcha's past the machine.
And after all it is humans that build the machine in the first place. So even the best system is still limited to capability of the databases and or programmers.
People tell me that no human could beat the computer at chess but thats only because we did not find the human that can ..
Chess is childsplay compared to complexity of the human body let alone the brain.
Is it that the systems are trying to do too much, rather than be very good at lessor tasks..
At meeting today I spent the better part of the meeting defining a less complicated system.. It seems some folks are hellbent on designing super complex systems to do trivial tasks. Whereas more time should be done getting the bugs out of the more simple system ???

[Kursk]

The complexity of decision support is highlighted by the increasing failure rate as the number of alerts increase. Focusing alerts on the MAIN behaviors we want to change is the answer. Most implementers I have talked to hone down the alerts to about 50 or less and continually refine the alerts and more importanly work on the order sets so that it's easier to use a thoroughly vetted order set and modify it at order entry time then to go ala carte. Order sets contain inherent logic that can standardize care, use EBM where applicable and prevent errors of omission. That is why organizations need to get moving on order sets prior to CPOE - to gain some consensus and acceptable standardization of care from the staff prior to implementation. The process of order set creation and modification will continue thoughout the life of the CPOE system.

[hirschr]

Thanks for the bashing, as if we don't get enough from everyone else.


I do not intend to doctor bash but... how many doctors actually are in the office to see their first patient at the time of the appointment? How many grand rounds started with a full house at exactly noon? How many OR 7 am cases start late because the surgeon is not there? Why does almost every hospital get a JCAHO Type I violation for medical records because there are missing H&P's for patients? Why does our small community hospital have 800 delinquent charts awaiting signatures and dictations? How many doctors really read the nurses notes/ the therapist's evaluation/ the pharmacist's dosing recommendations?

We are all very smart and good at what we do and many of us do amazingly philantrophic things but we were bred in a culture that is one-sided and that makes change difficult unless you can show "what's in it for me" rather than what's in it for the patient, as it should be.

[Kursk]

Show me any culture in which change is painless.

It's always about "what's in it for me" for any sustained behavior, except for those exceptional people we call saints. That's human behavior, evolution if you will. Then of course, physician cooperation with hospitals in the past has led to a long string of unhappy outcomes, so it's also a learned behavior.

Signing charts is not the equivalent of saving lives. It is a stupid process that needs to be changed. It is "after the fact" behavior. If every hospital is getting a "violation" for this doesn't it tell you something? It tells you that you need to review the reason for the rule and the process that leads to innumerable deficiencies. My state fought against electronic signature for over a decade!

One sided? Try this - take no responsibility for your own problems, ignore medical advice, yell loudly when you don't get prompt attention because someone else is sicker, call 24-7 for anything for free and sue if you are unhappy. Sue if your doctor is late for an appointment.

I acknowledge your criticisms of the practice of medicine and of doctors in general. I have said the same things at times in frustration. I don't agree that the majority of doctors are rich arrogant technophobic assholes driven only by self interest.

I reiterate: doctors will do the right thing when shown the way by good leaders using good tools that work and do not increase the complexity of an already hopelessly complex process. They will not crucify themselves in the name of change for no clearly seen better outcome just to satisfy vendors and regulators that continue to oversimplify the problems facing healthcare for a soundbite on the evening news. Doctors are not alone in creating the adverse (and often perverse) environment in which we now ply our once noble trade; however we take the lion's share of blame for anything that goes wrong.