Lessons Learned in Physician Design and Use of Advanced CIS and CPOE It''s About Time!
Competing Demands for Physicians' Attention
It's about time and it's about decision-making. Increasingly, organizations report that broad physician interest in using an advanced clinical information system (CIS) — including computerized physician order entry (CPOE) — depends on their perceptions and beliefs about the impact of using technology during a busy practice day. Once the impact of time is understood, physicians can appreciate the features that support decision-making and safe, efficient practice.
Jaen, et al., described a competing-demands model for influencing physician behavior.1 During a busy work day, physicians are focused on providing patient care and performing procedures, managing a practice, and balancing their total time between work and other activities. Physicians are influenced by competing demands for their attention. Consequently, any strategy such as advanced CIS that well-intentioned managers have for helping physicians must be built around pragmatic, easily accessible tools that support decision-making and improve physician workflow. Any strategy that does not meet these characteristics is likely to fail.
Gaining Physician Interest
In our experience, starting early with physicians allows for the long lead time usually required to educate and fully engage physicians in a long-term and complex project like implementing an advanced CIS. Given that, several strategies have emerged for initiating physician interest.
Ask Them
Assessing physicians' perceptions, needs, and even fears about automation and CPOE informs project leadership and begins to engage doctors. Identify existing physician meetings and use those meetings as a forum to gain physician input. This is the simplest approach. Conducting focus groups in similar specialties has proven to provide a deeper understanding of physicians' points of view.
One organization successfully conducted six dinner meetings that incorporated structured focus groups to begin its contact with physicians on this initiative. The groups were primary care, critical care, surgery (including OB/GYN), subspecialty medicine, emergency medicine, and surgical subspecialties. It was important to include physicians who are likely supporters of advanced CIS and physicians who may be reluctant to embrace such a change. Individual interviews with key physicians will supplement this information gathering.
Include Them
Including physicians in the initial stages has proven to communicate a sense of collaboration to the medical staff. These activities include information systems strategy and system selection processes. This author has been in many organizations where physicians have reported in interviews their strong support for physician participation in these early activities. It is not uncommon for them to say that this has been the first time that they have known leadership to include physicians early in a decision. While leaders may be trying to spare physicians the time commitment of these activities, the gain to the project becomes transparent.
Another early strategy is to identify a physician leader for the initiative. While the organization may not be ready to commit to dedicated physician leadership at this point, identifying a physician who can spearhead the above activities has proven to be effective.
Engaging Physicians in Design
As the organization progresses in its journey toward advanced CIS, keeping physicians involved before actual implementation is critical. While this must be balanced with managing physicians' expectations about how soon and to what degree the system will be in place, the value to the design and ultimate implementation is significant.
Organize Them
It is important to create a structure for physician involvement in design and implementation planning. Typically, organizations will maintain or create a physician oversight committee to review and endorse policies and physician-design-team products. This group of senior physicians will ensure the integration of newly created enhancements of clinical practice with existing policies of the medical staff. It will be necessary to charter a new physician group to conduct the design work related to workflow redesign, related policies, screen development, order-set creation, and other activities. While paying physicians for this type of activity may or may not be a part of your organization's culture, most organizations will pay physicians for this type of extended work on such a project. Other physicians participate on an ad hoc, unpaid basis.
Give Them Work to Do
It has been demonstrated that if physicians are invited to participate in such work, they want their work to be efficient and productive. Physician workflow committees should be structured and focused on decision making. Agendas should clearly delineate the decisions that need to be made. Participants should leave each meeting knowing that they have made decisions or moved toward decisions. These meetings should not be allowed to become debating sessions. Planning these meetings requires significant effort, knowledge, and organizational skills. Types of decisions that physicians make will include:
- What are the guiding principles about system design?
- What is the workflow around prescribing medication, including policies about
verbal orders and telephone orders?
- What order sets will be designed and how will they be used? Will they be
used to support evidence-based leading practices? To what degree can order
sets be personalized?
- How will physician screens be organized and to what degree they can be personalized?
- How will physician education and training be conducted?
- How will the organization roll out the CIS? To which units? Which modules?
Building Support
Rogers described key steps in the adoption of innovation.2 Two of the early steps are observation and trial. While some physicians may conceptualize how a new system will work and trust that it will meet their needs, many will need some time to observe the system and to try it out before they are ready to regularly use it. This raises the question of how to sequence implementation of CIS components. One school of thought suggests going live with all components at the same time. However, most will opt for a sequenced implementation, if time and technology requirements can be met. A typical sequencing would be for physicians to access results of lab and radiology reports for a period of time before initiating order entry.
Additional support will come if physicians have barrier-free remote access (office and home) to results. Physicians report this as having the most impact on their appreciation of how advanced CIS can positively influence their time and workflow. Increasingly, physicians are accessing patient information at home in the morning, and again in the evening, to streamline their rounding and ordering processes. This avoids unnecessary trips to the hospital and increases availability to family members.
If remote access to results can be enhanced with electronic signature, all of the above benefits will be increased. Such positive attention to physicians' time will pave the way for more effective adoption of order entry. By observing and trying the systems, physicians are prepared for the next steps.
An additional step in preparing physicians for order entry is the development of order sets. Order sets serve two major purposes: ease of ordering and support for leading clinical practices. Order sets that are designed to support the management of common daily physician tasks will make it easier for physicians to use CPOE to admit, transfer, and discharge patients. For example, a physician can bring up an admission order set for a patient with congestive heart failure (CHF) that supplies the common orders required for nursing, diagnostic evaluation, medications, and other treatments. The order set provides the approach to managing CHF and prevents the physician from having to create each individual order. However, at any point in the process he can create a unique order customized for the individual patient.
Mature CPOE systems will need common order sets for the admission, transfer, and discharge of adult, pediatric, surgical, and other patients. They will need disease-specific order sets, such as ER management of acute myocardial infarction, pre-operative orders for hip replacement, and management of normal newborns. In addition, systems will need order sets to manage common conditions that occur across multiple disease categories such as pain, DVT prophylaxis, and ventilator weaning.
Engaging a broad representation of physicians in the accelerated design of these order sets populates the new system with locally endorsed tools. Participating physicians gain awareness of the planned rollout (through observation and trial) during this process.
Achieving Use and Proficiency
The specific goals of physician adoption are to achieve optimal use of the tool and to have users quickly become proficient in that use.
Key questions about rolling out and going live with physician use of advanced CIS and CPOE focus around which components, by whom, where, and when. The sequencing of components is discussed above. The other questions should be tailored to the hospital system's size, complexity, physical organization, and nature of the medical staff and its groupings.
Initial pilots and subsequent go-live processes may be focused on specialty-specific units and motivated physician groups. Some examples and benefits of potential places to start are:
- Orthopedics unit. Predictable; focused; accustomed to a structured approach to care; few consultants on unit; and physically segregated unit.
- Medical-surgical combination (such as the orthopedic/rehabilitation unit). As in orthopedics, yet includes all common types of surgical and medical orders.
- OB/Gyn. Isolated activities; few consultants; and common procedures.
- Hospitalist group. High-volume users; very familiar with inpatient care; and motivated staff.
- Larger specialty groups. Easier to spread the word and high peer influence.
First, Make it Easy
To restate, we want physicians to use this tool proficiently. To this end, it is important to focus on the basics of efficient and safe order entry. This is defined by easily accessible, pragmatic order sets supported by clear, intuitive screen design. Core drug alerts (allergies, interactions) will support safety. Generally, more complex alerts and rules should be implemented once initial adoption and proficiency are achieved. Multiple alert messages are likely to confuse and annoy early learners.
It is important to note that there is a comfortable balance point between designing an easy-to-use system and one that supports evidence-based leading practice. One result will be reduction in practice variation. Early physician participation and discussion of the issue will help the organization achieve this balance.
Case Study: Small Midwest Hospital System Implementing Multiple Components of New Advanced CIS
Highlights of physician contributions:
- Physician computer committee (PCC). Legacy group of senior physicians involved
in system strategy and software selection. Oversight and endorsement of design
processes and products. Input into rollout approach. Monthly meetings.
- Physician design committee (PDC). Newly formed group of 15 physicians with
broad specialty representation. Monthly three-hour working meetings. Development
of guiding principles for physician order entry. Participation in system-wide
design sessions with detailed decisions (total effort: nine days). This group
contributed to innumerable decisions and had fun doing it.
- Order set design. A total of 175 order sets developed in four months. Target
of approximately 400 order sets for go-live. This work was done by members
of the PDC and by ad hoc meetings of specialty groups (six hours each).
- Implementation planning. PCC and PDC involved in this process. Developed rollout approach, physician education/training plans, and physician communication plan as an iterative process during the system design.
Summary
In our experience, physicians involved in this process find it intellectually stimulating and fun. Ask, include, and organize them. Give them work to do. Engage them in design and rollout planning.
Many physicians have long envisioned the potential of automation to enhance safe and effective practice, yet they have doubted the capability of organizations and technology to create a system that supports efficient workflow. It's about time.
Endnotes
1 Jaen, C.R., Stange, K.C., Nutting, P.A. "Competing Demands of Primary Care: A Model for the Delivery of Clinical Preventive Services." Journal of Family Practice (Feb.): 38(2) (1994.): 166-71.
2 Rogers, E. Diffusion of Innovations Fourth Edition. The Free Press: New York. 1995.
