Study: Physicians Resist Electronic Order Entry

A survey by the Harvard Medical School finds that physician resistance, high cost of systems and immature products are the top three obstacles blocking CPOE (computerized physician order entry) systems.

Physicians resistance to computerized physician order entry (CPOE) systems is impeding their adoption more than the cost of such systems, according to a new study by the Harvard Medical School.

Researchers conducted extended interviews with 52 senior managers at 26 hospitals and identified physician resistance, high cost of systems and immature products as the top three obstacles to implementing CPOE.

Fewer than 15 percent of all U.S. hospitals are estimated to use CPOE, in which physicians enter orders for medications, tests and other services electronically.

The research also gathers experts advice for pushing past these barriers. These include recruiting "physician champions" to represent clinicians needs, using the most computer-literate staff, such as younger doctors, to help physicians learn new systems, and making sure vendors are sufficiently committed to get through difficulties in implementation.

In addition, CIOs hoping to secure the $3 million to $10 million investment for CPOE should frame the requests in terms of improving patient safety rather than getting a return on investment.

The researchers said several CIOs in the survey decried the difficulties in making a business case for CPOE. A health information consultant familiar with the report agreed that savings are hard to quantify.

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Margret Amatayakul, a former head of the Computer-based Patient Record Institute, said improvements to patient safety represent a probability of saving in terms of fewer adverse events, decreased chances of lawsuits and a generally healthier population. But the savings for CPOE, she said, are less obvious, "unlike some other systems where you know for sure that certain costs are going to go away."

Nonetheless, costs are not the biggest concern. The authors conclude that "overcoming the financial barrier alone may not be sufficient to enable hospitals to adopt CPOE," and that "the fear of physician rebellion" could quash implementation efforts.

Physicians primary objection to CPOE is that submitting orders on a computerized system takes more time than making the same request on a paper form.

Amatayakul sympathized with doctors frustrations. "To me, the biggest issue is that some of the systems that are implemented do not have robust clinical decision support that provides value to the physician being asked to use the system. The only improvement may be transcription errors, because basically, the physician is being asked to perform a clerical function," she said.

CIOs interviewed in the study who had tried and failed to implement CPOE said poor user interfaces and processing speeds rendered systems unusable. Some accused vendors of selling "vaporware," promising functionalities not supported in purchased systems.

But Amatayakul was quick to point out that no single group bears sole responsibility for slow adoption in CPOE, and that issues cannot readily be categorized as vendor, physician or provider problems. For example, she said, vendors might be able to offer services to make CPOE more appealing to doctors, but a hospital might not want to buy them, or a hospitals existing system might not be able to support them.

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The study also found that lack of interoperability between CPOE and other hospital systems, as well as between older and newer versions of CPOE systems, ratchet up costs and threaten to make investments in money and training obsolete. The researchers posit that cross-platform standards would spur adoption and suggest that the government could promote standards with grants, regulation and Medicare policy.

Eric Poon and his colleagues at Brigham and Womens Hospital in Boston conducted a series of interviews with hospital executives. Almost half of the 26 hospitals reflected in the survey had allocated resources to CPOE but had not yet implemented it, five had fully implemented CPOE, three had attempted to but abandoned the attempt, and six were considering implementing CPOE. The results of the survey were published in this months issue of Health Affairs.

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