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The Health Care Industry

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The health care industry is expanding rapidly and becoming more complex in the treatment and diagnosis plan of care. Medical errors along with the risk of harm have become a growing concern of the community and the health care industry. Implementation of health information technology (HIT) will help to sustain the growing complexity of health care and reduce these risks. However, few hospitals in the United States have implemented HIT systems such as computerized physician order entry (CPOE). Once implemented and successfully integrated with clinical decision support systems (CDSS), CPOE can help to improve patient safety and quality of care by reducing medical errors. CPOE implementation is not an easy task and has many barriers. Implementation would require proper planning, projected cost analysis, cooperation of physicians, administration, nursing staff, and other ancillary personnel. The following discussion will look at benefits and issues of implementing CPOE, while describing ways to successfully implement it into clinical practice.

Patient Safety & Quality of Care: Implementing Computerized Physician Order Entry (CPOE)

Business Scenario

Approximately 98, 000 deaths per year are attributed to medical errors (Poon, et al., 2004). These errors yield an estimated cost between $17 to $29 billion dollars a year nationwide (IOM, 2000). When an error occurs, the medical team loses the trust of the patients, the family, and even the community. Medical errors cause physical and physiological damage to the patient; thus, extending their stay in the hospital putting them at a greater risk of developing other complications. Many of these errors are preventable and can be decreased by the successful implementation of computerized physician order entry (CPOE). CPOE allow doctors to write orders, communicate with nurses, consultants, and other members of the medical team. When integrated with clinical decision support systems (CDSS), CPOE helps to decrease prescribing errors by guiding physicians to enter complete and accurate patient orders (Wolf, 2003). Other benefits of CPOE include allowing the organization to address many quality issues, provide standardization of care, improve communication, and capture data for management and research (Kuperman & Gibson, 2003). Despite the proven benefits of CPOE, only 10% to 15% of hospitals use this system (Poon, et al., 2004).

Several challenges exist when trying to implement CPOE into clinical practice. These challenges include large investment and continued cost to maintain the system, a fragmented health care delivery system, and time needed to train staff. Other barriers of CPOE implementation include failed integration of CPOE with exiting software, and drastic changes in the workflow from paper to paperless charting.

Another major challenge to implementing CPOE is the physician resistance to change. Any process that disrupts workflow may seem daunting to staff. CPOE changes the entire system of writing orders and profoundly alters the way the participants do their jobs (Wolf, 2003). Physicians may feel comfortable with the already well established paper charting and see computer charting as a challenge which demeanors their expertise. Some physicians may have a hard time learning the new systems and may chose to only provide patient care within a controlled environment such as their private practice.

Analysis of the Organization and Business Process

Cost of Implementation

According to Kocakulah and Upson (2005):

CPOE systems require extensive network connections and IT support functions. Capital, software, installation, and start-up costs would be expected to be between $1.7 million and $2.2 million for a hospital between 350 and 400 beds in size. However, reports on actual applications of CPOE systems at hospitals have uniformly commented that projected savings found in the literature were not achieved. This would indicate that the previously sited cost estimates include economic opportunity costs that would be realized by society, but not by the hospital applying CPOE. (p. 18)

Cost analyst of CPOE involves technical cost, process redesign cost, and implementation and support cost. Technical cost of CPOE includes the hardware, software, technical support, and integration with other existing systems (Kuperman & Gibson, 2003). Other technical factors to consider is the number of work stations needed to support the functions of CPOE, making the system accessible from outside the hospital, and interfacing CPOE software with other clinical applications (admission, laboratory, pharmacy, radiology and nursing documentation).

Redesign cost are based on the current system already established in the hospital and the hospital size. A hospital with established well integrated systems will require fewer up dates; thus, decreasing redesign costs. Larger hospitals or medical centers which require substantial software modification, a large scale development of work stations, and large training endeavors would be faced with projected cost equivalent or greater than ten million dollars (Kuperman & Gibson, 2003).

Training and support activities accounts for a substantial amount of cost (Kuperman & Gibson, 2003). Adequate staff support must be provided during the course of training. It is important for clinicians to be adequately trained to use any new system to promote its efficacy and prevent errors related to lack of knowledge. Change all at once may be difficult for the organization to absorb; therefore, the implementation phase must roll out in phases to ensure CPOE's success.

Organization & Staff Resistance

CPOE drastically changes the workflow of the physicians and other medical staff. It requires change from paper to paperless charting. This may seem very intimidating to the physicians and the staff. Physicians must feel like they play a key role in CPOE development in order for it to work. A well respected physician champion is needed to help achieve a buy-in from other colleagues. Ramirez, Carlson, and Estes explained how the neonatal intensive care unit (NICU) used a physician champion to test the use of CPOE on a small number of patients. The NICU team evaluated glitches in the system and reported areas which needed improvement to the IT department. The champion doctor found the use of CPOE much easier than expected and on day two he was using CPOE order sets on all his patients. This champion physician was able to solicit the support of other physicians who were eager to start using CPOE once they completed



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