Introduction

Computerized Provider Order Entry (CPOE) refers to functionality that allows providers to enter medical orders directly via computer, replacing the more traditional paper, verbal, telephone, and fax methods.  Ambulatory CPOE (ACPOE), which refers to CPOE in outpatient settings, allows providers to place electronic orders for medications, laboratory tests, admissions, radiology exams, referrals, and procedures. 

Clinical Decision Support (CDS) capabilities integrated within ambulatory electronic health records and order entry systems provide clinicians with real-time support on a range of information related to diagnosis and treatment.  They also provide tools aimed at improving patient care and reducing medical errors and costs.  In addition, decision support may add rules to check for drug-drug interactions, allergies, medication contraindications, and renal and weight-based dosing, further enhancing the ability to reduce medical errors.

To study the adoption and use of ACPOE, the Agency for Healthcare Research and Quality (AHRQ) funded several projects to implement ACPOE and CDS tools in outpatient practices.  This brief highlights the early lessons learned from those projects as reported to the AHRQ National Resource Center for Health Information Technology (health IT) during key grantee interviews.  These findings are divided into the following four categories:

• Leadership
• Implementation and Training
• Clinician Adoption
• Postimplementation Considerations

For more lessons from the AHRQ portfolio, click here (PDF, 112KB; HTML).

Leadership

Lesson 1:  Leadership is critical at both the institutional and practice levels.

The importance of leadership from preimplementation throughout the life of the project emerged as a theme among the AHRQ-funded projects.  Issues arise during all three phases of the project (preimplementation, implementation, and postimplementation) that require strong, involved leadership at two levels:

• At the institutional level, grantees agreed that strong, stable leadership, with a specific commitment to health IT, is critical to successful implementation.  Grantees said that working in an environment committed to health IT and having dedicated resources and adequate funding are necessary for success.
• At the practice level, the involvement of physician champions--respected clinicians who have embraced health IT--was more effective in persuading resistant colleagues to adopt ACPOE than the efforts of administrators and others.

Implementation and Training

Lesson 2:  Conduct pilot testing before introducing ACPOE to the entire community of users.

A pilot test assesses a tool under the operating conditions and in the environment for which it was designed, using a small group of people from the target audience, such as physicians, nurses or other end-users. AHRQ-funded projects emphasized the need to conduct adequate pilot testing prior to introducing ACPOE to the entire community of users.  The goal is to ensure that the ACPOE tool works as intended and, if it does not, to modify the tool as needed prior to go-live.

Pilot testing is more productive with users who are open to ACPOE and who will be more patient and cooperative as problems are identified, as opposed to users looking for reasons to reject new tools.

Lesson 3:  For groups with multiple practices, roll out ACPOE incrementally to end users.

After pilot testing is complete, grantees recommended the ACPOE tools be rolled out slowly, one practice at a time, so that project leaders can observe use of the tool in a real-world environment with different types of users.  Those practices more willing to adopt tools should implement them first.

Incremental implementation allows time for problems to be identified and necessary changes to be made without causing potential frustration to large numbers of users.

Lesson 4:  Maintain good relationships with vendors and developers to speed resolution of software bugs and glitches during implementation.

All grantees stressed the importance of having a good relationship with their vendor, product development staff, and IT developers. 

• For projects that involve internally developed systems, good relations can help developers obtain early and frequent feedback from users.  One AHRQ-funded project held a roundtable discussion with developers and system users that was instrumental in anticipating and correcting problems.
• When a vendor system is used, customization will be required.  Good relations with the vendor can expedite the ability to address customization and other implementation issues.  An unexpected upgrade created implementation problems for one AHRQ-funded project, but because the project leaders had a good relationship with their vendor, the issue was resolved quickly.

Lesson 5:  Construct alerts carefully so that they bring important information to clinicians at the point of care.  Poorly designed alerts increase the risk of implementation failure.

Experience with inpatient CPOE systems has shown that alert fatigue is a common problem.  High-volume, low-acuity, and disruptive alerts, such as an alert about a minor medication interaction, annoy clinicians, who then tend to ignore the alerts.

• During preimplementation, the questions of which alerts to present and when and how to present them should be considered carefully.  Otherwise, clinicians will be more likely to overlook important alerts and decrease their use of the tool as time passes. 
• Careful post go-live monitoring for alert fatigue is essential.

Lesson 6:  Training is a crucial component for successful ACPOE adoption.   Both lack of and poor training leads to poor adoption.

Preimplementation training is critical.  Training for new users, training for updates to the tool, and refresher courses for current users also needs to continue during the implementation and postimplementation phases.

One AHRQ-funded project observed different adoption levels at each of its practices. After researching this issue, project leaders concluded that the differences were due to training:  practices that emphasized training had higher adoption levels.

Clinician Adoption

Lesson 7:  Clinician buy-in is critical for successful adoption of ACPOE.

Adoption by clinicians remains a challenge in any effort to implement health IT.  A common theme among the AHRQ-funded projects was the absolute importance of clinician buy-in.  If clinicians do not buy into the ACPOE tool, they will not use it and the project is likely to fail.

• One AHRQ-funded project reported that achieving clinician buy-in prior to implementation was an important factor in the project's success.
• One grantee expressed frustration with variations in ACPOE adoption among the organization's clinics. The organization had implemented CPOE on the inpatient side, where use was mandatory.  The ambulatory clinics, however, were not required to use the new tool. Adoption rates were far higher on the inpatient side than on the ambulatory side.  This grantee felt strongly that new health IT systems, such as ACPOE, must be mandatory in order for them to be adopted successfully. Mandatory adoption, however, is not an option for many implementers.

Lesson 8:  ACPOE should support and enhance current workflow.

Clinicians are not likely to use a tool if it interferes with their current clinical workflow or increases demands on their time. 

One AHRQ-funded project found that a vaccine reminder that opened at the same time as the patient's medical chart was not well adopted.  Clinicians preferred to have the reminder directed to a medical assistant responsible for vaccine administration, or at the end of the visit, when orders were being entered.

Lesson 9:  A user-friendly interface is necessary to obtain clinician buy-in.

Many clinicians have little or no expertise or experience working with IT systems.  They may resist adopting ACPOE unless the user interface is clear, easy to navigate, and fits naturally into their clinical workflow.

After pilot testing, one AHRQ-funded project reported that a weight-based dosing tool was difficult to locate, required too many clicks to use, and was not effectively integrated with the medication management system.  Project leaders modified the tool to make it easier to find prior to roll-out, so that clinicians would adopt it more readily.

Lesson 10:  The organization needs to highlight the value added by ACPOE.

Studies have shown that clinicians are more likely to adopt health IT systems if they recognize the value added by the system.  AHRQ-funded projects made the same observation: organizations need to make clear the value-added features of the new system and educate clinicians about them.

One grantee reported great success with its e-prescribing tool but very low success with its laboratory and imaging order tool.  Clinicians understood the value added by the e-prescribing tool because it sped the process of writing prescriptions compared with paper-based prescribing.  Clinicians also recognized the value added by the resulting medication history documentation.  However, there was no perceived value of ordering laboratory tests and imaging studies electronically, and thus the clinicians did not use this tool.  The grantee noted that articulating the value of this tool might have increased its use.

Lesson 11:  The speed of the tool is crucial in securing clinician adoption and preventing providers from abandoning the ACPOE system.

Busy clinicians have little tolerance for any system or process that impedes their work.  If clinicians feel that the system, or some feature of the system, is slowing them down, they will abandon it over time.  It is important to identify technologies or workflows that minimize actual or perceived delays.

One AHRQ-funded project found that clinicians were migrating from personal digital assistant (PDA) use to laptop use.  Investigation of this trend revealed that PDAs were slower than laptops and clinicians were changing to the faster device.

Postimplementation Considerations

Lesson 12:  Develop a process for collecting feedback on the tool after go-live and monitor adoption patterns.

AHRQ-funded projects recommended having a process for collecting post-implementation feedback on an ongoing basis and monitoring adoption patterns.  Without such a process, opportunities to identify problems and improve the tool are lost.

• Users commonly provide new insights about the tool after implementation.  These insights can lead to improvements, which can help increase clinician buy-in and adoption.
• One project noted that clinicians new to the health care system adopted the tool faster than veteran clinicians of that health care system.  In addition, full-time clinicians adopted the tool faster than part-timers. Training strategies that target different groups of clinicians may be needed.

Lesson 13:  Control groups are an important part of evaluation, as measuring the impact of ACPOE on patient care may be difficult due to the rapidly changing health care environment.

Grantees observed that the rapidly changing health care environment affects the ability to measure the impact of health IT on patient care.  If ACPOE implementation coincides with other changes in the environment, it may be difficult to identify the causes of specific impacts. 

One AHRQ-funded project reported significant changes in patient blood pressure and low-density lipid (LDL) cholesterol levels after ACPOE implementation.  However, these changes were also observed in control practices that did not have ACPOE.  Project leaders theorized that recent emphasis on adhering to specific medical protocols caused improvements across the board unrelated to the new technology, an observation which may have been missed without the control group.

AHRQ Funded Projects: Evaluating the Impact of Ambulatory CPOE

The following AHRQ-funded projects are seeking to evaluate the impact of Ambulatory CPOE on the quality, safety, and efficiency of health care:

• Trial of Decision Support to Improve Diabetes Outcomes (Randall Cebul; Cleveland, OH)
• Improving Pediatric Safety and Quality with Health Care IT (Timothy Ferris; Boston, MA)     
• Improving Safety and Quality with Outpatient Order Entry (Tejal Gandhi; Boston, MA) 
• Health Information Technology in the Nursing Home (Jerry Gurwitz; Worcester, MA) 
• Impact of Health Information Technology on Clinical Care (John Hsu; Oakland, CA) 
• Rural Trial of Clinic Order Entry with Decision Support (Matthew Samore; Salt Lake City, UT)

Authors

Caitlin M. Cusack, M.D., M.P.H.
Julie M. Hook, M.A.

Current as of December 2008