Getting doctors to place their orders on a computer has always depended on the doctor and the computer, and the debate over requiring the practice continues as stakes get higher in a climate of medical-error consciousness.
One healthcare organization, the University of Illinois at Chicago Medical Center, has spent $10.3 million on computerizing the medical information of its 450-bed teaching hospital, an adjacent outpatient center housing 12 primary-care and specialty centers, and eight satellite clinics in a 20-mile radius.
It took a gamble: Physicians weren't forced, only enticed to use the system's computerized records and direct ordering capabilities. The gradual phase-in of clinical users and data sources turned out to be a gamble won-85% of physicians use the system, says Joy Keeler, the medical center's chief information officer.
Starting in 1997, the project concentrated on bringing together all the sources of information needed for clinical diagnosis and care using applications developed by Cerner Corp., Kansas City, Mo. With those applications in place, the medical center is introducing medication alerts beginning with digoxin toxicity, Keeler says.
At Good Samaritan Regional Medical Center, the use of alerts is at an advanced stage but without the assistance of physician order entry. Considering what's been accomplished without it, the introduction of such a system might be more hindrance than help, says Robert Raschke, M.D., a critical-care physician who has been instrumental in developing the decision-support program.
A physician ordering system has to be smooth from the start or it might jeopardize the good work brought about by the current computer system at Good Samaritan, Raschke says. "If it's done right, it should make things easier and not harder," he says. "The wrong system could sour people to the idea and develop resistance to what you're trying to do."
The main drawback is that "as a doc, if I want to order digoxin, this is how long it takes," he says, writing an imaginary scribble. Replacing that with security measures, computer windows to wade through and passwords he might forget, a physician can be confounded by the process, Raschke says. "Instead of 10 seconds, it could take 10 minutes."
That's why he favors choosing a physician-oriented system cautiously and deliberately "instead of getting one just to get one."
At Blount Memorial Hospital in Maryville, Tenn., managers are enthusiastic about using computerization to improve patient safety (See related article, p. 4). But physician order entry is not yet part of the program.
"There really aren't enough good physician order-entry systems out there right now," says Jeanne Ezell, director of pharmacy. "We looked at them last year and didn't like them."
With increased demand because of patient-safety issues, Ezell says information systems companies likely will produce more and better choices soon.
Other institutions have set up their clinical information infrastructure with the aim of enlisting physicians at the start.
"Our vision was physician order entry," says Terri Andrews, clinical systems manager at Alamance Regional Medical Center, Burlington, N.C. The medical center sought to supply as much information support as possible to the point of decisionmaking. "We had always expected clinicians to carry a lot of information around in their heads ... I think that's unrealistic."
At Montefiore Medical Center in New York, installation teams have methodically introduced computerized order entry to care units one at a time, beginning in March 1999. The units already computerized represent about 600 of the two-hospital network's 1,100 beds, and another 100 beds are targeted in June, says Dorrie Napoleone, director of clinical information systems. The system was developed by IDX Systems Corp., Burlington, Vt.
As the teams implement the computerization and educate physicians and other clinicians, they're removing paper order forms as they go. "It's either electronic or it's not," Napoleone says. "That's our strategy and I don't think I'd change that."
Montefiore, affiliated with the Albert Einstein College of Medicine, includes 2,000 attending physicians, 800 residents and 180 medical students in an academic medical setting. Alamance Regional and its 238-bed hospital, by contrast, rely on a partnership with independent community physicians, and that called for coaxing rather than mandating participation in computerized order entry, Andrews says.
Physicians place 50% of the orders at Alamance directly into the system, and about 80% of doctors place some portion of their orders into the clinical system on a monthly basis. Developed by Eclipsys Corp., Delray Beach, Fla., the order-entry capability went into testing in November 1999 and expanded to all four medical/surgical units in February 2000. Enhancements are made periodically based on physician feedback, Andrews says.
Hospital managers persuaded doctors to come on board by showing them how the system has reduced entry errors and staved off problems through early alerts, she says. Among other ammunition, the medical center conducted a study showing that when nurses or nursing-unit secretaries entered orders for physicians, their error rates were double that of physicians who entered orders themselves.
What's more, the errors made by nurses and unit secretaries often were more serious than those of physicians, Andrews says. Doctors might forget something minor such as not checking the "as need" box for medication. Orders transcribed on behalf of doctors were more likely to get the dose wrong or specify a wrong route, such as intravenous instead of oral administration, she says.
Alamance Regional will introduce an automated medication administration record this summer, which Andrews says will be another reason for physicians to call up and use the system.
Sarasota (Fla.) Memorial Healthcare System launched an order-entry system from Eclipsys in October 1999 and required its use by physicians. But some initial technical problems created early resistance among doctors, prompting management to pull back from its insistence, says Denis Baker, CIO of the healthcare system.
About 30% of orders now are entered directly by physicians, and the pharmacy modifies those orders only 2% of the time compared with 8% when unit secretaries transcribe them, he says. Sarasota Memorial has demonstrated a range of other clinical and business benefits since the system's early shakiness (See related article, p. 38).
Executives now have to decide when the time has come that the system is so comprehensive and effective that its use should be made mandatory again, accepting that some doctors might go elsewhere, says Bruce Berg, M.D., associate chief medical officer.
"If you spend a little more time up front, you'll get tenfold on the back end," Berg says. "A physician doesn't always see that."