With 898 beds, Cedars-Sinai Health System in Los Angeles is among the largest academic medical centers west of the Mississippi.
And on Oct. 22, those of its 1,900 doctors who have not been certified to use its new computerized physician order entry system will lose their privileges.
Some physicians are resisting, medical staff leaders concede. Rumor has it that a few have threatened to sue rather than change the way they practice. But what is being called the "big bang" approach to Cedars-Sinai's CPOE rollout is the only way to make the necessary leap toward proven patient safety improvements in a fair and consistent manner, the leadership contends.
"Our rationale behind this is not to be punitive," says Michael Langberg, M.D., CMO and senior vice president for medical affairs. "The value of a CPOE system is not only to improve the speed of sending orders to ancillary departments, but also to provide alerts and alarms in real time. We believe that to be better for patients.
"We're committed to a single standard of care," Langberg stresses. "If I'm a member of the board or senior management, how can I justify why some patients get better care while we unroll the project?"
CPOE is one element of a more-than-$20 million information system called Patient Care Expert (PCX), which also includes management of contracts, patient accounting, admissions, discharges and transfers.
The first full, two-week pilot completely supported by PCX will begin July 31 and involve about 150 doctors with a subset of patients on the Cedars-Sinai obstetrics unit. Afterward, the department will return to paper orders while the CPOE system is tweaked and finalized based on lessons learned during the pilot.
Training requirements and physician support are integral parts of the plan.
System testing and improvements will continue up until the rollout. By then, physicians who have taken a Web-based exam that shows they have competency in CPOE and can navigate key components of PCX will be placed on a certification list. If they are not on the list when the system goes live, they will be suspended.
Once the system is rolled out, nurses will not be able to take even verbal orders from uncertified physicians, because those physicians' name will not be in the system. The suspension is reversible immediately once the doctor is certified.
"Human-change management is at least as important as the technical pieces," Langberg insists.
It helps that Cedars-Sinai already has a cultural foundation with a sophisticated system for real-time viewing of lab results, imaging and medical records. Medical-staff champions of the new system and residents who tend to be more technically proficient than some older doctors have offered support as "super-users," Langberg says.
Borrowing an educational approach used at Stanford Hospital & Clinics, where CPOE was implemented last summer, Cedars-Sinai uses medical-staff newsletters to feature PCX goals and progress and solicit suggestions for improvement, says M. Michael Shabot, M.D., chief of staff and medical director of Cedars-Sinai's Enterprise Information System.
Physicians can be trained in classes or over the Internet. Shabot completed his certification online from a hotel room in Las Vegas.
"The system will allow physicians to enter orders from their office, home or anywhere in the medical center," Shabot says. "Our main building is 1.9 million square feet. Now, to enter or authenticate care could be a 15-minute round trip. (PCX) is a real time-saver."
Shabot says he expects marked reductions in verbal and phone orders. Accessing medication advice on indications, dosages, allergies and drug-to-drug interactions with a mouse click will provide additional safety measures.
"There is little in medicine that will touch as many facets of how we care for patients, nothing of this magnitude," says obstetrician Paul Hackmeyer, M.D., immediate past chief of staff and a big-bang booster. "Education is not sufficient," he says "Pleading with doctors is not sufficient. There's got to be a line drawn in the sand.
"Studies show that incomplete implementation is fraught with hazards and may lead to more errors. The doctors who think change is a bad thing on principle will be in for a rude awakening. If it's going to be a showdown, they'll wind up losing, because we have the moral high ground."
Internist Cheryl Dunnett, M.D., medical director of the independent, 70-physician Cedars-Sinai Medical Group, claims to be "one of the least computer-savvy people around." She hasn't taken the PCX training yet and says she can't predict what CPOE will be like.
"It's a little bit frightening to learn a whole new system," Dunnett admits.
"But I don't think we can look back. This is not something being done to the physicians. It is more being done for the patients."