CPOE projects are like many tricky enterprisewide implementations, and CIOs from health care and other industries can learn important lessons about change management from hospitals that have gotten CPOE right, including Brigham and Women’s, Duke University Medical Center and Health System, Intermountain Health Care in Utah, and St. Joseph Health System in Orange County, Calif.

"The simple truth is that CPOE is not a turnkey solution," says Brian Strom, chair of the department of biostatistics and epidemiology at the UPenn medical school. "Getting it right takes a tremendous amount of monitoring and tailoring. No one expected Word 1.0 to be perfect, so it’s not surprising that CPOE 1.0 isn’t perfect either."

To Err Doesn’t Have to Be Human

Until the turn of the 21st century, only a few major hospitals had attempted to design and implement CPOE systems. But then in November 1999, the Institute of Medicine published a report that galvanized the nation’s medical community. The report, "To Err Is Human," put forth some disturbing figures. Avoidable medical mistakes kill anywhere from 44,000 to 98,000 people a year—more than breast cancer, highway accidents or AIDS. The report also said that more than 7,000 deaths are caused by medication errors.

CPOE quickly rose to the forefront of health IT systems as a promising means of preventing medical errors. Large vendors such as Cerner and McKesson developed and updated CPOE systems, and hospitals large and small began to adopt the new technology. The road has not always been smooth for those adopting the systems, however. In January 2003, in a high-profile case that spooked the medical world, doctors at Cedars-Sinai Medical Center in Los Angeles, unhappy with the extra time it took them to enter orders on the computer, staged a rebellion and forced the hospital to shelve the CPOE portion of a $32 million implementation project after three months of use. Then, in March of this year, researchers at UPenn published a study in the Journal of the American Medical Association (JAMA) documenting that their CPOE system, an early model from Eclipsys, could cause 22 types of medication error risks.

The researchers, led by Ross Koppel, a sociology professor at the UPenn School of Medicine, surveyed staff using the CPOE and shadowed doctors, nurses and IT staff to see how they used the system. One risk discussed in the study was the difficulty staff had in discerning which patients the doctor was ordering for, because the CPOE display was fragmented and required switching between multiple screens. Such clunky features increased the risk for faulty orders on a regular basis, the study found.