The UPenn study generated heated discussion and dozens of editorials in medical journals. Critics castigated the study for failing to compare data from the pen-and-paper era and for focusing on what many consider an out-of-date system that is not representative of systems widely in use today. But CPOE experts say that, nonetheless, the study highlighted some important truths about the difficulty of implementing CPOE. And the UPenn researchers say that more recent studies on a newer system show that while the doctors and nurses prefer it to the former system, the new system has not solved all the original problems that could lead to medication errors. Most notably, the structure and format of the screens can still cause medical staff to prescribe drugs for the wrong patient, the researchers say.

All of this debate comes as hospitals are facing increasing pressure from the government and patient safety groups to install systems such as CPOE and electronic medical records (EMRs), which replace paper files by placing medical and patient records on a computerized system. The U.S. Medicare system recently announced plans to offer lower-priced medical records software to doctors. (See "Feds Sweeten the Pot" on Page 80.) So far, slow adoption of CPOE and EMRs has been attributed to lack of funding and physician resistance. The difficult experience at Cedars-Sinai highlights the scope and amount of preparation needed to implement large-scale clinical systems. A move to CPOE can have a serious impact on the way that doctors and nurses do their work, and those hospitals that have been successful with CPOE have worked to avoid the kinds of disruptions that have made clinicians shy away from using the systems.

"CPOE will be the biggest clinical change initiative most hospitals have ever undertaken," says Dr. David Classen, who helped design the CPOE system at Intermountain Health Care in Salt Lake City and is now a consultant on CPOE to The Leapfrog Group, a Washington, D.C.-based health-care consortium.

How to Get It Right the First Time

Hospitals going through this massive change need to first focus on how doctors do their work to avoid inconveniencing them with additional tasks, says Asif Ahmad, CIO of Duke University Medical Center and Health System. Ahmad, who implemented CPOE at Ohio State University before coming to Duke, says the key to success lies in working closely with the doctors and nurses to help design the system, even if using vendor-built software. At Duke, Ahmad cochaired the CPOE task force with the hospital’s chief medical officer, and within his IT department, there are six physicians as well as 30 nurses and four pharmacists reporting to him. "It’s imperative that CIOs in hospitals build technical and clinical teams," he says. "People responsible for building or overseeing CPOE systems need to understand the clinical system." Although Duke bought its CPOE system from McKesson, doctors helped customize it to fit in with their way of doing things. When a doctor or nurse clicks a button to admit a cardiac patient, for example, the system shows them tasks and treatments such as administering aspirin.