"If physicians help design CPOE, and it’s done the right way, it’s not going to cause errors," Ahmad says.

Duke’s CPOE system, which went fully live on all 590 patient beds as of June 20, includes 259 "order sets," specific instructions for standard medical procedures that were jointly developed by physicians. "The idea was to get all the cardiologists in one room and tell them they can’t leave until we agree on a set of directions on how to manage patients," he says. "Sometimes there are personal preferences but we have to agree to make the system work." During the first nine months of the process, he held regular meetings with doctors and nurses to map workflow for each speciality and unit of the hospital. As a result of these meetings and close consultation with medical staff, the team of doctors and IT staff were able to avoid design problems they viewed as potentially harmful to patient safety. For example, the design team made sure that information on a single patient remains on the same page or screen and staff cannot swing to another patient’s page until the orders have been completed for the initial patient. "If you display more than one patient on the same screen, you have a greater potential for error," Ahmad says.

Ahmad also says doctor input pushed the IT team to create a "single sign-on," which allows physicians to look at test results on one system and then move into the CPOE system without having to log out and log in again. And in order to combat "alert fatigue," Ahmad says Duke is working on building a corollary system that will send most alerts outside of CPOE. Then, doctors will be able to do their work without the nuisance of constant pop-ups telling them about interactions that are not dangerous to the patient. A select group of pharmacists, doctors and nurses monitoring this corollary system will be able to respond to serious alerts.

Big Bang Versus Gradual Approach

Benjamin R. Williams, CIO and senior VP of strategic innovation at St. Joseph Health System, an hour south from L.A., agrees that a close relationship with the medical staff is key to CPOE success. Williams watched closely as doctors rejected the system at nearby Cedars-Sinai and has carefully structured the CPOE initiative at his own network of community hospitals to involve doctors from the start. He designated champions of the system among the medical staff to convince more reluctant doctors to use the system. He also decided to phase the CPOE rollout over a period of several years and encourage doctors to use it, rather than force them to do so all at once, which is what Cedars-Sinai did. Phasing it in has also allowed his team to make fixes and respond to doctors’ concerns about the system’s design.