Computerized physician order entry (POE) is defined as a process that allows a physician to use a computer to enter medical orders directly. The concept is receiving an increasing level of attention because the Institute of Medicine report “To Err is Human” notes that POE holds potential for decreasing the number of medical errors in hospitals.1
This is because the system can offer decision support at the time it is most needed. Despite its touted benefits, however, POE is not widely used. In a 1997 mail survey of hospitals, we found that POE reportedly exists in one-third of U.S. hospitals, but is really used in less than two percent of them.2
Comments from the survey respondents indicated that administrators are looking forward to POE implementation but fear that physicians will resist it. Historically, physicians have been reluctant users.3–6
We designed a study not only to find out why there is resistance but also to investigate the complex interplay of factors that influence the success of POE implementation.
A description of the process in the context of a teaching hospital illustrates why POE is an intriguing implementation issue:
An intern attends rounds early in the morning with her team of residents and an attending physician. The group discusses each patient either at the bedside or just outside the room. During the course of the discussion, suggestions are made about what tests and medications to order for the patient. The intern writes some notes as a reminder about what to do later. At the conclusion of rounds, the intern is expected to enter orders into the computer for most patients. She seeks an unused machine, logs on and locates the first patient in the system. She may order labs and then begin to order medications. To order a medication, she first needs to find its name in an alphabetical list and select a dosage from a menu and then a schedule for administration from another menu. If the dosage or schedule desired is different from normal in some way, she may need to type in exact instructions and be creative about abbreviating words because the space for free text may be limited. She sends the order for the first medication and, to order a second, goes back to the alphabetical list and starts again. If she orders something that might interact with another substance, she receives an alert when she asks the machine to send the order. When the intern is finished with the orders for the first patient, she pulls up the record on the second patient and starts again. She is pleased that the medication is received on the floor within an hour. Because the data are entered in a structured manner, and because they enter a large database, an accurate record of that order now exists for billing and other tracking purposes.
Without the computer, the physician would write a list of orders in longhand or check boxes on a form, one list per patient, and a ward clerk or nurse would take over the process after that. The clerk may need to clarify the order, especially if the writing is hard to read. It may take the intern ten minutes per patient to write the orders and answer questions. Messengers or a pneumatic tube may be used to deliver the order to the pharmacy. A drawback of the manual system is that it may take six hours before the medication reaches the floor. However, the physician may spend less than a half hour writing orders for all patients. Using POE may take much longer or be perceived as taking much longer.
The purpose of this study is to describe perceptions of POE held by diverse professionals at both teaching and nonteaching sites where POE has been successfully implemented. The professional groups include clinicians, administrators, and information technology personnel. Success is defined as heavy use (over 80% of orders are entered electronically) by a large number of physician users. The reason for studying successful sites is that they can serve as models. The focus of this study is on commercial systems that have the potential for being widely adopted. The present study is designed as a cross-site study so that the perceptions of diverse professionals can be compared both within organizations and among different settings. The field investigators (JSA, PNG, ML, JAL) were an external, multidisciplinary team unaffiliated with any of the selected sites at the time of the fieldwork.