Emory Case Study

The main reasons why Emory decided to implement CPOE systems were to reduce the number of medication errors, as before CPOE went live, physicians at Emory would place orders by writing them on an order sheet attached to the patient chart, and in some cases, they would call a nurse to write the orders on the order sheets. When this happens, it was not uncommon for the physicians to sign off orders that weren’t verified correctly by the nurses. There’s also the concern of lost paperwork, or illegible orders. Therefore CPOE systems are mainly designed to reduce, or eliminate handwritten orders.

These are all good reasons, but CPOE did not exactly eliminate all medical errors as some physicians, who are not as familiar with technology, would often put in the order for the wrong patient. However, it is definitely more efficient, as the doctors have the responsibility to enter in the order themselves, and they are entering it into the computer so it improved legibility.

Before adapting to CPOE systems, physicians would communicate verbally to the nurses to place the work order, but now with CPOE, every work order is now computerized. Physicians can enter in the information themselves digitally, and medication and other orders can be placed correctly.

Workaround, is when you use other methods than what the system is originally designed for, to get the work done. An example of this would be the physicians letting nurses place orders, without entirely verifying it, instead of writing it down themselves. I personally did not have much of an experience in working around the technologies that I use.

Some suggestions that I have for creating a culture where people are willing to adapt to unforeseen problems while using complex system like EHRs and CPOE, would be to just take it slowly step by step, and to train physicians to use technology. The systems should also be more user-friendly. Developers should work with physicians and nurses to develop one that would help them understand how to use the software better. I don’t exactly remember any major system changes while using computers, but while I was in my java programming class, I was first introduced Dr. Java, and then later introduced to Eclipse, which checks the java code more efficiently, but there’s more shortcut buttons that you need to familiarize yourself with to make use of the software.

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Emory Case Study

• What are main reasons why Emory decided to implement CPOE systems? Were these good reasons? 

Emory decided to implement CPOE because they are more reliable and easier to access than the previous system. After implementing CPOE, doctors can initiate orders online instead of signing papers. It reduces the probability of losing the paper. In addition, doctors can send the patients' exam online instead of through faxing.

They were good reasons because they free doctors and hospital workers papers, which are burdensome and hard to manage. CPOE allow both doctors and patients to view the details online.

• Why won’t CPOE’s eliminate all medical errors? 

CPOE cannot eliminate all medical errors due to man-made mistakes. According to a ground nurse's experience, CPOE is extremely difficult to use. Though CPOE has benefitted many emergency physicians in a significant way, it also brings trouble for those less technology savvy physicians. They would click on the wrong patient names.

The overall feedbacks from physicians are positive.

• What are the some differences between how Emory placed orders before CPOE and then after CPOE? 

After CPOE, nurses no longer need to take notes from the doctor and let the doctor sign the order. Doctors will type in the orders himself. Doctors can also view the information through the sheets with a remote access. It improves efficiency and minimizes the mistakes.

• What is workaround, and how does a change in workflow make workarounds more noticeable? 

Workaround means that hospital workers work in a different way to achieve the goal instead of the normal way. They perceive that some problems are very hard to solve.

A disintermediation in Emory CPOE shifts the workload of nurses to physicians. Physicians complain about that because they have to do more. Nurses have problems reviewing the order because they no longer receive verbal orders from doctors. Pharmacists love this change because they are freed up from writing orders all day to walking around on the floor.

• Have you ever experienced anything like this in your work or school systems? 

U of A Campus Recreation Center has just renovated its locker room and introduces a new towel tracker. This move causes disintermediation between the towel renters and workers at rental area. Additionally, renters would no longer need to get into line and return the towels due to the micro trackers on the towel. While it saves trouble for most of us, people who are not so acceptable to the change needs to register their finger prints.






I suggest that people should be informed of the benefits change bring in a long run so that more people are welcoming the changes.

Emory CPOE Study

•What are main reasons why Emory decided to implement CPOE systems? Were these good reasons? 
 The reasons the Emory implemented CPOE was due to the number of unintentional medical errors that had been occurring, generally, in health care and as a delineation, the Emory hospital system.  Almost 900,000 injuries occurred, in 1984, due to errors in patient management in the U.S. - where more people died versus car accidents, breast cancer or AIDS.  Some examples of such type of errors occur through multiple transcriptions of an order or orders of medications.  Any attempt to mitigate the number of preventable errors, that does not worsen the problem, would seem reasonable to implement.  Though, as discovered in the article, there were consequences that resulted from implementing CPOE and hard evidence was not provided as to whether or not the incidents of errors decreased.

Why won’t CPOE’s eliminate all medical errors?
Initially, CPOE's will not eliminate all medical errors because of the learning curve involved in the adapting to the new system.  Changing such a process involves coming up against a great deal of rigidity by the involved agents, as described in the article, and they have to unlearn habits.  In the long-run, such incidents may decrease as knowledge and familiarity with the CPOE system increase by those in health care.  However, it is still dependent on human involvement which always opens the potential for error.

•What are the some differences between how Emory placed orders before CPOE and then after CPOE?
Before CPOE's more of the order handling was in the hands of the unit clerks and nurses who were entering everything by hand which could result in greater human error.  After CPOE was implemented, the doctors had greater responsibility in the placed orders and they were writing the orders through computers and not by hand.  There were some issues with the new system as not all the physicians were as proficient with correct entry and some confusion ensued on the proper form for entry.  There was also no gatekeepers keeping a "check" on the proper transmission of orders.  Some animosity resulted for both the physician increased workload and nurses who felt the system was too complex and cumbersome.

What is workaround, and how does a change in workflow make workarounds more noticeable?
A workaround was a way that an order would eventually make it to its desired result though not going through the normal process, but working around it.  These workarounds are generally inefficient and knowledge of how to do it was in a limited amount of persons' hands.  These workarounds were exposed when the CPOE system was in place as they could no longer "successfully" function like they could before CPOE.

Have you ever experienced anything like this in your work or school systems?
Yes, I experience such an occurrence of some new implementation every semester that involves an "de-training" of an old process and training of a new process.  The people who are no on board with the change do seem to create a bottleneck.  Many times such a new process is not effectively communicated to all the possible people involved and it is not unusual to find this and have to explain how a process has changed to another person.  There is definitely a domino effect that takes places and with pushback or poor communication the positive effects that could have resulted can be stunted.  Then an individual might feel entitled to say "see the process isn't working, lets go back to the old process".

Are there any suggestion you have for how to create a culture where people are willing to adapt to unforeseen problems with such a complex system like EHRs and CPOE? Have you had to go through any major system changes in other parts of your life?
I think the best way to create a culture where everyone becomes more accepting to change is to be very clear of the consequences that the current system is having and then show clarity about how instituting specific changes will help to overcome such consequences.  And that every person's role in accepting this change is pivotal.  If there is any rigidity from people, then the consequences may end up worse than the consequences of the original system.  Also, sympathizing and empathizing that adapting to such changes are not going to be easy, that there may be headaches, but in the long-term it will be of greater benefit.

Emory Case: A Study By Ben Ampel

What are main reasons why Emory decided to implement CPOE systems? Were these good reasons?

There were errors in the system due to manual order sheets. These paper sheets had to be verified, but sometimes were not before an order had already been carried out. Handwriting, lost paperwork, and a high number of changing hands for the paperwork created a high amount of errors.

CPOE allows medical institutions to move away from these handwritten papers, and removes the need for the nurse to potentially make mistakes when taking notes from the physician. Physicians now also have remote access to these sheets, allowing them information away from the hospital, which is reason itself for me to think that this was a good plan. The plan to improve patient care also seemed to be a success, although there was a mixed response from the physicians.

Why Won't CPOE's eliminate all medical errors? 

No system that has human input will ever eliminate errors. Many doctors are older and very hesitant to learn to operate the new system. They may accidentally select the wrong patient in the system, or enter information in an incorrect field. I'm an MIS major and I still make mistakes in the systems I use, of course doctors are going to make mistakes in their personal system.

But, overall, Dr. Matthews in the study states that errors were drastically reduced. So even though errors still exist, CPOE's have reduced overall error, and created a net benefit.

What are the some differences between how Emory placed orders before CPOE and then after CPOE? 

It used to be that physicians would give a verbal order to their nurse. The nurse would then write the information down on an order sheet. The nurse would then verify the order by reading it back, and then the physician would sign off on it.

Now, the nurse has been taken out of the equation. The physician takes down all information on a computer, and saves the information right there. The sheets can be looked at through remote access, and medication can be ordered immediately from the system.

What is a workaround?  How does a change in workflow make workarounds more noticeable?  

A workaround is a way of completing a task in a way that the system was not intentionally designed for, or avoiding an problem part of the process. Workarounds can potentially be time saving. If workflow is changed, workarounds may become unusable as the system no longer allows the task to be completed without following all steps, which could exaserbate issues if the previous problem in the system was not fixed or updated.

Have you ever experienced anything like this in your work or school systems?

At the Rec Center, we've added new electronic waiver forms for patrons to sign when they purchase a membership. The way the system works is you're supposed to click through the entire assumption of risk form on a tiny touch pad and then sign, however the pad times out after 20 seconds. But if you click through one page and then tap where the "sign" button appears later, you can get into the signing part of the program, saving about 30 seconds of tapping through waiver, plus the potential problem of the pad timing out and needing to restart.

What about other workarounds you do for software you use now?

Other than what is done at the Rec Center, I try to use hot keys to automate processes in my software, but I'm not sure I use any actual workarounds in my day to day life to avoid issues or bugs in the software.

Are there any suggestions you have for how to create a culture where people are willing to adapt to unforeseen problems with such a complex system like EHRs and CPOE?   

I believe training and information is the most important part of the process. If doctors know from the get-go that these systems will save them time and energy, they will be much more willing to deal with problems as they come. If physicians can't see the benefit of a system, then any unforeseen problem will just anger them further, leading to a much less productive day. Also keeping someone on staff who is always available to help with problems can help with productivity and positivity.

Have you had to go through any major system changes in other parts of your life using computers?

Again, the Rec Center likes updating their horrible system all the time, which only creates new and interesting problems to deal with. The people who actually use the system on a day to day are never consulted about changes that should be made, and this is obvious with every new update. Integral parts of the system break regularly, while areas of the system that are used maybe once a week for special cases work flawlessly.

Emory Case Study

What are main reasons why Emory decided to implement CPOE systems? Were these good reasons?

Emory chose to implement a CPOE system to modernize their previous process that involved manually filling out order sheets. Some physicians would do this themselves, or even have a nurse do it for them. There were frequent errors occurring with orders, as things could be lost in the process, handwriting could be misinterpreted etc. I think the fact that too many errors were occurring is a good enough reason to choose to implement the CPOE. While it was an expensive change to make and a big one process wise, overall it led to a reduction in the number of errors occurring. 

Why won’t CPOE’s eliminate all medical errors?

Unfortunately, even in a computerized environment there is still the possibility for users and their input to create issues. An example of this is the physicians or whoever is doing the entries accidently placing an order for the incorrect patient. Additionally, ownership of placing orders was transitioned fully onto the physicians, when they did not complete them all previously, so that can cause errors as well.

What are the some differences between how Emory placed orders before CPOE and then after CPOE?

Now, all orders are placed by the physician directly, whereas it previously was often completed by nurses. They place all orders through the computerized system, and can place multiple orders for a patient simultaneously. The physicians can now also place the orders from anywhere they access the internet, not just in the hospital. This is all much different from previously writing orders or needing someone else from the hospital staff to do so.

What is workaround, and how does a change in workflow make workarounds more noticeable?
A workaround is a way that a process is circumvented, often without realizing you are explicitly doing so. For example, actions in a process that were considered unspoken rules, like not formally disclosing old orders, when that was supposedly part of the old process, issues can occur.

Have you ever experienced anything like this in your work or school systems?

Yes, I had experience creating a new electronic system to standardize a business process previously conducted over email. It quickly became clear that business users can be excited for a new system or way of doing things, but there can still be a lot of animosity towards change and doing things a better way unless they truly had a strong dislike for the old system.

Are there any suggestions you have for how to create a culture where people are willing to adapt to unforeseen problems with such a complex system like EHRs and CPOE?

My largest suggestion for those for those implementing large systems such as EHRs and CPOEs is to make stakeholder communication the foundation of the implementation. From gathering requirements through a go-live, the more opinions you can gather and education you can give, the better off you will be. Even though it can be a pain as the developer or implementer of the system, your subject matter experts will be more than happy to offer their insight and tips, and they’ll likely be very valuable and encourage adaptable culture.

Emory Case

Change of any sort can be difficult but more so for an industry that has been doing something the same way for about a century. Emory Healthcare was founded in 1905 and, although they made some small IT advances in the 90s, used the same way of order processing until around 2005. When President Obama and congress made it a focus to enhance health information technology by enacting a stimulus package that invested $19 billion in the area. This change was met with resistance but Computerized Provider Order Entry Systems (CPOEs) were made with the goal of reducing adverse drug events and making the process more efficient as a whole.

Emory Healthcare is the largest health care system in Georgia so the overhaul that they experienced was on a large scale. They have 4 hospitals with 1,184 licensed patient beds along with 9,000 employees. Whenever you implement a change that will affect people on this big of a scale there will definitely be some hurdles. In the past, physicians would write patient orders on order sheets or have nurses do it for them. Nurses were supposed to read back the order and physicians would sign off if it was correct but there were some instances where the physician would sign off on it after the order was filled. This could create some errors because of miscommunication and was not an efficient way of filling orders but was what they were used to for so long.

CPOEs changed this process and put the responsibility mostly on the physician. This may have caused some unwanted work for the physician but was a much needed advancement. The physician or another provider with the correct privileges would enter the orders on the hospital computers. The physician could put in orders from anywhere with internet access which made things more efficient. The implementation of this was met with mixed reactions. Some liked the customization but other less technologically savvy physicians saw it as a hindrance to their work.

The value of CPOEs is still debated but most healthcare employees would agree that it is a needed and important step for our healthcare system. Adapting to the digital world will be easier and easier as the years go on because almost everyone has some sort of understanding about technology. Studies have shown that they do reduce adverse drug events but they are not conclusive. They can also cause different kinds of errors not seen in written orders. The investment in health information technology should be continued as more advances arise making it easier for patients to get quality care.