American College of Physicians: Internal Medicine — Doctors for Adults ®

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Monday, December 9, 2013

Why does computerized physician order entry take so long?

Computerized physician order entry (CPOE) is being rolled out across our nations’ hospitals. The old days of written, and often illegible, orders from doctors are fast becoming a thing of the past.

The potential for this measure to improve patient safety and transform medical practice is unquestionable. As a physician who has worked in several different hospitals since finishing my residency, my time in practice has coincided with the new age of technology in medicine (the iPhone was released as I was finishing my residency). Yet one common theme has been present in all of the hospitals I’ve practiced in. Despite all the promising technology, the computerized order entry systems that have been introduced have largely been slow, tedious and difficult to work with.

Having been intimately involved in CPOE implementation myself, I cannot help but feel slightly disappointed that it hasn’t lived up to expectations. The process can only be as good as the final infrastructure allows it, and unfortunately the implementation is frequently happening on suboptimal software platforms. It would be akin to planning a great traffic system over roads that are completely broken and don’t allow the cars to go at the desired speed. The wrong way round to do things! There’s a large dichotomy between the idea and the technology infrastructure. And to be fair to health care organizations, policies such as meaningful use have meant that hospitals have been forced into a corner of needing to roll everything out quickly in order to receive significant and much-needed federal incentives.

From my perspective as a hospital medicine physician, let’s go through a typical everyday scenario. This has happened in every hospital I’ve worked in, and is not unique to any one institution. The nurse will request an order from the doctor, who may need to drop whatever he or she is doing and find a computer to log into. Typically during the day, a free computer can be hard to find! Logging in will take several seconds, and booting up the system several more. Then we have to deal with a less than optimal interface, multiple clicking will be involved, typed data entry using a keyboard, then a password. Following this, a few seconds to make sure the order has “gone through.” This applies to something as simple as ordering a Tylenol. A complex scan or test that requires some “text entry” to make the order clear, can take minutes.

Why is order entry so cumbersome? It’s often quicker to buy an item online than it is to enter a simple order into a medical system! And whenever we do this it takes time away from our patients in an arena where time is already scarce. A recent study published in the Journal of General Internal Medicine revealed the disappointing statistic that medical interns now spend only 12% of their time in direct patient care, and up to 40% in front of computers. Slow order entry undoubtedly contributes to this.

And it’s not just doctors who are affected. The situation applies to everyone involved in the order entry and retrieval process. Every day, I also see nurses frantically wheeling around their portable computers for most of their shift, reviewing and confirming orders, frequently spending more time with their screens than the patients who truly need them.

In our new technological age, here’s what we really need:
• touch screens, undoubtedly the future,
• quick password entry and rapid screen loading. We cannot afford situations where the software takes up to 30 seconds to load up,
• minimal clicking or scrolling to get to where we want within the program,
• a user-friendly interface, and
• ease of updating and modifying the system if problems are discovered after implementation. This is often very difficult to do, but a vital need for any health care institution

Many of our current systems utilize older platforms, require constant use of the mouse, and have a pretty terrible user interface! Cars, planes, our home devices—the mouse is on the way out, so why do we use them so much in health care? Other technologies have progressed rapidly, yet the health care industry finds itself behind the curve. Our computerized systems may be complicated and have a stringent need for security, but they are still too slow compared to where they should be. I once spoke to a physician administrator who was involved in implementing a hospital IT order entry system, who told me that it wouldn’t necessarily be designed to “save the doctor any time.” This seemed to be taken as a given. It shouldn’t be.

Computers and technology need to be optimized with the workflow of frontline physicians. Let’s view the clinical interaction with the computer as a triangle—the doctor, the patient, and the technology. Too often, it is a straight line with the computer coming in between the doctor and patient. This also means that the patient will not feel the full benefit of the new technology.

I’ve witnessed many IT project teams that will include as part of their clinical advisory group, physicians who don’t regularly practice medicine. I’m sure the idea of involving these physicians is well-intentioned, but how can someone who doesn’t see patients possibly be best placed to design a system for practicing doctors? Whether it’s order entry or data entry, we need to have frontline physicians with knowledge of IT at the forefront of software development, completely involved in every stage of design and implementation. Well before rolling out any new system, give other hospital clinicians a chance to test it out and provide feedback. To use Apple as an example, the initial designers were all users of the product they were creating, who understood the need for providing a good end-user experience. Successful products like the iPhone were the result of their endeavors. We need to adopt the same philosophy for health care technology.

Physicians should not be required to stop their daily workflow for anything longer than a couple of seconds to request orders. The final aim should be for the process to take not much longer than simply speaking. This applies equally to when the physician is entering any other orders, such as admission or medication instructions. Hopefully in a few years, this debate would have moved on when we’ve finally got some better systems in place. It’s probable that some of them are already under development, but we need them yesterday, not in 10 years’ time.

A handful of hospitals are already getting there, and enable order entry with a few touches of a smart screen device. That’s the way forward. Medical professionals must not be hindered by the computers which are supposed to help them. The successful health care IT of the future will be the software that enables the doctor or nurse to spend maximum time with their patients. Collectively we must do better, and doctors, IT experts and hospital administrators need to all work together to achieve this goal.Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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