Why Doctors Are a Pain

When Children's Health System's Jones wants to get through to his most demanding group of users (the physicians), he goes to grand rounds. As he joins the residents, interns and attending physicians in the Milwaukee hospital's auditorium, the topics range from neuroblastomas to psychological sequelae after paediatric trauma. But when Jones attends, the discussion includes IT.

Doctors are not technophobic. Quite the opposite, says Bradford Holmes, health-care research director at Forrester Research (US). "When it comes to clinical technology - new laparoscopic technology or a new defibrillator - lots of them are technology addicts,"he says. But when it comes to information technology, doctors, Holmes says, "have a limited desire to learn new software and applications, particularly if it will take them a lot of time."

So when Jones decided to introduce a CPOE system at the hospital last year, "There were months of going to grand rounds, physician directors' meetings, any open discussion that we could find,"he says. He had already built some credibility with these users shortly after his arrival in 1996, when he upgraded a hospital information system to handle administrative processes like registration and billing.

This time around, he enlisted the help of critical care paediatrician Dr Carl Weigle, a 12-year veteran of Children's Health. Since the doctors weren't exactly clamouring for automated order entry, having a veteran physician touting the system definitely helped. Getting ardent users to advocate with their peers is the best way to get buy-in for big technology changes. "That's just the way things work in the medical culture,"Holmes explains.

But that was just the first step. What draws doctors in are features that improve patient care, save time or generate revenue. Weigle and Jones found that their best selling-point for CPOE was patient safety. According to the National Institute of Medicine, in the US avoidable medical errors kill between 44,000 to 98,000 patients a year, and automated order entry, which eliminates mistakes due to indecipherable handwriting, offers a powerful solution to that problem.

Jones recruited the most enthusiastic users to help in the selection and implementation of the CPOE system. As the new part-time medical director of information services, Weigle also tried to involve the users that were the most dubious about the project. "The ones that were asking the smart questions, the tough questions, I tried to recruit to our selection team because I knew they would ask the important questions,"Weigle says.

Among the unconvinced was Weigle's boss, Dr Thomas Rice, director of the paediatric intensive care unit. "I was sceptical of how the technology could help me as an end user,"says Rice, who has worked at the hospital for 27 years. According to Rice, the flexibility of the IT team in responding to his and other doctors' concerns was critical. "Mike's biggest strength is that he's open,"Rice says. "But the key has been having [Weigle] involved; he understands the physician end of it."

Once the interdisciplinary team decided to invest $US6 million in the installation of the CPOE system from Eclipsys, the next hurdle was training. For the busiest users, this can be the point of pain. You may have sold them on the benefits and given them all the right functionality, but if they don't have time to learn how to use it, all is lost. So Jones decided to cut training time. "We limited it to one hour and just trained them in the basics,"says Jones. He also ended up training the most gung ho residents separately from the attending physicians, who were not as motivated to learn. "We had tried training the old guard and the new guard together in the first training session. The attendings were complaining and asking how is this going to work, while it was going too slowly for the residents,"Jones explains. "One approach did not fit all."

He supplemented the hour-long intro to CPOE with ongoing support from users more familiar with the system. "Doctors learn according to Â'see one, do one, teach one'. You watch someone do an appendectomy, you do one, and then you teach someone else to do it,"Holmes explains. "You have to ditch the manuals and the long classroom sessions."

Following the launch - half of the physicians were brought on board in June 2001 and the other half in September 2001 - Jones provided 24/7 user support the first two weeks after each rollout. The implementation has included a great deal of follow-up work. "Someone in IT makes the rounds once a week to all areas of the hospital to listen to and document complaints,"he says.

Adoption rate is now nearly 100 per cent, according to Jones, although a certain number of surgeons tend to rely on residents to do their computerised order entry. He has resigned himself to the fact that some may never use the system.

But the successful introduction of CPOE has further enhanced the IT department and the CIO's credibility among hospital users. Jones is considering several upcoming projects, including a new picture archiving communications system, a move to electronic medical records, updated operating room systems and a pharmacy robot. But he understands that each user group can handle only so much change. "We would get in trouble if we introduced too much change at one time,"says Jones.