cpoe/ehr implementation

CPOE/EHR Implementation 1

EHR/CPOE IMPLEMENTATION


Executive Summary

This thesis follows the implementation of Computerized Patient Order Entry/Electronic Health Record (CPOE/EHR)

system implemented by Partners Healthcare System (PHS) during 2002-2003 for all its constituent practitioners. It

looks at the problems faced during implementation of the system and identifies new potential problems that the

system may encounter. Particularly in consideration is the effort it takes to convince healthcare professionals to

switch to CPOE/EHR, the cost of installing the system, the potential of automating redundancies in the system and

the potential of healthcare professionals getting skewed data out of the system suggestions. It looks at the

management challenges faced by the administration when bringing about CPOE/EHR to PHS and divulges in some

techniques that were used for tackling these issues.

It defines ways in which the system is being used to improve patient healthcare and save millions of dollars for the

government, healthcare facilities and patients alike. This thesis also finds ways to combat the potential problems

that may arise later and the system and looks at related government policies and statutes which apply to the

implementation. Finally some metrics of success are discussed their effectiveness in driving a result.

Problem Definition

CPOE/EHR Implementation can face a host of problems that can hinder the process flow and the acceptability of

the system by the people involved. The initial problem is convincing everyone involved to not only consider

CPOE/EHR as an effective solution but helping them switch over to a system they are not accustomed to. Further

problems encountered include setting up the huge IT infrastructure, training of all personnel involved with system

implementation and usage, and offsetting the cost of implementing such a system.

Issues can also arise related to automation of redundancies in the system if workflow patterns are not considered

and redesigned to be adjusted in the new system. This has the potential of creating lost time and financial

resources as the system is being essentially designed to save time. Further problems that CPOE/EHR can face

include the potential for reliance on computer generated suggestions. Having suggestions being provided to the

healthcare professionals by the system based on historical and statistical data analysis has far reaching

consequences. It improves the quality of healthcare being provided to the patients however it still has the


potential for negative consequences. A mindset may emerge where the healthcare professional believes the

software to be error free which may be anything but so. Suggestions made to doctors during diagnosis are entirely

reliant on statistical data and historical records which may be plagued with inaccuracies. A healthcare professional

that becomes too reliant on the system may ignore personal hesitation towards a certain procedure or medicinal

prescription if the system suggests it to be successful.

Diagnosis

The main trouble areas encountered by PHS during the feasibility testing included convincing the healthcare

professionals to switch to a system where they have to abandon their current practices and switch over to CPOE.

For the extent of this case study we shall discuss the fact that Partners HealthCare System had about a third of the

doctors involved with the program who were practicing medicine out of their own offices and had no formal

relation to the PHS program. (Kesner, 2010) states that among the rest of the doctors who were affiliated with PHS

had a lot had their own practices outside of the hospital.

To integrate this scattered mass of healthcare professionals into a singular system required not only convincing,

but sufficient IT infrastructure and networking prowess. Among the many different healthcare professionals who

were affiliated with PHS but were running their personal clinics as well a multitude of platforms were used for data

logging. The project team responsible for bringing CPOE/EHR to PHS had to consider this factor while designing the

system so that the existing platforms could be modified and networked into one system.

The healthcare professionals were generally welcoming to an IT based data entry system however a significant

portion had qualms about switching; having to perform data entry by healthcare professionals during initial

meetings with the patients was seen as disruptive and overly cumbersome. There was also a significant cost of

installing CPOE system at a healthcare professional’s clinic and the “anti-kickback legislation” prevented any

subsidizing of system integration by PHS this are discussed later in this thesis.

Proof of Causes


It is inevitable for a group of hospitals to have doctors delocalized into private practice clinics after hospital hours

for maximizing their earnings. Further; surveys stipulate (McNamara, Wong, Brown, & Pitt-Catsou, 2009) that

adults at a mid or late stage of their careers are less likely to adopt change than their younger counterparts and

hence offer resistance to any new ideas. Setting up computers and large networking equipment which include

centralized data centers also carries significant costs with it and cannot be ignored when a need for spreading a

network over a whole city or a larger area is observed. Additional costs are added by logging of extra man hours

required for training as training large portions of the staff will require them to attend these sessions after their

shifts are over. If small quantities of the staff are trained it just means extra man hours being input by the training

staff as they have to conduct multiple training instead of one.

Any system which is divided into multiple levels of operations which are not completely interlinked with each other

at all levels is bound to have a multitude of redundancies. With a manual system the chance of having this

redundancies increase as it becomes increasingly difficult to network with every component of the system and find

out if there are any unnecessary steps being taken.

Action Plan

i) Project Management

There were several phases of this project which included

a) Formulating a plan for the implementation

b) Performing a change readiness assessment

c) Setting up the required network infrastructure to accommodate all the healthcare professionals

involved with this program

d) Convincing them to connect their personal clinics and healthcare centers to join in the network

e) Training for the personnel managing the network and all end users

f) Providing post implementation support through further training and a dedicated helpdesk

The project was expected to achieve high success rate in the following fields


a) Improved knowledge of patient’s condition and medical history during diagnosis

b) Improved success rates in deciding of economical medical procedures at lower risk

c) Improved data sharing among healthcare professionals for successfully achieving the above

mentioned goals.

The main tasks of the project included

a) Setting up the IT resources to perform the training and implementation of the system

b) Having a centralized data input and access system for all patient’s records with vital information

available to their healthcare professional easily

c) Systems that will support the healthcare professionals in making the correct decisions of therapy

and drugs for the patients by suggesting known working solutions

d) Systems that will evaluate the most successful practices and document them as well as learns

from current ongoing practices to improve its decision making.

e) Having adequate warning systems with the suggestions provided by the program to prevent

healthcare professionals to accept all suggestions as best solutions.

For successful completion of this project, PHS required support from its entire healthcare professional’s team to

not only adopt the program but to help in the initiation and programming phase for an improved result. It also

sought the help of a professional IT and networking team who could help it in setting up the systems required to

implement a project on such a huge scale. However it is essential to make the process grow instead of dumping

the whole system on the healthcare facility. By starting small problems that were not identified during the system

workflow redesign phase will crop up and can be eliminated as they come. Introducing new tools a few at a time

and integrating small portions of the hospital into the system is the way to go as it prevents a massive

communication and training storm which will disrupt the process flow of the facility.

By far the biggest risk involved in this process was the possibility of rejection from the healthcare professionals for

following this program if they failed to see a direct benefit to them from using it. A secondary risk was healthcare

professionals accepting suggestions from the system without considering additional risks that the software had not


calculated. This could result in an actual increase in readmission rates which would reduce not only the quality of

healthcare being provided but also devalue the software from its benefits. Further there is always a need of

bypasses in the system for emergency cases and this could result in bypassing occurring during instances of non-

emergency which would make the installation of this system ineffectual.

Some of the risks played out during the Cedars-Sinai CPOE implementation C.Connolly claims in her article (Cedars-

Sinai Doctors Cling to Pen and Paper, 2005) that this was not a failure of the system but the failure of the software

being unable to deliver a user friendly intuitive interface that the physicians and nurses could understand. Multiple

orders were required to be placed by the doctors before the nurses could get the information across to them.

There was insufficient training and the administration tried to convert too much of the system at once instead of

compartmentalizing the process. These are all red flags in the world of CPOE/EHR as every one of these steps

brings along with it its own problems.

Further risks include a fear by the clerk/help desk level of employees that they would lose their jobs, CPOE/EHR

looks to automate the processes that this workforce is generally performing. If the employees are not counseled

about the process and reassigned new areas of work they are likely to cause negative sentiments about the system

in their area of influence as they will see the system as their replacement. It is essential to perform a change

readiness assessment before proceeding with system implementation so that there is a smooth transition from

one system to the other without any reaction from the people involved.

The Initial task of setting up the central data acquisition and storage system can take approximately up to 6

months, however this may be entirely dependent on the existing IT resources available to the project team, further

decision supporting systems can be expected to be up and running 5 months from project startup. The systems

that evaluate successful practices and learns from the current ones is expected to have an additional lead time of 6

months, however seeing as it is an ever improving system it can be seen as an open ended process.

ii) Operations Management


A major problem faced by EMR/CPOE system is the process of automating redundant systems. The part where a

system procedure is being automated may be saving time, but the procedure itself being redundant is a total

waste of time in itself.

A programmer who is unfamiliar with the usefulness of any procedure, required for the patient or healthcare

professional to follow, is going to automate that system in any case. He may never realize the procedure is

redundant or may be significantly sped up by changing certain steps involved. Such shortfalls in the system can be

eliminated by incorporating lean management. By having the end users and healthcare professional experts

involved in the workflow redesign such redundancies can be by passed at an early stage, it also prevents any

variation in the system that a particular section of the staff will be opposed to at its root. This brings out positive

results faster and creates a positive sentiment about the system early on.

The easiest way to analyze the efficiency of a system is to observe before and after implementation process times

involved. A patient entering a hospital has to fill out several forms before he is able to see a healthcare

professional. He is going to repeat the same process every time he visits the same or associated health care

professionals outside the hospital.

By having CPOE the process can be simplified to having a singular patient code assigned to each patient which will

bring up his complete record from the centralized data storage. The patients can be provided magnetic strip cards

which carries their patient code with them which will significantly improve patient wait times and level of

customer service. The complete set of processes that are redundant and removable can only be identified by the

end users of the product which are the healthcare professionals and hence lean management is the most effective

tool for this setup. Having a senior healthcare professional for advice on all process changes can guarantee process

control. It is always advisable to have a physician telling an IT professional what he needs instead of an IT

professional telling a physician what he will have to do to run the system.

Further ways to quantify successful implementation is to measure the improvement in quality of care being

provided to the patients before and after the process has begun. There is no singular way to measure success but a

general idea may be gleaned from measuring the drop in medication errors and misdiagnosis due to lack of


information or wrong information available to the physician. Statistical analysis of the data being gathered is

required however with CPOE/EHR in place it becomes easier to gain this information as it is already being recorded

and quantified by the software. A simple process of data evaluation would immediately provide results that can

ascertain if the process implementation has brought about any positive changes to the system.

iii) Quantitative Reasoning:

CPOE provides a rich data platform on patient response to medicine and therapies which can be analyzed for

appropriate drug dosages and treatment recommendations to particular categorized groups. Complete compliance

with the CPOE format will allow statistical analysis of millions of patients which when correlated with their bio data

available, presents the opportunity to advance medicinal practice success rate.

For acquiring base data, assumptions have to be made on correctness of data input by healthcare professionals

and patients alike. It is not unlikely that a physician adapting to the system enters data incorrectly into the system,

or when more advanced systems are installed that the patients asked to update their medical data from home

provide misleading data by error of input. Systems and warnings in the software can bring the amount of incorrect

data by determining normal values and alerting the physician if the data being entered is off the scale. False data

or wrongly entered data is likely to skew the results.

Statistical analysis of success rate of procedures or medicines provided to the patients can be conducted once

significant base data is available after implementation of CPOE. Initialization of the system also normally starts with

either integration of previously available EMR data into the new centralized data network or if no existing

electronic data is present it may involve inputting the data into the system. Once the data is available to the

software it requires only basic statistical analysis tools to perform data analysis and find out why certain

procedures are successful or unsuccessful in patients. The extent of the data available may even let the experts

determine common causes of failures and success that require expensive surveys and time consuming data

collection practices that not only delay the results but increase the cost of solutions provided to the patient.

However data cleanup will be required for clearer results, certain patients may have responded very well to a

procedure but a group of patients with pre existing allergies or health conditions can react to the same procedure


in negative ways. A healthcare expert in that field can then determine the accuracy of the procedure and the data

that may be neglected or provided as a precaution when implementing those medicinal procedures. For this

purpose it is essential that a panel of healthcare experts is available with the statistical analysis team for their

expert opinion on the data found. If they find that the results being presented by the analysis are unlikely to occur

they can order further research and analysis with preset conditions to see if the results can be reproduced. This is

an opportune time for the hospital to consider its existing set of criteria concerning pharmacy and procedures, if

they find any shortfalls in the system they can be identified and removed with the support of statistical analysis

and a committee dedicated to finding the best workflow pattern.

A simple way to archive the impact of statistical data analysis is to represent the procedural rejection in patients

before and after implementation of the strategy. As an estimate the rejection rate for a particular medicine

prescribed to patients coming in with complains of heart palpitations, Figure 1 portrays expected data that may

be observed once the system is in place

-25 -20 -15 -10 -5 0 5 10 15 20 250

15

30

REJECTION RATE IN PATIENTS PRESCRIBED MEDICINE FOR HEART PALPITATIONS

24 MONTHS BEFORE AND AFTER BEGINNING OF STATISTICAL ANALYSIS

REJECTION PERCENTAGE

Figure 1 REJECTION RATE IN PATIENTS PRESCRIBED MEDICINE FOR HEART PALPITATIONS

Another KPI that will be tracked is the number of erroneous prescriptions per 100 patients for the entire PHS

system. This will help in visualizing the actual progress made in the field when benchmarking against previous

results. Figure 2 shows data along these lines once CPOE/EHR is fully functional at PHS


-25 -20 -15 -10 -5 0 5 10 15 20 250

5

10

ERRONEOUS PRESCRIPTION FOR PATIENTS VISITING PHS CONSTITUENT CLINICS

24 MONTHS BEFORE AND AFTER BEGINNING OF STATISTICAL ANALYSIS

ERRONEOUS PRE-SCRIPTIONS PER

100 PRESCRIPTIONS

Figure 2 ERRONEOUS PRESCRIPTION FOR PATIENTS VISITING PHS CONSTITUENT CLINICS

The results generated by statistical analysis will be interpreted and monitored to improve the system and eliminate

system weaknesses. Further analysis may be performed to observe patient wait time after arriving at a healthcare

facility, patient discharge time once they are told that they are free to leave by their physician and similar statistics

that monitor the overall quality of healthcare being provided and patient satisfaction with the system. Monitoring

the results will identify system flaws and constitute reiteration of system workflow patterns as required. It may

also identify the need of stricter control over data entry and stricter functions of bypass available to the physician

when entering data in to the software.

iv) Leadership:

(Smith, 2013) mentions several steps to cater change management for bringing about CPOE/EHR to an

organization these include

a) Executive and leadership coaching

b) Physician engagement

c) Training

d) Communication


Training and motivation seminars are essential to the development of this program, healthcare professionals need

to be motivated to participate in the designing process. This is the only way to ensure that problems that can only

be identified by people using the system are targeted and removed as much as possible. Motivation seminars

include educating the doctors about the benefits of using CPOE/EHR not only for themselves but for the patients

involved. It can be generally believed that healthcare professionals have the will to help people in their hearts

when they are entering this field. Calling on their motivation to bring the best solution to the patient they can be

convinced to switch to this system.

Secondly a very important aspect of convincing an organization to accept CPOE/EHR as into their system is to

convince their leaders about the effectiveness of the system first. Before it can be achieved it is essential to

perform a change readiness assessment. This includes conducting a workshop where all the leaders of the team

are invited and a brief seminar is conducted. Further in a post seminar session brief interviews are conducted with

individual members so that their change readiness can be evaluated. Here questions are asked about their

understanding of the system and how it will affect their workflow as well the workflow of their subordinates. If the

leaders understand the process and are able to deliver a compelling argument to their subordinates the task of the

project management team becomes easier. This also presents the opportunity for the team leaders to assess the

CPOE transition team and see if they are competent and skilled enough to lead them through a tough time of

transition.

Further PHS contacted medical insurance companies and cut a deal with them to pass on financial benefit of

improving the system through which a lower number of health hazard cases will arise. As people enter adulthood

they are less likely to accept change as they become accustomed to the norms of their life and consider it easier to

follow routine practices rather than adapt to a new system. A financial benefit along with the promise of better

healthcare is usually sufficient for most of the healthcare professionals to transfer to a system which may seem

cumbersome at first but ultimately is beneficial for all parties involved. It can be safely assumed that all healthcare

professionals enter the field with the intent of helping out people in general in their mind. Hence when offered a

solution which not only provides better quality of healthcare but also prevents excessive preventable financial


burdens all the while providing them with a system compiled with less overall errors they are likely to accept and

welcome the change.

As a healthcare professional it is essentially their responsibility to always offer the best solution to the patient

which will not only be of high quality but will not burden their patients financially. The initial strategy employed by

PHS was to convert the more willing people into the system before focusing their efforts to the neutral and

unwilling portion. This helped create not only trust in the system as people were able to see the results but

motivated them to embrace and integrate their practices with it. The project team learned from the people who

were easily inclined towards joining hands with them to convert to CPOE/EHR, they took this experience to the

primary healthcare providers who recommend the patients to the hospitals and convinced them to centralize their

data with PHS by showing them the benefits of switching.

This includes statistical data from CPOE/EHR proving it brings down reorder times, clarification calls from

pharmacies/labs and other related institutions and the willingness of medical insurance companies to pass on the

benefit of lower readmissions and erroneous prescriptions. Finally the remaining practitioners who did not see any

financial benefit from switching or were not inclined to switch, either left the system or sold it off to people who

were more willing to partake in it. This way PHS had managed to convert completely to their early stage of EHR by

2009.

Through frequent seminars for the CPOE/EHR system implementation the healthcare professionals involved were

educated about what is required from them for adapting to this system. Further efforts for smoothing out the

transition may include fliers and pamphlets that can be distributed to all practitioners to spread awareness about

the benefits of this system and guide the transformation process towards fulfillment. Regular trainings for all IT

and networking staff are essential for their training and development and identifying the needs of merging existing

technologies at the clinics and offices of healthcare professionals with the centralized database system. IT

professionals also require the lead of physicians and nurses in finding out the optimal workflow patterns post

automation of the system. This requires a dedicated team of healthcare professionals working with the IT team to

find the best solutions that will decrease the time any patient has to spend in a healthcare facility to receive quality


healthcare and at the same time decrease the amount of time healthcare professionals have to spend processing

the needs of that patient thus improving quality of service.

A complete system of direct and indirect reporting is required for the system to run smoothly as it is spread out

over a massive scale. IT and network professionals based in the hospitals take care of the basic networking

problems. Mobile networking teams visit the clinics and offices of healthcare professionals and provide constant

support for any issues that they may face to facilitate the transformation to CPOE system. Higher up in the order

panel of healthcare experts, work with the programming team to clean up the data gathered from the patients by

the system and provide solutions and suggestions for all healthcare professionals during diagnosis and

prescription. This system of decision support is present in all CPOE/EHR software but requires constant cleanup

and analysis to reach a state where it becomes essentially error free.

v) Financial Impacts

For initial phases of the system an estimate of the expenditure required for the project is made, this includes the IT

hardware including the examination of existing resources and the requirement for more resources as well as

upgrading the existing resources as seen fit. It also includes estimating the expenditure on training and motivation

seminars which are essential to the project success and the inclusion of additional man hours required for this

training. It also includes hiring any new IT or training related employees to conduct the proceedings. A big step in

the financial aspect of CPOE/EHR implementation is also acquiring the required financial resources by convincing

the leadership of the healthcare facility and this can only be achieved by convincing them of the positive aspects of

the system. It is essential for the organization to have a change ready leadership before these steps are taken as

shift to CPOE/EHR carries a big cost along with it which may make it difficult for the project team to convince the

leadership if they are already not considering the solution as positive.


If the system is successfully installed it is not only an improvement in healthcare service provided to the people but

it offers financial benefits to all parties involved. Through meetings with medical insurance companies PHS

negotiated improved earnings for the health care professionals as a better system will less incidents resulted in less

insurance payouts. It also provides cheaper medical procedures and medicine to the patients by analyzing the

medicinal and procedural trends and cutting the research times of new medicines and procedures among a varied

group of patients, this improves the overall satisfaction level of customers attracting people to gain healthcare

from that organization bringing in more patients and financial earnings.

However the project had the potential of failing if it faced significant disinterest from healthcare professionals, i.e.

if they could not be convinced to switch over to this system. This is a very realistic possibility if proper training and

motivation seminars are not provided before and during system implementation. Initially the system may look like

it is asking the healthcare professionals to do the jobs of clerks as well as dispensing quality healthcare. The system

may actually increase the time, difficulty and amount of information a doctor has to input into it to perform tasks

that they previously performed manually but it saves time by reducing the number of clarification calls performed

to ensure the correct test or medicine is being provided to the patient. It may also look like it is taking the jobs of

clerks out of the equation and rendering them jobless. However through proper guidance and reassignment of

duties the workforce can be utilized in other areas and not lose their effectiveness in the system. In this scenario

without proper guidance and training the total cost of infrastructure, training, motivational seminars, and all IT and

networking personnel involved will fall on the parent group of hospitals which will see a rise in healthcare costs at

their facilities.

To perceive all financial matters the data required includes calculating the total drop in erroneous prescriptions

and medical procedures. An estimate of medical insurance payments avoided and paid out to the healthcare

professionals. And a complete data set of all the expenditure made on the project including employee salaries,

networking equipment, over time logged and training and motivation seminars.

This data may be gathered by having strict data entry protocol for all transactions occurring within the hospital and

clinics and offices of healthcare professionals. It also requires regular statistical data analysis to provide number


and figures containing average drop of accidents correlating to the system installed. As well as having an organized

bookkeeping protocol during project implementation and related activities.

vi) Policy:

A number of policies and laws passed by the United States affect the system among these include the anti kickback

legislation and the affordable care act. On July 31st 2008, the commonwealth of Massachusetts passed a law in the

senate that forces the department of health to (SENATE, 2008)

“…before October 1, 2012 … adopt regulations requiring hospitals and community health centers, as a

standard of eligibility for original licensure and renewal of licensure, to implement computerized

physician order entry systems as defined by the department. …”

Hence in the state of Massachusetts it is now compulsory for all healthcare providing facilities to have a certified

CPOE system for practicing and providing service.

Another policy that stops the hospitals from providing financial benefit to the healthcare clinics and facilities for

installing this system is

“U.S. Code § 1320a–7b - Criminal penalties for acts involving Federal health care programs” (1320a–7b)

Which states

“Whoever knowingly and willfully solicits or receives any remuneration…in return for referring

an individual to a person for the furnishing or arranging for the furnishing of any item or service for

which payment may be made in whole or in part under a Federal health care program, or ….in return for

purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any

good, facility, service, or item for which payment may be made in whole or in part under a Federal

health care program. Shall be guilty of a felony and upon conviction thereof, shall be fined not more

than $25,000 or imprisoned for not more than five years, or both.”


This stops the hospitals from providing remuneration to the healthcare professionals associated with them for

adapting to a CPOE system.

Another policy that affects this system directly is the Affordable Care Act (Act, 2012) which added penalties to IPPS

hospitals if they have high readmission rates, this means that hospitals and clinics would be encouraged to follow

CPOE/EHR system to lower readmission rates and prevent penalties being enforced upon them.

In order to comply with the policy passed by the commonwealth of Massachusetts (SENATE, 2008)

“…The systems shall be certified by the Certification Commission for Healthcare Information Technology

or a successor agency or organization established for the purpose of certifying that health information

technology meets national interoperability standards.”

Any healthcare facilities that do not employ CPOE system after the date stated in the policy will simply not be able

to provide healthcare services and will have to shut down their facilities. Failing to comply with the kickback

statute may result in a serious fine and the potential of imprisonment. This can destroy the reputation of a

healthcare facility which causes more financial damage than the fine itself.

vii) Information Technology

PHS had a preliminary stage of EHR system in place they called it Longitudinal Medical Record (LMR), this system

mimicked EHR and was aimed at producing similar results, however since it was not forced to be followed by all

constituent members of PHS it had limited functionality. Once PHS decided to implement the CPOE system it

managed to extend its existing LMR system, modifying it and bringing about improvements so that it may be

incorporated into the entire network of people connected to PHS. The biggest challenge was centralizing the

patient record system so that all the different formats that were being used by the healthcare professionals could

be brought under one unified database.


All the IT projects had business sponsors and project managers, these personnel ensured that the correct solution

within the time limits and budgeted funds was reached. They guided the projects by focusing of project needs and

quantifying deliverables so that target achievement became a reality. It is important for the IT team to have

adequate resources for their process implementation; this requires dedicated trainers who are professionals in

their job. A technician or a software developer is just that, if they have great communication and training skills it

can be considered an added bonus. However it takes a professional trainer to be able to ascertain the amount of

information being provided to the trainees is not too much, to provide them the information in a friendly and

encouraging environment and that they will be able to store that amount of information.

It is also essential for training material to be developed before hand and be updated along with the changes in the

system. Web resources for self training and self help, guides and individual coaching as required are some of the

tools necessary for this program. Also required, before training begins, is an adequate space for training the people

involved. If such a space is not available within the hospital premises it is suggested to hold the training sessions in

training rooms available outside it. Following the progress of the trainees through results being generated in the

system or otherwise is also an essential aspect of the training.

A large team of IT professionals was required to integrate the entire system of 6000 plus medical professionals into

one centralized system. A Large quantity of data was being generated on daily basis and hence required not only

constant sorting but filtration as well. This data came not only from the patient visits but voluntary data submission

by the patients from home. One major concern with data generation at this scale is the potential of security lapse.

Health insurance portability and accountability act of 1996 protects the data of all patients entered into record

from being leaked or used without permission of the patients. It carries penalties of up to 1.5 Million USD (HIPAA

Administrative Simplification , 2013) for multiple violations that occur after 2/18/2009. This meant that very strict

security protocols were required to control the data being transferred and any leakage of data or misuse by

healthcare professionals handling the data could result in a serious penalty. Another major concern with data

leakage is the loss of image for the organization involved and hence serious security measures were required.


Another key aspect of IT preparedness is the disaster preparedness plan, this involved planning for power outages

and critical system failures; this includes having de-linked backups of the entire data which is updated at regular

intervals. Also in case of emergency power outages power backup systems or in the worst case scenario manual

backup systems must be available so that process flow does not come to a standstill. It is always better to be

prepared for the worst case scenario however unlikely it will be rather than reacting to an emergency as it occurs.

Metrics for Measuring Plan Outcomes

First and foremost measuring success is a measure of improve in service quality for the patients of PHS, this can

simply be measured by the average wait time of patients during entry and discharge to the hospital or clinic as well

as quantifying the drop in bad prescriptions or therapies recommended to them by accident or due to lack of

information available. The data provided by the statistical analysis becomes crucial at this point; it is of utmost

importance that the data is as error free as possible. Correct information about the expenditure on healthcare,

patient wait and discharge times and most essentially the success rate of medicinal procedures and prescriptions is

required to truly determine if the system has been implemented successfully.

Further data can be collected during implementation which calculates the percentage shift towards CPOE, any

organization that has chosen CPOE/EHR cannot and should not try to convert the entire system at once. Since only

a small portion of the system is being converted at a time, the percentage of orders being placed via CPOE can

calculate the basic implementation and success rate of the system. Further the system will have data on the

number of medication orders changed before being implemented due to the decision support function alerting for

allergies or other possible adverse effects, keeping track of these changes will gain support of the system among

the healthcare facility’s staff as it prevented a potential accident.

A by-product of CPOE/EHR is the amount of paper saved by the organization; this is also easily calculable and

provides a great positive statistic for the hospital to boast for its move towards a greener technology. It also frees

up a lot of space used for storage of paper and files that are now all electronically stored and have electronic

backups. Another positive aspect is that no order placed using CPOE will have a missing date or time, hence a


calculation of the drop in such orders will guarantee a positive result as soon as the system has begun its

implementation stage.

Another way to quantify success is to accumulate the number of bypasses used by the healthcare professionals in a

given time period. This is the easiest way to calculate the acceptance of the system by the physicians. A lower

bypass rate is indicative that the healthcare professionals have adapted well and are now comfortable in using the

system and hence less post implementation training and motivation is required. However a high by pass rate

means that the physicians and nurses using the software are not accepting the change or have had insufficient

training on the system and hence have to frequently use emergency bypasses to get through their workflow. This

should also determine the frequency of on spot trainings and the need of permanent transitional staff required at

the healthcare facility.

Another measure of success is calculating the financial benefit gained not only by the institution but by the

government as well. A survey conducted by Medical Expenditure Panel of National Institute of Health Care Reform

(NIHCR) (Sommers & Peter, 2011), taking into account data from 2000 to 2008, showed hospital readmissions rates

as high as 8.2% among adults aged 21 and older with an Index Hospital admission within in 30 days. This number

rises to a staggering 32.9% if a period of one year after admission is catered for. This puts immense financial

pressure on the government as the survey claims that

“In an annual basis, expenditures were $16.3 billion for hospital readmissions up to 30 days after

discharge and $97.2 billion for readmissions up to one year after discharge…”

The policy of imposing penalties on institutions with high rate of readmissions has thus been imposed as discussed

earlier in this thesis. Thus a reduction in the rate of readmissions brought on by CPOE/EMR is of financial benefit to

all parties involved including most importantly the patients receiving healthcare. Financial benefit is also available

to the healthcare professionals who transition into this system, particularly speaking of this case PHS found that

physicians were earning about 70% of the amount paid by the patients for healthcare. By negotiating with the

medical insurance companies this number was brought to 100% and in some cases special bonuses above this


amount for healthcare professionals bringing down their procedural errors and readmission rates through

employment of CPOE/EHR.

It is important for the benefits of CPOE/EHR to not only be reported to the leadership of the hospital care but to

the personnel involved with its implementation and use so that they may be motivated to keep using that system

and do not think that the slight inconvenience they face during order entry is all in vain. The idea that the hospital

has forced them into an inconvenience can only be removed if they can be convinced of the positive aspects that

CPOE/EHR brings with itself.

Overall it can be stipulated that CPOE/EHR brings benefit to any organization that decides to participate in the

transition, the improvement in quality of healthcare it brings to an institution as well as the financial benefits that

all parties can reap from it speaks for itself. It can be argued that CPOE/EHR is the leader of information

management in healthcare, as it uses the modern resources of IT and networking and utilizes the statistical tools

available to perform functions that were being done manually and were hence riddled with error. Its greatest

achievement, in bringing down the cost of medical research, may yet not be seen clearly by the public in general

and may not even be perceivable but it is not doubt the future of healthcare.


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Act, A. C. (2012, Feburary 08). Readmissions Reduction Program. Retrieved March 28, 2014, from http://www.cms.gov/: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

Connolly, C. (2005, March 21). Cedars-Sinai Doctors Cling to Pen and Paper. Retrieved March 31, 2014, from http://gunston.gmu.edu/: http://gunston.gmu.edu/healthscience/740/Presentations/cedars-sinai%20cpoe%20washpost%203-21-05.pdf

HIPAA Administrative Simplification . (2013, March 26). Retrieved March 28, 2014, from http://www.hhs.gov/: http://www.hhs.gov/ocr/privacy/hipaa/administrative/combined/hipaa-simplification-201303.pdf

Kesner, R. (2010). Partners Healthcare System (PHS): Transforming Healthcare Services Delivery Through Information management. Northeastern University, College of Business Administration.

McNamara, T., Wong, M., Brown, M., & Pitt-Catsou, M. (2009, March). Employers of choice. Retrieved March 28, 2014, from www.bc.edu: https://www.bc.edu/content/dam/files/research_sites/agingandwork/pdf/publications/SRH01_EmployersofChoice.pdf

SENATE, N. 2. (2008, July 31). AN ACT TO PROMOTE COST CONTAINMENT, TRANSPARENCY AND EFFICIENCY IN THE DELIVERY OF QUALITY HEALTH CARE. Retrieved March 28, 2014, from www.mass.gov: http://www.mass.gov/legis/bills/senate/185/st02/st02863.htm

Smith, P. A. (2013). Making Computerized Provider Order Entry Work. Florida: Springer London Heidelberg New York Dordrecht.

Sommers, A., & Peter, J. C. (2011, December). Physician Visits After Hospital Discharge: Implications for Reducing Readmissions. Retrieved March 29, 2014, from http://www.nihcr.org/: http://www.nihcr.org/Reducing_Readmissions#section7

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