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Implementation strategies

 

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Implementation Strategies 


Basic Strategies and Decisions

Two basic strategies are to role out CPOE throughout the organization at once, the so called "big bang" approach and the incremental approach.  Most organizations have done an incremental approach or a "partical big bang" that may exclude units with different workflows such as OB in an initial rollout.  Another key decision is if only physicians will use the system or if nursing (and other clinical staff) will also use the system.  If all clinicians use the system, nursing can help train physicians.   If only physicians use the system, it may be easier to "clean up" the paper order sets if nursing does not have to enter "legacy paper order sets" for physicians who are not using the system.  If a rollout is done incrementally two options are by location and by specialty.   By specialty may be easier in many cases since it allows the implementation team to focus on a limited number of order sets at one time. 

 

Pros and cons of the different strategies 

 

Strategy Positives Negatives  
Big Bang 
  • Not a dual system
  • Eliminates the need for dual processes for everyone, chart tracking etc.
  • Underlines the importance the org is placing on CPOE 
  • Clean break with paper vs. e-orders for tracking verbal orders, telephone orders etc. 
  • No reason not to be in the system if you are a nurse - new orders will only be found in the EHR.
  • Requires significant resources to support all the physicians
  • Challenging to do a house-wide wkflow redesign - especially surgery 
  • Negative impact on house-wide productivity
  • Impact on patient flow 
  • Tidal wave of work downstream - suddenly routine tests are being sent instantly and not queued in a bin and lots of calls to ancillary services for help to find orders.
 
By unit 
  • Consistent area for support
  • Focus resources more effectively
  • Workflow need only be reworked for the one unit  
  • Difficulty in tracking whether the order was paper or electronic for vo/to signatures.
  • Difficult for staff who travel from unit to unit to know what the metholodogy to use
  • Patients also move from unit to unit making it difficult to find previous orders. 
  • Change requests and change management complicated since the requests are coming from those who are live and will affect those who are not and vice versa. 
  • Keeping paper order sets updated with the changes made in the electronic version.
  • Challenging for provider to provider communication (JC Issue?) 
 
By specialty group 
  • Safety in numbers - positive peer pressure 
  • Focused time for serious review for specialty order sets
  • Support models may be less intense 
  • Multiple can be done at the same time if small 
  • Dual workflow has to happen on all units 
  • Subliminal message that everyone else has to learn dual workflows including providers still on paper
  • The dual world makes it difficult to know if an order has already been entered. 
  • Pharmacists need to be able to merge orders from two sources or nurses need to be allowed to enter med orders. 
 
Progressive pilot strategy folowed by residual big bang    

 

 

 

Implementation basics

To ensure a smooth technology adoption, target the following elements:

¨ Project sponsorship: Include nursing leadership as soon as possible.

¨ Reporting structure: IT and nursing must work together, viewing the initiative as an organization-wide endeavor. Consider moving clinical resources into your facility's IT department.

¨ Project champions: Incorporate the clinician's/end-user's perspective into design and implementation decisions.

¨ Delegation: Create teams to facilitate the initiative's success, from conception to follow-up.

¨ Support structures: Develop resource libraries for all involved teams. In addition to training for core team members, make available recent publications that address CPOE issues

 

Stories 

Alamance Regional Medical Center

How to implement CPOE successfully at your Hospital by John Halamka, MD