The Story of Evolving the World's First Computerized Physician Order Entry System and Implications for Today's CPOE Decision Makers
"At El Camino, we believe that being a leading institution is important. We want to be at the forefront of engaging physicians and participating in major changes in healthcare," states Mark Zielazinski, CIO at El Camino Hospital in Mountain View, California.
El Camino Hospital was one of the organizations involved in building the world's first clinical information system [now referred to as a Computerized Physician Order Entry (CPOE)-based system]. Zielazinski wasn't there at the time, but he knows the story. More importantly, in his current role as CIO (with more than 20 years of healthcare experience), he's responsible for driving change in the El Camino institution, including what happens regarding its CPOE system.
Once Upon a Time
Development of a clinical information system began back in 1969 as a joint project between El Camino and Lockheed. When the system was moved from its development site - the NASA center in Mountain View, California - it was installed at El Camino Hospital, going live in 1971. Through its evolution, that early CPOE-based system eventually became part of Eclipsys Corporation's current award-winning product line and is now known as the E7000 system.
El Camino enjoys - even today - 100 percent physician buy-in on its clinical information system. "Lockheed worked with a hospital committee back in the '70s when it was being built, and the committee included 28 of the physicians and 12 nurses who would be using it," says Zielazinski. "So it was pretty hard for them to not embrace it once they were done and, over the years, it has become an ingrained part of our practice."
Throughout its existence, El Camino's system has migrated through a lot of different mainframe platforms, and its operations have been outsourced during that entire 30-year period. Through a series of joint ventures and hospital mergers and acquisitions, the location and control of the El Camino data center running the system moved several times during the '80s and '90s. Then, in 1997, El Camino entered into an outsourcing relationship that included transferring 36 of its IT staff to the outsourcer, along with running the data center, telecommunications services and help desk.
But things change over time in a technology-driven world.
The Rest of the Story
In 2001, El Camino started looking at replacing its original E7000 product. "We needed to upgrade because, while we were the first hospital in the world to do CPOE, the tool that we have is really a remnant of that early development in 1970," explains Zielazinski. "It doesn't have rules engine capabilities and doesn't have some of the routing capabilities and other things in a modern-day CPOE."
Today's CPOE systems, according to The Leapfrog Group initiatives to improve patient safety, should have automated, rules-based surveillance and alerts, as well as automated outcomes and measures that are tied to a real-time ordering system.
El Camino's dinosaur system doesn't allow that. "It does some things like order checking, and it does order sets and some field edits; but it really doesn't get to complex decision trees or to rules-based information or those type of things. It also doesn't easily hook to outside data sets or bring in outcomes data. So it's very limited as to what we can do, and we have to change," says El Camino's CIO.
In the process of looking at alternative CPOE-based systems, the hospital's administration also began evaluating whether its current outsourcing provider was the right choice. Like the dinosaur technology, the 1997 outsourcing contract permitted no flexibility and assumed El Camino would run its system on a mainframe for the life of that contract. The hospital wanted better pricing terms, better service, and a way to migrate from the data center supporting El Camino's mainframe applications to its new environment. Most importantly, Zielazinski says, "The community was crying for its hospital to have technical leadership and be a driver in healthcare innovation and standards."
Through a formal request for proposal process (including the incumbent provider as a bidder), El Camino eventually selected Eclipsys as its new outsourcing partner. The new arrangement was more attractive in its flexibility, its leveraging of the provider's resources, and the provider's healthcare expertise and innovation. The contract permits El Camino to choose non-Eclipsys products if it desires, and still have Eclipsys run those products and manage the outsourced relationship.
CPOE Decision Points
In contrast to El Camino's 100 percent physician compliance, many hospitals now implementing CPOE-based systems have physician acceptance rates of only 20-30 percent. El Camino's current task force evaluating a system replacement includes 14 of the hospital's physicians. Physician involvement is a key success factor in implementing a clinical information system, according to Terry Williams, vice president of Eclipsys' Business Solutions Group.
With dozens of competing vendors' products and almost a 10 percent penetration of CPOE systems into the marketplace, there should be many success stories. Williams, however, attributes the lack of success to the fact that "a basic level of capability in a product does not bring physicians to the table, wanting to fundamentally change the way they work."
So what features should reside in a best-of-breed CPOE system and what will enable successful adoption by a hospital's physicians? Hospitals should seek the following characteristics:
- The system should not radically change a physician's workflow. It should improve the workflow without turning it on its ear.
- It should accommodate tailored filters of data that go to specific end users. Too many alerts every time they sign on to the system drives clinicians away because it's bothersome clutter. On the other hand, if the system tightens the range of action alerts that are meaningful to a clinician, the system will have value.
- It should be flexible in accommodating different workflows. A surgeon making rounds after surgery has a different workflow, for instance, from an internal medicine physician. The system should be able to accommodate those variances in need for knowledge, alerts, escalation features, etc.
- It should not require an army of people nor any special coding expertise to build the knowledge into the system. The system should be nimble in customizing and making changes to the basic product.
- If an application is built for the Web (as opposed to existing applications becoming Web-enabled), it lowers the total cost of ownership because of the ability to push technology changes or upgrades out quickly without having to load software in multiple locations.
- A system that allows user dial-in access from any computer device anywhere gives physicians flexibility in how and when they access and use the system's information.
Finally, an effective training methodology will drive value in the system and increase the number of physicians who voluntarily adopt the system.
"However, we have found that simply training a physician on an application is not the way to get adoption," states Williams. "There are some physicians who won't find training classes adequate or who won't even attend the classes." An outsourcing solution with a provider that has other strategies for how to engage those physicians, how to transfer knowledge, and how to follow up with those who have learning curves is important.
Lessons from the Outsourcing Journal:
- Involving physicians in the evaluation of CPOE systems as well as input of the knowledge base, alerts and workflow features will speed and increase successful adoption of the system.
- If a CPOE system's ongoing operation is outsourced, be sure the contract is flexible for technology changes over time.
- Today's CPOE systems, according to The Leapfrog Group initiatives to improve patient safety, should have automated, rules-based surveillance and alerts, as well as automated outcomes and measures that are tied to a real-time ordering system, should hook to outside data sets and bring in outcomes data.
- A CPOE system should improve a physician's workflow. If it alters the workflow radically, the physician will not adopt it.