Dissecting Physician Resistance to CPOE

After spending the last 4 years, designing, planning, and implementing Computerized Physician Order Entry and closed loop medication at a large university hospital — covering neonatal to geriatric patients — few articles have served me better than reading the work of Dr. Dean Sittig and Dr. Joan Ash on how CPOE changes physician-nurse workflows and communication (Clinical Information Systems: Overcoming Adverse Consequences).

During my interactions with physician and nurses, the following consequences have been present. The simple truth is that physicians and nurses do get angry when trying to learn a new system, or right after the computer interface has changed.

Implementation of clinical informatics creates emotional aspects and unintended consequences, such as the following:

More/New Work for Clinicians

• Work unit secretaries use to do, now requires physician time to complete

Unfavorable Workflow

• Hard stops in CPOE are just a bad idea and lead to angry physicians.

Never Ending Demands for System Changes

• Physician hate when the user interface changes too often, so have an educational plan for when changes are made.

Problems Related to Paper Persistence

• Many complex items like TPN, CHEMO, etc., must be ordered on paper.

Untoward Change In Communication Patterns and Practices

• With CPOE, physicians can enter orders from anywhere in the hospital and the nurses never know.

Negative Emotions

• When Computers do not work at stressful moments, physician get angry.

Generation of New Kinds of Errors

• Computers can change how meds are ordered, and confusing interfaces can lead to mistakes.

Unexpected and Unintended Changes in Institutional Power Structure

• Physicians have always prided themselves on being able to treat patients their way.  With CPOE, physicians are forced to use certain meds and protocol restrictions.

Over-Dependence on Technology

• One of my rules to all clinicans is: “IF the medication dose does not look right, it is NOT right until to prove otherwise.” Just because it is on a computer screen does not mean it is always correct.

Shifts in Power Control and Autonomy

• Power shifts to committees like Pharmacy and Therapeutics,  Medical Directors etc.  Physicians loose the freedom a blank sheet of paper provides.

Hopefully in future blogs we can expand on the issues physician consider important when implementing a wide range of EMRs and other core clinical technologies, as well as figure out some ways to address them.