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Doctors pull plug on paperless system

California's Cedars-Sinai turns off its computerized physician order entry system after physicians revolt, demonstrating that implementing new technology is easier said than done.

By Tyler Chin, amednews staff. Feb. 17, 2003.

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Information technology is often touted as the cure for all that ails the delivery of quality medicine, but some physicians say this cure can be worse than the disease.

Cedars-Sinai Medical Center in Los Angeles turned off its computerized physician order entry system in January, after hundreds of physicians complained that rather than speeding up and improving patient care, it actually slowed down the process of filling their orders -- assuming those orders didn't get lost in the system.

"I'm not opposed to change ... but it's got to be new and better," said Dudley Danoff, MD, a urologic surgeon who helped organize physician opposition. "This was new but certainly not better" than paper.

Cedars-Sinai's decision was extraordinary but not unique. David Classen, MD, of First Consulting Group, says he knows of at least six other hospitals that have pulled paperless systems in the face of physician resistance and other problems.

The issue, Dr. Classen said, is not necessarily one of the quality of the technology. The success of paperless order entry and electronic medical record systems has to do with how they're implemented as much as what is being used, experts say.

In Cedars-Sinai's case, the hospital believed that by working with a 40-physician medical executive committee, it had sufficiently involved physicians in the design and implementation process. But rank-and-file doctors said the committee did not represent their interests.

The Cedars-Sinai pullback "will reinforce the importance of the cultural and organizational issues in successful implementation, and in that way it will ultimately be beneficial," said Dr. Classen, vice president and head of patient safety practice at First Consulting Group. "Physicians must be the champions of this particular process in order to bring it successfully to conclusion."

Counting on technology

Physicians and hospitals have been under pressure to automate, particularly since the Institute of Medicine's 1999 report estimating that up to 98,000 Americans die annually from preventable medication errors. Since then, the IOM has been joined by the Leapfrog Group, a coalition of large Fortune 500 employers, and others in urging the industry to implement information technologies to improve patient care and reduce errors.

Clinical systems such as computerized physician order entry will eventually become common because "you can't practice high-quality medicine without them," said Don Detmer, MD, speaking for the Institute of Medicine. "Modern medicine is not getting simpler, and only with computer systems can you keep up with the growth of the knowledge base. I don't honestly think we have any alternative."

But implementing those systems will be a struggle and will require close partnership between physicians and hospital leadership, said Dr. Detmer, who served on the IOM committees that released two reports -- "To Err is Human" and "Crossing the Quality Chasm."

The value of partnership is a lesson Cedars-Sinai learned the hard way.

During the last three years, Cedars-Sinai developed Patient Care Expert, an information system that includes registration, billing and computerized physician order entry. It mandated that physicians use the CPOE system but was forced to uninstall the piece after hundreds of physicians complained that it was poorly designed, slowed patient care and was dangerous because orders weren't being transmitted or were getting lost, said Stephen Uman, MD, an infectious disease expert and former chief of staff at the hospital. The other pieces remain in place.

The CPOE system also was cumbersome and didn't follow physician workflow, said Dr. Uman, who helped organize physician opposition. To order an antibiotic, for example, doctors had to go through three or four different screens and wait six to eight seconds between screens. "For somebody ... who has 15 to 20 patients in the hospital, when you add three or four minutes per order or five to 10 minutes per patient, that comes up to two or three hours of extra time a day," Dr. Uman said.

Cedars-Sinai maintains that the CPOE system worked. "The system performed as designed and exactly as it was intended," said Michael Langberg, MD, Cedars Sinai's chief medical officer and senior vice president of medical affairs.

Approximately 600,000 orders were logged on the system between October 2002 and January 2003, and 10,000 orders were entered daily, said Dr. Langberg.

Given the high volume of orders, Cedars-Sinai would have experienced patient care problems had the system been unsafe, but that did not happen, he said.

Still, Cedars-Sinai decided to take down the CPOE system. In addition to the physician resistance, Cedars-Sinai also discovered other problems that were greater than it had anticipated, including the impact computerized order entry had on ancillary departments, the complexity of the implementation and the work involved in making the transition to CPOE, Dr. Langberg said.

Cedars-Sinai plans to work on those areas so that it can reinstall the system later.

There's also still the issue of physician communication to work out. Hospital systems that have had successful implementations -- such as Montefiore Medical Center in New York -- have credited physician involvement in all phases of the design process. Although Cedars-Sinai believes it involved physicians from the get-go, many doctors still feel left out.

"They poorly designed the system, poorly sold it and then jammed it down our throats and had the audacity to say everybody loves it and that it's a great system," Dr. Danoff said.

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