A NEW MODEL FOR SUCCESSFUL CPOE DEPLOYMENT AND

IMPLEMENTATION IN HOSPITALS

Majid M. Altuwaijri

College of Public Health and Health Informatics

King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Saudi Arabia

Keywords: CPOE, CSF, CPR, PMO, and Knowledge barriers.

Abstract: In spite of the importance of information technology (IT) for many health organizations to help manage the

enterprise daily transaction, IT project failure rates still remain high. This suggests continued exploration of

new process model and organization structure to nurture strong project performance. In this paper we

propose a new model for successful implementation of IT projects. The proposed model calls for the

establishment of a program management office (PMO) to implement corporate strategy for project

management and to transform the organization into a learning one. The model is explained in details using

an example of a Computerized Physician Order Entry (CPOE) implementation.

1 INTRODUCTION

Between 50,000 to 100,000 Americans die each year

due to medical errors and about 1 million people are

injured (IMO, 1999). In response to these chocking

numbers reported by the Institute of Medicine

(IOM), some healthcare organizations embarked on

computerized physicians order entry (CPOE)

systems.

Health care organization leaders are becoming

well aware of the potential value of advanced

clinical information systems such as Electronic

Medical record (EMR) or computerized patient

record (CPR) to improve outcomes, reduce

medication errors, increase health care efficiency,

and eliminate unnecessary costs. Many health

organizations have invested significantly to plan,

procure, and implement these advanced systems,

including the current focus on computerized

physician order entry (CPOE) (Haux, 2006).

However, despite their knowledge, investments, and

best intentions, most healthcare organizations have

not realized a return on their investments (Berger,

2004). One probable reason for this problem is that

the key users – physicians and other clinicians – are

not using the technology to its greatest potential or,

in too many cases, have not begun to use the

technology at all. CPOE represents a monumental

step forward for healthcare organizations because it

embodies a shift from traditional, paper-based care

coordination activities to automation of the order

entry processes. This shift can be an agent for

change, eliminating confusing or illegible hand-

written order documentation, minimizing

transcription errors and fundamentally reducing

clinical mistakes (Snyder, 2006).

In this paper, a new model for successful

implementation of CPOE project in hospitals. The

model consists of three main components; the first

component is concerned with the stages taken by

organization to deploy new technology innovations

which is in turned composed of four stages:

visioning, matching vision, deployment, and

evaluation and improvement. The second component

deals with the main knowledge barriers to IT

innovation diffusion as suggested by literatures. The

third component is concerned with the critical

success factors of IT innovation implementation as

suggested by various literatures.

2 CPOE SYSTEM OVERVIEW

CPOE is a process of electronic entry of physician's

orders and instructions for the treatment of patients.

These orders are communicated over a CPR to the

179

M. Altuwaijri M. (2008).

A NEW MODEL FOR SUCCESSFUL CPOE DEPLOYMENT AND IMPLEMENTATION IN HOSPITALS.

In Proceedings of the First International Conference on Health Informatics, pages 179-185

 SciTePress

medical staff (nurses, therapists or other physicians)

or to the departments (pharmacy, laboratory or

radiology) responsible for fulfilling/documenting the

order.

CPOE is not a technology, rather it is a workflow

design (or redesign) of clinical processes that

integrates technology to optimize physician ordering

of medications, laboratory tests, etc. (AHRQ, 2001).

CPOE uses clinical decision support systems and

links to hospital systems to generate prompts and

alerts during the ordering session to notify of

potential errors such as contra-indicated medications

or routes or duplicate orders. Integration with other

hospital information technology systems including

electronic patient records, pharmacy, laboratory, and

other services provides the physicians with all

information necessary to develop and transmit an

effective, error-free order (Metzger, 2003).

In May 2001, thirteen CPOE experts from around

the world gathered at a 2-day conference for the

purpose of developing recommendations for CPOE

implementation (Ash, 2003). A list of high-level

considerations was generated to benefit

organizations thinking about implementing CPOE as

follows:

 Motivation for Implementing POE

 Vision/Leadership/People

 Costs

 Integration/Workflow/Health Care Processes

 Value to Users/Decision Support Systems

 Technical Considerations

 Management of Project

 Training/Support/Help at the Elbow

 Learning/Evaluation/Improvement

3 PROJECT MANAGEMENT

OFFICE

In this context, we adopt the PMO's definition

proposed by PMI (PMI, 2004): "An organizational

body or entity assigned various responsibilities

related to the centralized and coordinated

management of those projects under its domain. The

responsibilities of the PMO can range from

providing project management support functions to

actually being responsible for the direct management

of a project". A PMO focuses on the activities with

relation to projects including training, process

standardization, consulting, identifying of best

practices, project prioritization, and reviewing

project progress (Bolles, 2004).

4 INFORMATION SYSTEMS

SUCCESS

DeLone and McLean in 1992 conducted a

comprehensive review of IS success literature and

proposed a model of IS success (Delone, 1992). It

suggested that the success can be represented by the

system quality, the output information quality,

consumption (use) of the output, the user’s response

(user satisfaction), the effect of the IS on the

behavior of the user (individual impact), and the

effect of the IS on organizational performance

(organizational impact). An updated model was

proposed in 2003 (Delone, 2003) as shown in figure

1. The primary differences between the original and

updated models included:

 The addition of Service quality category to

reflect the importance of service and support

in successful e-commerce systems,

 The addition of "intention to use" to measure

user attitude, and

 The merging of individual impact and

organization impact into one category

concerned with net benefits.

5 KNOWLEDGE BARRIERS

Various study researches highlighted several barriers

to innovation (Attewell, 1992; Tanriverdi, 1999;

Nambisan, 1999). The adoption and implementation

of complex IT solution is influenced by the

organization's ability to lower or remove the various

knowledge barriers. Knowledge barriers associated

with the adoption of larger-scale IT solutions can be

categorized into four categories: project/economic

barrier, technical barriers, organization barriers, and

behaviour barriers (Pare, 2007).

Figure 1: Updated Delone & McLean model of IS success.

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 Project/Economic barriers: This category is

concerned with the financing and project

management issues faced when acquiring

innovation.

 Technological barriers: This category is

concerned with the lack of knowledge

required to carry out technical tasks needed to

adopt new innovations.

 Organizational barriers: This category is

concerned with the difficulties of deploying a

new technology into existing practices and

processes.

 Behaviour barriers: This group is concerned

with the resistance to change among

individuals affected by the implementation. It

is also concerned with organizational power

dynamics.

6 THE PROPOSED MODEL

Figure 2 shows a new model for successful

implementation. The model consists of three main

components; the first component is concerned with

the stages taken by organization to deploy new

technology innovations which is in turned composed

of four stages: visioning, matching vision,

deployment, and evaluation and improvement. In

visioning phase, institutions define the corporate

mission, objectives, and strategy. This phase is

mainly concerned with identifying and prioritizing

the organizational problems and opportunities that

form the basis of the need to acquire innovations

(Rogers, 1995). The second phase is concerned with

the fit between a need identified in the first phase

and the innovation proposed. In this stage we should

determine whether the innovation will truly solve (or

at least solve) one of the problems identified in the

first phase. At the end of this phase, the

organization decides weather or not to approve the

innovation project.

In the event that the project is approved, the third

phase of the process, deployment, begins. This phase

includes all decisions and actions related to the

deployment of the innovation. It includes also the

assimilation and the integration of the innovation

within the organization. At the end of this phase, the

IT innovation solution is deployed within the

organization. Evaluating performance is an

important step for ensuring the quality of the

innovation deployment. This phase emphasizes

process flow optimization and continuous expansion

of the system to gain competitive advantage.

The second component deals with the main

knowledge barriers to IT innovation diffusion. The

third component is concerned with the critical

success factors of IT innovation deployment as

suggested by various literatures (Ash, 2003).

After the successful deployment of innovation,

the list of benefits and lessons learned feeds a

knowledge base which in turn feeds all three

components described in the model. Knowledge

sharing behaviours facilitate learning among Project

team members and enable them to resolve problems

similar to situations encountered by others in the

past, thus enabling more successful projects.

The proposed model calls for the establishment of

a program management office to implement

corporate strategy for project management. The

main goal of this office is to translate the

organization's strategic plan into projects and

programs. The PMO is accountable for enterprise-

wide distribution of project management best

practices. Therefore, for the model to work properly,

Organizations should invest in project management

training for the staff working in the PMO.

The main advantages of this model is the strategic

alignment of projects which bears on the synergy

created by the management of relations between

projects, and the ability to develop a better

understanding of the challenges faced in carrying out

information systems projects, the factors for success,

and the strategies required to take advantage of IT.

The acts of sharing are very important since a

project's knowledge will not have much impact on

the organization unless it is made available to other

projects. Such learning organizations would be

aware of the repeated knowledge barriers to

innovation adoption and a well defined plan to

address these barriers would be developed.

Moreover, the knowledge base will help these

organizations refine their strategies and prioritized

plans. This allows for focusing on preparation for

future projects which is rarely covered in literature.

7 APPLYING THE MODEL FOR

CPOE DEPLOYMEENT

Figure 3 shows the detailed model for CPOE

implementation as explained in the following

sections:

7.1 Visioning

Institutions should align the strategic vision process

with the budgeting process to produce a realistic

prioritized strategic plan. The strategic plan will be

used as an input to the IT strategic plan in order to

ensure that the IT plan is closely integrated with the

A NEW MODEL FOR SUCCESSFUL CPOE DEPLOYMENT AND IMPLEMENTATION IN HOSPITALS

181

Figure 2: The proposed model for IT diffusion.

organization's strategic initiatives and business

directions and provides the opportunity to use IT as

a tool to enable systems integration as well as

deliver information as a strategic resource. The

visioning phase should address the Economic

barrier. Moreover, there are some strategic CSFs

related to this phase such as top management

support, business plan and vision, and cost/benefit

analysis.

7.1.1 Addressing the Economic/ Project

Barrier

Organizations deploying CPOE solutions should

address the financing issues faced when acquiring

the solution. These barriers include barriers

associated with project management skills.

Moreover, multi-site implementation of CPOE

presents special concerns. Firstly, each site had its

own processes which may not be consistent with

other sites. Secondly, multi-site organizations need

to choose whether the implementation is done

simultaneously in all facilities or in one facility at a

time.

7.1.2 CSFs for the Visioning Phase

 Motivation for Implementation: The IT

strategic plan along with the organization's

strategies should provide a clear

communicated business plan and vision to

steer the direction of the CPOE project and

other IT projects. This factor influences the

funding, the political support, and the clinical

leadership.

 CPOE Vision, Leadership, and Personnel:

Successful deployment of IT innovation

requires strong leadership, commitment, and

continuous support by top management. A

shared vision about the CPOE project should

exist throughout the organization.

 Cost/Benefit Analysis: This analysis is

instrumental for organizations in order to

secure fund. This analysis would act as the

basis for defining the success criteria for the

CPOE project.

7.2 Matching the Vision

The PMO office plays an important role in matching

the fit between projects, proposed by departments,

and the organization vision and strategies. In this

phase the organization should decide if the projects

proposed match the vision or not. In case there is a

match, a decision is made to invest on the proposed

solution. If there is no match, the PMO office should

update the organizational knowledge base and

record the reasons. In some cases, the project

proposals need further research before a decision is

made. This phase is affected by the same barrier and

CSFs as in the previous phase.

7.3 CPOE Deployment

7.3.1 CPOE Package Selection

Organization should make an extensive review of

available CPOE Systems to select the package that

has the best match of the organization's vision and

strategies. The decision should be based on several

factors including price, supplier support, ease of

implementation, closeness to fit to organization’s

business, technological risks, and local experience.

7.3.2 CPOE Project Life Cycle (PLC)

Organizations implementing CPOE systems usually

modify business processes (as reasonably required)

to conform to “best practices” discovered during the

implementation of the CPOE project. These

opportunities for process improvements would be

identified during Business Process and Fit/Gap

Analysis workshops, consulting visits and by the

project team members as they become familiar and

comfortable with the software. Process change

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proposals would be considered and approved by the

project management, steering and policy committees

as part of the governance of the project. This phase

is concluded when the CPOE solution is deployed

and is running within the organization.

7.3.3 Addressing Knowledge Barriers

 Technical barriers: These include the technical

infrastructure readiness. Organizations might

need to upgrade their network infrastructure,

upgrade the data centre’s servers, and recruit

technical and functional analysts to support

the project. Data migration from legacy IT

systems to the new CPOE is an essential task

in this project. Finally, a maintenance contract

is required to ensure the availability of the

CPOE solution.

 Organizational barriers: These include change

management processes to align the CPOE

with existing practices and processes.

 Behaviour barriers: These include end-users

resistance to new innovations. Organizations

should conduct a lot of training sessions to

introduce the new innovation.

7.3.4 Critical Success Factors

 Integration: Organization should have a clear

plan for integrating the CPOE into existing

environments and workflows. This factor is

also concerned with integrating the CPOE into

other hospital applications and possible legacy

systems.

 Value to Users: Organizations should have a

clear change management strategy which

includes analysis of the current business

processes to identify the areas for

improvement. Physicians must be shown

CPOE benefits including the embedded

decision support logic that helps to improve

the quality of patient care.

 Project management: Organizations should

appoint a dedicated full-time project manager.

The management of the project covers the

technical and functional aspects. A qualified

project manager manages five main functions;

managing scope, managing project team,

managing quality, managing cost, and

managing time.

 Technology: Organizations should make sure

they have a good technical infrastructure

before “Go-Live”. The project team should

make a balance between customization and

standardization; where physicians of the same

specialty would have a common CPOE screen

which might be different than screens for

different specialties. Organizations should also

have a comprehensive system testing plan to

test the functionality of each module alone and

in conjunction with other modules.

 Training and support: Organizations should

have a comprehensive training plan which

includes functional and technical aspects of

the project. In large organizations, "train the

trainer" approach is usually considered.

Additionally, Organizations should consider

proper support plan including 24*7 support

for at least several days post go-live.

7.4 Evaluation and Improvement

Finally, evaluation and improvement phase come

into action after the CPOE system is already

deployed within an organization. It is important that

organizations define the success criteria of the

CPOE project and use it to monitor the project.

CPOE system should be monitored forever and

should receive continuous improvement.

Organizations usually assume that their operational

performance will be improved immediately after the

"go-live". Instead, due to the complexity of CPOE

systems, organizations should expect an initial

decline in their performance. Once the system is

stable and users are more aware of its capabilities,

improvements will take place.

8 CPOE BENEFITS, LESSONS

LEARNED

After the CPOE system is already deployed, the

PMO should measure the benefits realized by the

project and tie them to the organizational strategic

goals. It is also important that the PMO assembles a

list of lessons learned from this project. The list of

project benefits and lessons learned are then fed into

the organization knowledge base. The knowledge

base will provide projects information back to the

organization visioning process and will be used to

refine the list of CSFs and knowledge barriers for

future projects. The feed back loop will transform

the organization to becoming a learning one.

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Figure 3: The proposed model for CPOE deployment and implementation in hospitals.

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9 CONCLUSIONS

Enterprise-wide daily transactions are difficult to

manage due to their complexity and scope in terms

of rendering services to their clients. As a result,

many organizations employ Information Technology

(IT) to manage their enterprise-wide transactions

and to ensure quality of services. IT, when properly

selected and implemented, helps organizations

increase their efficiency and capabilities which

improves the organization’s competitive advantages.

In spite of the importance of information technology

(IT), IT project failure rates still remain high. This

suggests continued exploration of new process

model and organization structure to nurture strong

project performance.

In this paper we propose a new model for

successful implementation of IT projects. The model

consists of three main components; the first

component is concerned with the stages taken by

organization to deploy new technology innovations

which is in turned composed of four stages:

visioning, matching vision, deployment, and

evaluation and improvement. The second component

deals with the main knowledge barriers to IT

innovation diffusion as suggested by literatures. The

third component is concerned with the critical

success factors of IT innovation implementation as

suggested by various literatures. The proposed

model calls for the establishment of a program

management office to implement corporate strategy

for project management and to transform the

organization into a learning one. The model is

explained in details thru an example of CPOE

implementation.

The acts of sharing are very important since a

project's knowledge will not have much impact on

the organization unless it is made available to other

projects. Although knowledge exists at different

levels of an organization, for instance, at the individ-

ual, team, and organization levels, sharing of

knowledge at the individual level is critical to an

organization.

It is expected as organizations use this model for

several projects; more knowledge would be gained

and used towards more successful project in the

future. Critical success factors would be refined

more and be closely tied with organization culture.

Such learning organizations would be aware of the

repeated knowledge barriers to innovation adoption

and a well defined plan to address these barriers

would be developed. Moreover, the knowledge base

will help these organizations refine their strategies

and prioritized plans.

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