Dissemination and Adoption of Comparative Effectiveness Research Findings When Findings Challenge Current Practices. Conclusions


The adoption of a new medication or device that does not require significant changes to the workflow of clinicians and staff but instead funnels through the existing workflow is relatively easy, but the adoption of quality improvement strategies faces additional barriers because of the significant changes to organization, financing, and staff work that may be required. These barriers may neutralize the impact of even outstanding CER evidence.

The CPOE case study provides a number of lessons about translating evidence on CER involving delivery systems interventions into new practices. We selected CPOE as an example of a delivery-system intervention for which there is published CER evidence, but it is worth noting that CPOE not only has features that are typical of many such interventions but also has some that may be easier to implement. First, CPOE is both a new technology and a new set of workflow requirements, making it complex and requiring substantial up-front investment, as well as coordination, communication, and long-run commitments from numerous stakeholders with potentially conflicting goals. The staff involved directly in implementation of CPOE must undertake nontrivial workflow changes; as with other technology-based quality improvement interventions, effective use of CPOE requires dramatic changes in individual process and social interaction with peers.

Second, CPOE is a variable technology with evolving features and functionalities across a wide range of hospitals and vendors, depending on their needs and existing HIT capabilities. This poses challenges for end users (particularly hospital executives) who seek to use CER evidence for decisionmaking. Our case study suggests that these individuals often struggle to conceptualize the intervention and consequently may find it difficult to assess the applicability of the results to their own setting.

Third, the financial investment required to implement CPOE is large, and key leaders must have clear reasons and plans for implementation to overcome resistance from staff. Financial incentives appear to improve the business case for such a large investment. The experience of early adopters suggests that organizational factors and mission can be significant enablers even when financial incentives are not aligned.

Fourth, the range of target stakeholders for CER results concerning CPOE is broader than that of the typical users of other types of CER studies. Stakeholders include hospital executives, technology vendors, physicians, pharmacists, and other clinical staff. This may increase the complexity of messaging to effectively and consistently disseminate the CER results.

This case study illustrates that quality improvement interventions based on CER evidence (particularly those that improve patient safety) may benefit from some combination of strong mandates, systematic standards, and financial incentives that improve the business case for implementation.

Key findings from the CPOE case study are given in Table 6.2.

Table 6.2

Key Findings from the Bates CPOE Case Study


Key Findings



• Published studies tend to document unique CPOE implementations, which are perceived as not being generalizable.


• Adoption has been retarded by the significant tension between the needs for uniform standards/interoperability and local adaptability.

• Vendors prefer a captive market, a disincentive to standardization.


• High-profile reports and popular media coverage have helped promote public awareness of medication errors and have shown that CPOE is a demonstrated solution.

• Advocacy by health-care purchasers, CPOE venders, and patient safety groups also promotes awareness.

• There are still too few well-documented examples of how to successfully implement CPOE.

• Failed implementations have discouraged potential adopters, but lessons learned have led to the development of champion hospitals and implementation tools.

• The usual peer-reviewed-publication channels may not reach CPOE decisionmakers.


• CPOE is complex, may be incompatible with legacy systems, and will overturn current provider workflow; therefore, adoption requires careful coordination between stakeholders.

• Clinicians tend to skeptically resist adoption unless they perceive direct benefits to them or their patients but are usually enthusiastic users after implementation occurs—especially if quality improvement data show real improvements in patient safety.

• Implementation of very expensive technology is more likely if the entity that bears the implementation cost also derives financial benefits.

• Meaningful-use mandates and penalties for failure to implement HIT will very likely also drive implementation.


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