A number of factors are thought to have slowed CPOE adoption, many of which are not unexpected given the problems of introducing a new and complex technology (Rogers, 1995; Doolan and Bates, 2002). The key barriers to CPOE adoption cited in the literature and in discussions with experts are summarized below.
Complexity of the CPOE Intervention
The advantage of CPOE over existing practices is difficult for users to perceive, and CPOE tends to be incompatible with the typical user’s workflow. ADEs are rare and the value of averted medication errors may not be fully appreciated because they may not be directly observed. In addition, busy clinicians must invest time to learn the new workflow. Finally, CPOE systems have been difficult for hospitals to test on a trial basis because they are usually embedded in larger hospital information systems that cannot be easily or inexpensively changed (see technical challenges below).
Lack of a Strong Business Case for Adopting CPOE
The cost of installing CPOE systems is high, and the return on investment is unclear given current payment systems. As one expert noted, “He who pays is not he who gains.” Payers are more likely than providers to reap the financial benefits from implementation of these systems, through the avoidance of costs associated with treating medication errors (Birkmeyer, Lee, et al., 2002; Poon, Blumenthal, et al., 2004). Without payers “coming to the table” with proposals to share these gains, providers have had little financial incentive to adopt CPOE (Poon, Blumenthal, et al., 2004). Hospital executives may also be averse to the reputational risk of a CPOE investment and installation failing, as happened quite publicly for one early-adopting hospital (Cedars Sinai Medical Center in 2002). Vendor assertions about CPOE value are often considered suspect and self-serving and appear to have a limited role in hospital and physician decisionmaking. Some experts also stressed that financial decisions, particularly those using a return-on-investment (ROI) framework, tend to focus on relatively short time frames and not the years it may take to begin to see the ROI from CPOE adoption (if implementation is successful). As a capital-intensive investment, CPOE adoption may lose out to other projects offering a higher immediate ROI, such as new imaging or surgical facilities, even if physicians are in favor of it.
Technical Challenges of Integrating CPOE into Current Systems
CPOE is not a stand-alone product; it is typically integrated into EHR or clinical information systems, and it must also be compatible with other technologies such as pharmacy bar-code systems. Hospitals have too often attempted to integrate CPOE into legacy health-information systems designed to support administrative functions. These older systems, unlike EHRs, may be ill-equipped to handle the addition of a CPOE application, because key clinical data may be stored in separate systems using different technologies and thus are not exchangeable with the CPOE application. One expert explained that when hospitals attempt to absorb and build a CPOE application into a health-information system, “technology controls behavior, rather than behavior determining the needed technology.” Moreover, the increasing complexity of CPOE applications, including sophisticated add-ons such as clinical decision support, places further demands on existing health-information systems.
These technical challenges have created an “inefficient market” for CPOE, according to one expert. With many technologies, a dominant vendor emerges or multiple vendors compete, but they collectively reach consensus on standardized protocols (e.g., standard Internet protocols). CPOE systems, however, continue to lack interoperability, even with modern EHRs. While the CPOE market may mature and improve with time, substantial forces are working against interoperability and the broader sharing of information. In particular, lack of interoperability promotes sustainable business for individual vendors, as clients typically remain “captives” of that vendor if they want to make enhancements. Furthermore, hospital financial incentives tend to impede sharing of clinical data with competing institutions; in a fee-for-service environment, maximizing treatment volume is more important than realizing efficiencies through information sharing.
Until very recently, CPOE technology has not been a user-friendly quality improvement tool. CPOE systems are difficult to use, and vendor products differ sufficiently that clinicians who learn to use one cannot necessarily transfer that knowledge to use of another. CPOE products require substantial investments of staff effort and resources to set up and customize them to suit the local practice context (e.g., to define medication formularies or ensure that local pharmacies are represented in electronic prescribing databases). These factors form a substantial barrier, particularly for smaller hospitals or outpatient practices.
Clinician and Organizational Resistance
Many physicians and other clinicians hold negative views about CPOE, lack incentives to adopt the technology, and may strongly resist doing so. Past negative experiences with prototype EHR systems, a perceived negative impact of CPOE on workflow, and inadequate time for training may also create resistance. Completing all the steps to enter an order may be perceived as more cumbersome than giving a verbal order or handwriting one on a chart. Computing tasks may also be perceived by physicians as work that should be done by nurses and other staff. Such expec-tations can produce tension and conflict between professionals as workflow changes are imple-mented. The aversion to such changes among employees and organization managers is strengthened by highly publicized failed EHR implementation attempts (Morrissey, 2004). Despite the potential for net benefit, many clinicians tend to perceive successful adoption as unlikely (Doolan and Bates, 2002).
Limited Generalizability of CER Evidence from Quality Improvement Studies
Evidence of success of CPOE adoption at one hospital, no matter how meticulously documented and communicated, may fail to convince professionals and managers that implementation will be successful at other hospitals. The organizational and practice contexts that may enable implementation in some settings may not exist in others. Hospitals that lack health-information systems and those with legacy systems that cannot accommodate the addition of CPOE are unlikely to perceive CPOE implementation as an achievable goal. CPOE applications studied in seminal CER studies were designed and implemented within systems that were largely home-grown. While CER cannot and probably should not assess the effectiveness of an intervention in all imaginable settings, limited generalizability tends to weaken the persuasive power of CER results.
Lack of Knowledge and Guidance About Implementation
CER studies on quality improvement approaches may include descriptions of an intervention, but they rarely include detailed descriptions of how the intervention was implemented. Even hospital managers eager to implement CPOE may find that the implementation process is disruptive and protracted. The required coordination and cooperation among relatively independent pro-fessionals increases the risk that implementation will fail. While specific implementation guides for CPOE do exist, a technically skilled workforce, including talented HIT professionals, is necessary to ensure successful implementation (Ash, Stavri, et al., 2003). Learning by doing and trial and error are frequently part of CPOE adoption, suggesting that implementation guidance is only somewhat helpful.
Mistrust of Vendors
There is a widespread sense among hospital managers that the business case presented by vendors lacks credibility, especially since vendors have a strong financial incentive to peddle their own wares. The commitment of vendors to the long-term success of CPOE implementation is perceived to be low. Many lack a track record of successful implementation, and instances of vendors selling systems that fail to meet functionality needs also make hospital leaders and clinical professionals wary of newly developed and unproven systems.