Introduction
Computerized Provider Order Entry (CPOE) is a healthcare information technology (HIT) that involves the use of special software for provider orders rather than the traditionally employed pen and paper. Due to standardization and the elimination of handwriting, CPOE is known to improve communication, which results in better patient outcomes (Kruse & Goetz, 2015; Simon et al., 2013).
As a result, the Trinity Healthcare (TH) hospital has been interested in introducing the technology for some time, and its Information Technology (IT) Governance Council has approved and promoted a project aimed at CPOE Introduction. The present paper reviews the implementation of the CPOE technology at TH from the leadership perspective, applying the concepts of the Health Informatics Program to this specific HIT project. In particular, the paper considers the topics of strategic alignment, innovation leadership, IT governance, value creation, marketing and communication, risk management, and lean management and demonstrates the connections between these activities, indicating that their employment has promoted the success of the project.
Trinity Healthcare CPOE Innovation: Key Information
The introduction of CPOE at TH has involved 300 healthcare providers in the center. The key steps of the project include the assembling of the project management team, the analysis of the available options and the choice of the most appropriate one, extensive planning, execution and control, and ongoing evaluation (Houston, 2017; Shirley, 2016). The final stage is not finished yet; also, an additional implementation phase may be required depending on the evaluation results.
Cerner Corporation (2016) was chosen as a provider due to its reputation, experience of working with it that TH already has, and the benefits of its product. The process of change itself was predominantly guided by Lewin’s change theory and force field analysis and Roger’s theory of innovation diffusion. The former was employed for the organizational aspects of change (Mitchell, 2013), and the latter was used to improve the process of personal innovation adoption; after all, personal adoption is predictive of the organization-level routinization of the new practice (Pashaeypoor, Ashktorab, Rassouli, & Alavi-Majd, 2016). The project involved multiple leadership activities, and the present paper will focus on their analysis from the perspective of the Health Informatics Program concepts.
Strategy, Vision, and Alignment
Ensuring the alignment of the project with the strategy and vision of a company is required for the success of the former (Snedaker, 2016). As shown by peer and instructor discussions, such alignment is one of the major responsibilities of a leader. The CPOE project is intentionally aligned with the vision and mission of TH. Indeed, TH’s vision consists of improving the health of the community that it serves.
The vision of the project was defined as the achievement of improved patient outcomes by enhancing provider order entry processes at TH. This vision’s outcome is crucial and can indeed be enabled by CPOE, which is a major asset that has been shown to contribute to the improvement of care quality and patient safety, for example, by reducing medication errors and mortality rates (Khanna & Yen, 2014; Prgomet, Li, Niazkhani, Georgiou, & Westbrook, 2016). Thus, the CPOE introduction is in line with TH’s focus on better community health.
The strategy of TH is rather complex, but two major goals that the CPOE project was aligned with can be pointed out. In particular, TH aims to ensure the continuous improvement of quality of care and patient safety, and it has the goal of enhancing its practice with technology, including HIT. It is apparent that the adoption of CPOE is in line with these two goals, and the project has received similar goals: it aspires to improve the quality of care and patient safety by introducing CPOE, and it aims to enhance the practice of TH healthcare professionals with the help of CPOE.
Therefore, CPOE is capable of assisting TH in achieving its goals, and the visions of the two can be viewed as aligned. Figure 1 presents the relationships between the strategies and visions of TH and the project, demonstrating their alignment.
Due to the clear communication of TH’s vision and strategy by the company’s administration and IT Governance Council, it was not difficult for managers and leaders to ensure the strategic alignment of the project. In turn, this alignment guarantees the usability of visions and strategies as leadership tools by facilitating the communication of a coherent message to the followers (Snedaker, 2016). The latter outcome is especially important for engaging stakeholders in the process of change and motivating them to adopt CPOE (Simon et al., 2013). In summary, the leaders of the project have fulfilled their mission of ensuring the strategic alignment of CPOE implementation.
Innovation Leadership Strategies
As shown by the peer discussions, leaders are most important for innovation, which is true for the CPOE project as well. For example, Simon et al. (2013) report that in the cases of CPOE implementation that they have reviewed, leadership was a crucial predictor of the success of an adoption. Some of the key leadership activities that, according to Simon et al. (2013) were of importance, included the motivation and engagement of stakeholders and the elimination of psychological barriers like the fear of change. The latter is a major change-resistant force, according to force field analysis (Mitchell, 2013), which needs to be addressed. The project leaders took the mentioned aspects into account and developed appropriate strategies.
The primary strategy that has been employed by the leaders during the TH CPOE project for innovation promotion is the introduction of the innovation characteristics considerations that are promoted by Rogers’ theory of innovation diffusion. These considerations suggest enhancing the process of personal innovation adoption by modifying innovation-related perceptions. For example, if a person perceives the change as complex, they need to be provided with the information that dissuades this view, and if they consider it useless, its significance should be proven.
Rogers highlighted several key dimensions of innovation, including complexity, trialability, usefulness (relative advantages), compatibility, and effectiveness (Pashaeypoor et al., 2016). All these features were taken into account during the planning stage, and the procedures for the improvement of the participants’ knowledge of CPOE (advantages, usability, and compatibility with TH’s vision) were set in motion.
Apart from that, the trial of CPOE was a planned part of the project, which has already yielded some positive results. The professionals have also been provided with feedback mechanisms, which include regular assessments of their use of CPOE and attitudes towards it. These mechanisms have been helping the team to gain the data on the project and control its implementation. Thus, the engagement of stakeholders was carried out with the help of multiple leadership tools as a part of the strategy of innovation promotion.
IT Governance and Value Creation
HIT governance can be roughly defined as a complex of actions that are aimed at the strategic and effective use of technology in a healthcare organization (Snedaker, 2016). In TH, IT governance is established as a centralized system with the main body and several area councils, which is in line with TH’s prioritization of the use of HIT and its incorporation into the company’s strategy. As a result, the CPOE innovation has been actively supported by the organization as one of its HIT projects, which provided the required resources, facilitated strategic alignment and planning, and ensured the tracking of performance throughout the change. IT governance has also been a major mechanism for risk management, which is described below, and value creation.
Concerning the process of value creation, the project contributes some value to TH’s development by promoting new, improved, and standardized procedures for provider orders while also advancing an innovative approach to it. Also, the value of CPOE is relatively well-established. In particular, CPOE has been shown to improve the communication between specialists, reducing medication errors; given the fact that the latter can be viewed as a significant safety concern, this outcome is most important (Kruse & Goetz, 2015; Prgomet et al., 2016).
Apart from that, CPOE results in the standardization of order entry procedures and has been evidenced to be more cost-effective than hand-written orders (Kruse & Goetz, 2015; Forrester, Hepp, Roth, Wirtz, & Devine, 2014). Also, there is a possibility of improving the speed of health professionals’ work (Kruse & Goetz, 2015; Simon et al., 2013). In summary, CPOE is helpful to healthcare professionals and beneficial for patients and their outcomes, which proves the value of the technology and, by extension, the CPOE implementation project at TH.
IT Marketing and Influential Communication
As pointed out by Snedaker (2016), IT marketing is often neglected in HIT, and this issue is present in the current version of CPOE adoption at TH because the innovation is not yet marketed to the consumer. On the other hand, this issue is mostly connected to the fact that the project is not yet fully completed; after the evaluation phase indicates that the implementation is sufficiently successful, the information about it will be disseminated to all the stakeholders, including current and potential patients. It is noteworthy that the use of CPOE is in line with TH’s brand: TH positions itself as a modern and technology-friendly medical center. This fact should facilitate the marketing of CPOE use at TH.
Apart from that, it can be suggested that innovation has been marketed to the remaining stakeholders, which, as Snedaker (2016) demonstrates, is an important element of project management. As it was mentioned, communication has been a major element of the stakeholder engagement strategy, which is true not only for the employees: the people responsible for IT governance, especially project improvement, were also targeted by the project.
From the perspective of influential communication, the primary strategy of the project consisted of conducting research on CPOE and demonstrating its ability to create value better than the previously employed paper-and-pen methods. Again, Rogers’ ideas on innovation diffusion proved to be helpful in the process as they were used to demonstrate the relative advantages of the innovation (Pashaeypoor et al., 2016).
As for the employees, the training sessions were the primary element of influential communication, although briefs and the results of the research were also made available to them. As suggested by Rogers, the modification of the employees’ perception of innovation is crucial for successful adoption. As a result, influential communication has been a major consideration for the project. Apart from that, project marketing and communication will also be extended in future efforts: in particular, as recommended by Hanrahan et al. (2015) and Snedaker (2016), the outcomes of the project will not be just disseminated; they will be celebrated with the project management team and the engaged employees.
IT Risk Management
As shown in peer and instructor discussions, risk management is a major aspect of IT project development. CPOE implementation is related to multiple barriers and concerns. Apart from the considerations related to budgeting, training, and change implementation issues, there are HIT vulnerabilities and security risks (Hundt et al., 2013; Kruse & Goetz, 2015). These issues were carefully studied during the planning process to address them throughout the project. One of the tools that were employed to this end was SWOT analysis.
SWOT Analysis
A SWOT analysis of CPOE was a part of the project, and it involved the consideration of the major external and internal features that are likely to affect the process of CPOE adoption (Snedaker, 2016). The shortened version of the SWOT is presented in Figure 2.
As can be seen from Figure 2, the major concerns that were taken into account during CPOE risk management included safety and human error issues, as well as a certain amount of uncertainty (vendors and product). Also, the need for skilled workers was highlighted, as well as the problems related to change resistance. It may also be noted that the analysis detected sufficiently significant strengths, including standardization, teamwork promotion, reduced chances of miscommunication, as well as risks related to third party involvement and financial risks. Similarly, there are notable opportunities, including those related to learning, as well as the improved understanding of the risks and specifics of new technology, and employee development. The analysis is balanced and avoids focusing on risks only.
Strengths and opportunities indicate that despite the issues, the project has been worthwhile. Also, certain strengths and opportunities, including the lack of third-party connections and risk awareness can be viewed as the features that can assist in managing the threats and weaknesses, which constitute the CPOE risks. In summary, the employment of SWOT demonstrated that it is a simple but effective analysis tool, which has provided the project with important data on issues and available resources.
Risk Mitigation Strategy
The risk mitigation strategy was developed to respond to the above-mentioned issues and employ the strengths and opportunities. It is noteworthy that many solutions addressed multiple issues. For example, one of the solutions was the introduction of employee training; it reduced the risk of unskilled performance and related errors and employed the opportunity of developing the employees.
More than that, it also facilitated the process of change management due to the reduction of psychological barriers and resistance to change (Kruse & Goetz, 2015; Simon et al., 2013). Apart from that, the problem of malicious intent and safety concerns has been at least partially mitigated by developing a safety culture in employees with the help of training. Training has been the most important element of the project’s risk mitigation strategy.
Ongoing monitoring also contributed to the process of change management and safety concerns recognition (Hundt et al., 2013). Similarly, extensive research that preceded the project mitigated some of the uncertainty issues, including those of the choice of a vendor and resistance to change; the latter was assessed through the mentioned feedback mechanisms. The vendor and program issues were completely resolved by choosing a reputable vendor and a product that corresponded to the company’s requirements on the cost-benefit balance.
Also, company standards on IT security were expanded to include the CPOE considerations, which mitigated the safety issues. Thus, the use of several risk mitigation approaches has assisted the project in ensuring multiple mechanisms for addressing all the detected problems and concerns.
Lean Management and CPOE
It can be suggested that the CPOE project at TH involved certain principles of lean, which can be roughly defined as an approach to management that prioritizes the elimination of waste (D’Andreamatteo, Ianni, Lega, & Sargiacomo, 2015). First, CPOE is apparently in line with certain lean principles: it aims to reduce the use of inefficient paper order entries, which also tends to result in greater speed of working, improved cost-efficiency, and reduced number of redundant testing and duplicate therapies (Forrester et al., 2014; Kruse & Goetz, 2015; Simon et al., 2013). All these outcomes signify the reduction of waste of time and resources.
Apart from that, an important element of lean is a respectful attitude towards all stakeholders (Snedaker, 2016). The project prioritized stakeholder perspectives worked to involve the majority of them in decision-making through their representation in the project management team and has been continuously soliciting their feedback. In turn, this respectful attitude provided the project with important data and is likely to have facilitated and accelerated the process of adoption, eliminating the waste of time. Thus, the CPOE project at TH is indeed in line with the core principles of lean management.
Conclusion
The present paper shows that the CPOE implementation project at TH employed various leadership activities to achieve the best results. The support of the IT governance structures of TH has provided the project with advanced opportunities for strategic and visionary alignment and contributed resources that were employed for risk management. The latter was guided by SWOT analysis and included a mixture of mitigation strategies, the majority of which carried out multiple functions; for example, training resulted in reduced security issues, human errors, and malicious intent risks, and improved motivation, which facilitated the process of change management.
A major aspect of innovation leadership during the project consisted of ensuring the engagement of stakeholders, which was partially carried out with the help of internal marketing; also, external marketing is planned. It is also noteworthy that the project is in line with lean management, which is attributed to the employed methods and the ability of CPOE to reduce wasteful activities and create value. As a result of the mentioned activities and their combinations, the leaders of the project have managed to contribute to the achievement of TH’s vision by adding value in the form of a new and better method of provider order procedures.
References
Cerner Corporation. (2016). CPOE. Web.
D’Andreamatteo, A., Ianni, L., Lega, F., & Sargiacomo, M. (2015). Lean in healthcare: A comprehensive review. Health Policy, 119(9), 1197-1209.
Forrester, S. H., Hepp, Z., Roth, J. A., Wirtz, H. S., & Devine, E. B. (2014). Cost-effectiveness of a computerized provider order entry system in improving medication safety ambulatory care. Value in Health The Journal of the International Society for Pharmacoeconomics and Outcomes Research, 17(4), 340–349.
Hanrahan, K., Wagner, M., Matthews, G., Stewart, S., Dawson, C., Greiner, J.,… Williamson, A. (2015). Sacred cow went to pasture: A systematic evaluation and integration of evidence-based practice. Worldviews on Evidence-Based Nursing, 12(1), 3-11.
Houston, S. (2017). The project manager’s guide to health information technology implementation (2nd ed.). Milton, MA: Taylor and Francis.
Hundt, A. S., Adams, J. A., Schmid, J. A., Musser, L. M., Walker, J. M., Wetterneck, T. B.,… Carayon, P. (2013). Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit. International Journal of Medical Informatics, 82(1), 25-38.
Kruse, C. S., & Goetz, K. (2015). Summary and frequency of barriers to adoption of CPOE in the US. Journal of Medical Systems, 39(2), 15.
Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management – UK, 20(1), 32–37.
Pashaeypoor, S., Ashktorab, T., Rassouli, M., & Alavi-Majd, H. (2016). Predicting the adoption of evidence-based practice using Rogers’ diffusion of innovation model. Contemporary nurse, 52(1), 85-94.
Prgomet, M., Li, L., Niazkhani, Z., Georgiou, A., & Westbrook, J. I. (2016). Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: A systematic review and meta-analysis. Journal of the American Medical Informatics Association, 24(2), 413-422.
Shirley, D. (2016). Project management for healthcare. Boca Raton, FL: CRC Press.
Simon, S. R., Keohane, C. A., Amato, M., Coffey, M., Cadet, B., Zimlichman, E., & Bates, D. W. (2013). Lessons learned from implementation of Computerized Provider Order Entry in 5 community hospitals: A qualitative study. BMC Medical Informatics and Decision Making, 13(67), 1-10.
Snedaker, S. (2016). Leading healthcare IT. Boca Raton, FL: CRC Press.