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Philip A. Smith
Tim Benson
Series Editor
Making Computerized
Provider Order Entry Work

Philip A. Smith
Sanford
Florida
USA
ISBN 978-1-4471-4242-3 ISBN 978-1-4471-4243-0 (eBook)
DOI 10.1007/978-1-4471-4243-0
Springer London Heidelberg New York Dordrecht
Library of Congress Control Number: 2012949279
© Springer-Verlag London 2013
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
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now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
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any errors or omissions that may be made. The publisher makes no warranty, express or implied, with
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Printed on acid-free paper
Springer is part of Springer Science+Business Media (www.springer.com)

v
Foreword
It is better to be a dog in a peaceful time than be a man
in a chaotic period.
Ancient Chinese Proverb
Many believe the above proverb to be the source of the oft-repeated phrase, “may
you live in interesting times.” There is little doubt that in American healthcare at the
time of this writing (spring 2012) we are living through interesting times.
The last 30 years of American healthcare has witnessed remarkable techno-
logical advances in the fields of imaging, pharmacotherapeutics, and surgical
interventions, to name a few. However, simultaneously, U.S. healthcare has
come under scrutiny as society pays more attention to the dissociation between
the cost of healthcare and its demonstrable benefits to the American public, at
least as compared with the rest of the civilized world.1
One answer to this prob-
lem has been the pursuit of information technology as a structural answer to
both improved efficiency and effectiveness of healthcare delivery in our
country.
The president signed The Health Information Technology for Economic and
Clinical Health (HITECH) Act, enacted as part of the American Recovery and
Reinvestment Act of 2009, into law on February 17, 2009, to promote the adoption
and meaningful use of certified health information technology. Since that time, there
has been a marked increase in acquisition and efforts at implementation of elec-
tronic health records (EHRs) in large, medium, and small healthcare settings in our
country. This informatics transformation of American healthcare will have
ramifications for all aspects of the practice of medicine in our country for decades
to come.
This book is an essential manual to getting that transformation right.
Dr. Phil Smith, the Chief Medical Information Officer for the Adventist Health
System, and his team have demonstrated that implementation of computerized
1
Squires DA. The U.S. health system in perspective: a comparison of twelve industrialized nations.
Issue Brief (Commonw Fund). 2001;16:1–14.

vi Foreword
patient order entry (CPOE) in 26 hospitals in 28 months2
can be accomplished
effectively and safely realizing the benefits of these new technologies in the daily
practice of medicine.
Dr. Smith steps you through the vision, management, lessons learned and metrics
that every CMIO, CIO, and CMO should know to achieve successful acquisition,
configuration, and implementation of EHRs. The contents include examples and
experience from the 26 hospital Adventist system as well as lessons from leaders in
applied medical informatics throughout the United States.
These lessons have been learned from first-hand experience in system
configuration, design, and importantly, lessons of leadership in healthcare informa-
tion technology (HIT) management that are essential to guiding medical profession-
als through the challenging transitions from early adoption to effective benefits
realization.
This comprehensive guide elaborates on elements of the successful transition to
EHR adoption in detail including:
1. Leadership skills
2. Project management from the CMIOs perspective
3. Course correction in dealing with the inevitable resistance to change
4. Building a successful team and maintaining motivation.
However, beyond the comprehensive guidance Dr. Smith provides in this book,
he reveals the caring insight to the “diagnosis and treatment” of modern healthcare
informatics challenges that stems directly from his tradition as a physician and edu-
cator. The astute reader and student of this book should note the balance the author
strikes between firm leadership and guidance, and the clinician’s empathy and part-
nering skills to achieve the greater goal.
In these times of rapid change and growth in American healthcare informatics,
this book stands as an important work to advise, enhance, and sometimes comfort
the HIT leader as he or she navigates this essential transformation in American
healthcare.
May 2012 William F. Bria, M.D.
2
How 26 hospitals deployed e-order systems in 28 months. 2011. http://www.computerworld.
com/s/article/9222681/How_26_hospitals_deployed_e_order_systems_in_28_months.

vii
Preface
If I have seen a little further it is by standing on the shoulders of Giants.
–Sir Isaac Newton
Why should you read this book? Maybe you are planning a single hospital imple-
mentation of Computerized Provider Order Entry (CPOE) and want to pick up a few
pearls. Perhaps you are with a large health system and are tackling a new project
affecting all or most of your facilities. Alternatively, perhaps you want to assess as
to what level of fool would tackle a project to rollout CPOE to 25 community hos-
pitals, “big bang” over 28 months. The day I am writing this Introduction (August
2, 2011), our 26th hospital (yes, 26th) went live on house-wide CPOE, less than
25 months after our first CPOE pilot. In addition, our hospital physicians are all
using CPOE with a company-wide average of less than 13 % verbal/telephone
orders.
This book is about the process of making a complex project like this, or any other
CPOE project, a reality. It is not the work of one person, but rather requires a team,
leadership, clear vision, dedication, commitment, external drivers, experience, and
the tireless work of those before us in this industry, who have paved the way with
both successes and failure. Only by standing on the shoulders of the giants can we
see beyond ourselves and achieve big goals. I like to sum it up humorously with a
principle that has guided me in this project: “Do what has been shown to work in the
past, and don’t do what has been shown not to work.”
This book is not a scientific reference guide into medical informatics, but rather
a practical guide to visioning and executing successful automation of physician
workflow in hospitals. This is not a book on theory or a summary of research studies
in the field. Much smarter persons than I in the field have contributed the research
and efforts to bring us through the last 30 years from the first CPOE system to the
commercially supported systems of today. We all are indebted to them. There will
be points in this book where I challenge conventional “wisdom” in the area of
implementing CPOE. In the end, I hope that my peers will see this as an opportunity
for dialogue and further study.

viii Preface
I once heard a motivational speaker tell a story about a wise executive who was
quite successful at running his company.
An employee asked, “How is it that you have been so successful at your business?” The
executive answered, “I find it important to only make good decisions!” The employee then
asked, “How did you find a way to only make good decisions?” “Oh, that was simple,”
answered the executive. “Early in my career, I made lots of bad decisions.”
Throughout the book, I will be sharing hard lessons-learned and guide you
through the early warning signs that will help you avoid the pitfalls. Unlike the wise
executive above, I continue to make the occasional bad decision and learn from my
mistakes. As systems progress, and the regulatory environments change, there will
be new challenges and opportunities that will confront you in your efforts to auto-
mate physician workflow. However, there are principles such as vision, leadership,
project management, and change management that will always need your attention
for project success.3
Moreover, I would like to set the book up with a little prologue, so you will know
a little more about the author and the team, how we came to tackle system-wide
CPOE more aggressively than we might have otherwise. I hope this provides some
useful context to these teachings in this book. My journey was not through tradi-
tional medical informatics training, but rather through a series of eclectic events. So
my apologies up front to my many colleagues who are more scholarly in the field.
Your contributions to the industry have been many and great, and I thank you for
your passion into designing better systems and constructs for our future end-users.
My journey in medical informatics began in November 1993 when I converted
my family practice office in New Port Richey, Florida, from paper to an electronic
medical record (EMR). That first year, I found myself more productive and more
profitable, and really caught the bug. Back in 1993, using an off-the-shelf EMR,
I was keeping electronic problem lists, medication histories, allergies and remind-
ers. Pharmacists were amazed that patients arrived with printed prescriptions and
medication safety information. And patients who lived in Florida only during the
winter (we refer to as “snowbirds”) returned north each spring with a printed sum-
mary of care that today we would call a continuity of care document (CCD).
What was particularly useful to learn was the power of information in transform-
ing care even within a single office of two physicians at that time. Though not par-
ticularly related to CPOE, a brief summary of some of these may yield some clues
about my early passion for the EMR:
We quickly learned that we had 76 phone calls a day into the office and that over
half we had seen in the office in the prior 48 h. Of this latter half, the process
typically was that the patient would call the receptionist (front-office staff), who
would then transfer the call to the nurse (back-office staff), who would then take
a detailed message and promise to call the patient back after speaking with the
3
I strongly encourage physicians in the field of informatics to join AMDIS, the Association of
Medical Directors of Information Systems. Their conferences and discussion groups at www.
amdis.org are a priceless resource, and we encourage you to join.

ix
Preface
doctor. Then the nurse would catch the appropriate doctor between patients, and
jointly we would attempt to reconstruct what occurred at the prior visit, since
prior to the EMR the dictation of the visit was typically pending at that time.
Once the doctor devised a plan, the nurse would attempt to call the patient back
(and this was before the popularity of cell phones) and relay the physician’s
advice. Overall, it often took an hour or two to close the loop as well as our nurse
spending about 8–12 min per call and often longer.
We instituted a practice that each day the physicians would indicate patients
on our schedule that our office nurse would call the following morning between
8 and 9 AM. These patients were either work-ins (i.e., sick and worked into the
schedule acutely) or patients on whom we started new medications or treatments.
Because the encounter visit was in the EMR, as well as structured and clear, the
nurse could quickly call each patient proactively and inquire, “How are you feel-
ing and do you any questions or concerns?” The patients loved this service and
saw us as a team that cared for them. Moreover, the time the nurse spent per
patient was typically 1–2 min, freeing up much time and effort.
The second opportunity involved patient flow and our ability to design a better
schedule for our patients. Each physician had about 10,000 active patients. We
would see about six work-ins daily in addition to our pre-scheduled appoint-
ments. Through electronic scheduling we were better able to devise a schedule
that not only allowed us to see the walk-ins daily but stay close to our scheduled
time with our planned patients for that day. For us, we built a modified-wave
schedule, which had six appointment slots per hour – three at the top of the hour,
two at 20 min after the hour, and one at 40 min after the hour. This allowed us to
stay on time even though patients sometimes arrived later for their appointments.
Each hour, we left one slot that was open and we could only schedule after 3 PM
the prior day. As a result, we had a work-in slot for every hour, and patients soon
learned that we could see them the same day if sick. When there were open slots,
we used these to complete insurance inquiries or other paperwork. An unin-
tended, but positive, consequence of this was that patients rarely called us after-
hours (i.e., evenings or weekends) for medical advice. True emergencies went to
the Emergency Department, and others knew we could see them at their conve-
nience the next day.
The other big “ah-ha” was the difference in productivity between two physi-
cians with similar patients and the same EMR within the same office. Within 1
month of implementing our EMR, I was typically finished with all documenta-
tion for my 28–35 patients that day and out the back door about the same time
that the final patient was checking out with the receptionist. The net result was
that I shaved about 2–3 h off my daily office schedule. Prior to the EMR, I would
often go home with a stack of charts that I would dictate that evening, since I
invariably did not do my dictations real time. Once the EMR was live, I found
that I would take my history, do my exam, then document while the patient was
in the room. I frequently found that I had additional questions I could then ask of
the patient. My documentation became better since I was no longer trying to
recall the patient from among a day’s work while dictating in the evening. In

x Preface
addition, I took the time to note a more personal item in each record that would
better connect me to the patient at a future visit. I would say, “Mrs. Jones, how is
your niece doing in her first year at Harvard?” Typically, she would reply, “Oh,
Dr. Smith, how do you keep track of all these things?”
I would also personally demonstrate to patients how the computer would per-
form drug–drug and drug–allergy interactions on new prescriptions, as well as
producing a variety of patient education leaflets. By involving the patients, they
soon saw that the EMR as a benefit, and not an intruder, into the patient–physician
relationship. Yet even today I see physicians and nurses complaining about the
EMR in front of patients, rather than promoting the opportunities the EMR
affords to medical decision making and patient care.
In 1994–1995, I had my first opportunity in hospital clinical systems implemen-
tation through chairing the physician informatics committee at our local HCA
(Hospital Corporation of America) as we deployed Meditech’s clinical system
throughout the ten hospitals of Tampa Bay. I found the experience energizing and
saw a bigger picture as we were able to share secure patient information across
hospitals and well as remotely access the system from the office. That year I became
a 2-year transition from practicing medicine.
During 1999 through the first half of 2001, my friend Martice Nicks and I spent
much of our waking hours developing business process models of how health infor-
mation and data currently flowed and could flow if the industry was committed to
unify under a seamless information management model. Our company, Cognitive
Analysis, Inc. (CAI), brought together people from different disciplines to look at
transforming health information management. Martice, coming from nuclear envi-
ronmental engineering, and I, from healthcare, shared a common vision of tackling
this fragmented cottage industry. We recognized the complexity of the healthcare
industry and began to apply concepts that the nuclear power industry had leveraged
following the Chernobyl and Three Mile Island accidents. We found encouragement
in the Institute of Medicine’s To Err is Human…4
report in November 1999 and in
the Business Roundtable’s formation of the Leapfrog Group.5
However, running
low on cash, and venture capital gone due to the “dot.com” bubble bursting, we dis-
solved CAI in mid-2001 and I went to work for Cerner Corporation, as a physician
executive on the Care Transformation Team.
While at Cerner, I had the opportunity to first identify ways to optimize existing
clinical information installations, while having a hand in early adoption of CPOE on
a commercial platform. Not only did Cerner leadership have a great vision for the
future, but the drive and dedication of associates was endless. Cerner has a great
culture of innovation and collaboration and the Care Transformation Team was at
the forefront of optimization and change management.
In 2003, I transitioned as a physician in consulting at Cerner Corporation into a
dual role at the Adventist Health System (AHS). I became the Vice President of
4
IOM. To err is human: building a safer health system. Institute of Medicine Report. 1999.
5
Leapfrog Group for Patient Safety at www.leapfroggroup.org.

xi
Preface
Medical Affairs at the East Pasco Medical Center (now Florida Hospital Zephyrhills)
in Zephyrhills, Florida. Simultaneously I would contribute my knowledge at the
corporate level as the Chief Medical Information Officer (CMIO). I had previously
consulted with AHS in my role at Cerner and befriended its Chief Medical Officer,
Dr. Loran Hauck, an industry pioneer, who had first published positive outcomes of
utilizing clinical pathways (today, evidence-based medicine) through paper-based
order sets,6
another of those giants in the industry. I also had the blessing to report
to Brent Snyder, senior finance officer and chief information officer, for AHS and
another true believer in cutting-edge clinical information systems.
The second blessing came in March 2005 when we were ready to launch our first
CPOE site in May. We found that there was a possibility that another health system
would acquire the pilot hospital by end of year. Knowing how these things work, it
seemed unreasonable to bring up a medical staff on CPOE knowing that there was
a high likelihood that their new owner would rip out their CPOE system and replace
it with a standard EMR (electronic medical record), since most health systems were
not ready to embrace CPOE in 2005.
Some very special experiences came from that ordeal, however. First, I realized
that the whole concept of an admission order set was flawed. My experience to that
time was in making “soup to nuts” order sets that included everything you needed
to admit a patient with a condition such as pneumonia or heart failure. The “ah-ha”
however was patients today almost all have comorbidities, such as the patient with
pneumonia, worsening his heart failure and his diabetes. In the paper world, we just
ignored duplicate orders. However, in the electronic CPOE world, this creates end-
less reconciliation of duplicates by the ordering physician. There had to be a better
way. Therefore, we developed our “plug and play” model (see Chap. 2) that other
health systems would adopt, and we still use today.
We also realized that we would need to create a sustainable model to produce
large-scale order set content and maintain it across 37 hospitals (soon to be 44 hos-
pitals). We wanted a reproducible model that we could highly leverage. We will
discuss that topic further in Chap. 2.
Therefore, we proceeded to install our EMR model, minus CPOE, through
January of 2008 to 25 hospitals in a very rapid, “big bang” fashion, and put CPOE
on the back burner for the next 2 years. In addition, I left my dual role and became
a full-time CMIO in August 2007 to focus on CPOE planning. This gave us late
2007 and all of 2008 to plan for two house-wide hospital pilots in early 2009. What
I had gained, though, as a VP at Florida Hospital Zephyrhills was an appreciation of
the culture, climate, and operations of a community hospital within AHS. This
knowledge proved very useful in planning a large-scale, rapid rollout of CPOE
across 26 hospitals in nine states. Moreover, if you were counting, you saw we
started with 25 hospitals and ended with implementing 26. In addition, we have five
new (four through merger/acquisition) hospitals on tap for 2012. We will automate
6
Hauck LD, Adler LM, Mulla ZD. Clinical pathway care improves outcomes among patients hos-
pitalized for community-acquired pneumonia. Ann Epidemiol. 2004;14:669–75.

xii Preface
them with our full suite of revenue cycle and clinical systems, including CPOE,
physician documentation, and bar-code medication scanning.
In this book, I will share CPOE experiences, and then point out some key prin-
ciples and lessons learned along the way; not only from the AHS project but also
from other CPOE projects in my career. My hope is that you will read the book
once, and then refer often to the different chapters to deal with opportunities that
will help you right now with a current project and provide some thoughts for your
future project. In addition, each chapter concludes with a “fingernails on the chalk-
board” section of warning signs that you should heed. I hope that these will provide
some reality and humor during this process.
As we journey together, I will be introducing you to a variety of books and
resources that will help you find your way. I can only hope that you find this book
useful to you, your team, and to your many future successes. Moreover, I look for-
ward to your comments and thoughts on the topic via email: phil@medmorph.
com.
August 2, 2011

xiii
Acknowledgments
I would like to thank the countless people who have contributed to my journey in
healthcare informatics, leading to this book. At my current role at the Adventist
Health System, I must first thank Loran Hauck, SVP and Chief Medical Officer,
who has been my partner and friend throughout the CPOE process at AHS. Loran is
not only a pioneer in demonstrating the benefits of evidence-based medicine in the
hospital setting, but leads the Office of Clinical Effectiveness, who developed and
now maintains all the AHS CPOE content. I also thank Loran for being the first to
read this manuscript and provide feedback to the process.
Brent Snyder and John McLendon, both as CIOs at the Adventist Health System
(AHS), who have mentored and encouraged both my development and innovation
as well as supporting this effort of sharing our CPOE experiences to the world.
John’s belief in this project was been encouraging. Brent took the time to also review
the manuscript and help me sharpen it in places. Both of these men are true leaders
in IT.
In addition, I must thank Dr. Don Jernigan, CEO, and Terry Shaw, CFO/COO, of
Adventist Health System, who, with Brent, have provided the vision and resources
to drive adoption of clinical information systems across the enterprise. I also thank
Melanie Lawhorn, in our Communications Office, who has encouraged my writing
as editor for my internal blogs, and assisted me through countless hours of media
interviews.
Jackie Willis, VP and CCIO (Chief Clinical Information Officer), and Judy Best,
VP of business systems at Adventist Health Information Systems (AHS-IS), who
work tirelessly with our teams to constantly improve our systems and keep them
running.
From our teams at AHS, Charol Martindale has allowed me to use her two hopes
and one fear exercise to share with the reader. This filled a need to replace an exer-
cise that I had previously used at earlier implementations. Charol’s idea proved to
be a great ice-breaker for our executive workshops. Heather Linn has repeatedly
provided some of the common phrases and “fingernails on the chalkboard” regard-
ing change management. In addition, Judi Reed helped me to refine my thoughts on
how best to support those folk, who every day support our doctors, with CPOE.

xiv Acknowledgments
Moreover, our medical directors, Drs. Kshitij “Tij” Saxena, Raj Gopalan,
Qammer Bokhari, and Michael Wiederhold, have brought their own strengths and
energies to lead CPOE efforts and help to refine the physician roles for CPOE proj-
ects. Methodologies become stronger as men as these have led our physician engage-
ment efforts. They have been excellent students of the methodologies of this book,
and have applied it with their own successes. They have helped me focus the roles
and responsibilities of physician champions in Chap. 5.
In addition, there have been the teams of people, at AHS as well as Cerner
Corporation, who have contributed to the solid nature of CPOE and have helped me
to refine further, the methodologies and results. You know who you are, and I thank
you.
My special thanks to Izzy Justice, who was my first hands-on mentor in change
management, and John Kotter, whom I am yet to meet, and yet has influenced me
greatly through his numerous publications and his book, Leading Change. In addi-
tion, I must acknowledge Dana Alexander, who first applied the above change man-
agement concepts and tools with me for a major CPOE project. She also introduced
me to the Denison Organizational Culture Survey, which has proved to be a valu-
able tool in our CPOE readiness assessment process.
I thank Ari Black and Dan Denison at Denison Consulting for providing graphics
for Chap. 6. Dan’s company is a fantastic resource for any industry that must
embrace change.
Thanks to Neal Patterson, CEO of Cerner Corporation, for sharing his ever-
growing vision for the healthcare industry, and Paul Gorup, co-founder, who has
always been there with the actual resources to support innovations. They have com-
mitted resources to improve clinical decision support (CDS), a powerful foundation
for anyone wanting to realize benefits and patient safety from CPOE.
Over the past 12 years, there have been phenomenal CEOs and executive teams
who have demonstrated great faith in committing to the change management meth-
odology for these CPOE projects. Thanks for the belief and helping to make it bet-
ter. My personal apologies for all the lessons-learned we experienced through the
last 12 years.
I must acknowledge the countless others, such as project managers, informatics,
IT leads, trainers, physician support liaisons, hospital employees, and medical staffs,
who have embraced CPOE and continue to help optimize the process. You have
indirectly helped develop the book as you successfully managed change and imple-
mented CPOE across North America.
I must acknowledge Scott Pitman, my first CEO at AHS, who taught me the
importance of “shields and phasers” in protecting a team who are taking risks and
doing great things. Thanks for being a shield and helping to improve my phasers.
The reader will understand this later in the book.
In addition, I offer thanks to Drs. Jeff Rose, Dick Tayrien, J. Michael Kramer,
and Scott Weingarten. They have worked with Loran and me to found the Care
Collaborative, leveraging the experience of four large U.S. health systems and Zynx
Health in producing new CPOE content for community hospitals. Organizations
that have the opportunity to work with any of these physicians are truly blessed.

xv
Acknowledgments
Jeff was also my boss at Cerner Corporation and first introduced me to Leading
Change (Kotter, 1996), a pivotal book in my development of CPOE methodologies.
Jeff, I was paying attention!
I thank my family: Beth, my wife, for supporting my crazy work schedule
through the years and time to write this book while maintaining a huge project
schedule; Amy Jensen, my daughter, for repeatedly reviewing and editing the origi-
nal book proposal and manuscript, and her husband Van Jensen, himself a published
author, for his encouragement and advice throughout the process.
I cannot express my pleasure enough, that Dr. Bill Bria, co-founder of AMDIS
(Association of Medical Directors of Information Systems), took time to review the
manuscript and write his foreword to the book. Bill, you are a true leader of leaders
in this industry, and I thank you dearly for taking the time to read the manuscript and
offer your encouragement through the process.
Finally, I offer my sincere thanks and appreciation to Grant Weston, my editor, at
Springer, for championing the book proposal and leading me through the process.

xvii
Contents
1 Why the Concern for CPOE ................................................................... 1
1.1 Four Principles................................................................................. 2
1.2 Key Points........................................................................................ 7
1.3 Fingernails on the Chalkboard......................................................... 7
2 Vision: How You Start ............................................................................. 9
2.1 Building Up from the Vision ........................................................... 10
2.2 Managing Order Set Content........................................................... 11
2.3 Plug and Play................................................................................... 14
2.4 Visual Anchor.................................................................................. 15
2.5 Project Plan and Scope .................................................................... 15
2.6 Key Points........................................................................................ 25
3 Leadership and Governance ................................................................... 29
3.1 CPOE Policies ................................................................................. 31
3.1.1 Is CPOE Mandatory?........................................................... 32
3.1.2 Is Training Mandatory?........................................................ 33
3.1.3 When Is CPOE Required, and What Are the Exceptions? .. 33
3.1.4 When Are Verbal or Telephone Orders Appropriate?.......... 34
3.1.5 What Is the Process for Entering Verbal
or Telephone Orders?........................................................... 35
3.1.6 What Is the Role of Rounding Nurses or Scribes? .............. 37
3.1.7 What Is the Process for the Reconciliation
of the Patient’s Medications (i.e. Meds Rec
or Medication Reconciliation)?............................................ 38
3.1.8 What Is the Process for Direct Admissions
from the Physician’s Office to Hospital? ............................. 41
3.1.9 What Is the Process for Admission
from the Emergency Department (ED)?.............................. 42
4

xviii Contents
3.1.10 How Do You Manage Standing Orders and Protocols?....... 43
3.1.11 Standing Orders ................................................................... 44
3.1.12 Protocol Orders.................................................................... 44
3.1.13 Policy-Driven Orders ........................................................... 45
3.2 Physician Leadership....................................................................... 46
3.3 Key Points........................................................................................ 46
4 Project Management Key Opportunities............................................... 49
4.1 The Product Phase ........................................................................... 50
4.1.1 What Components Currently Exist
in the EMR Platform?.......................................................... 50
4.1.2 Is the EMR Fully Integrated or Best of Breed? ................... 51
4.1.3 Does the EMR Have a Physician-Friendly
Order Catalogue? ................................................................. 51
4.1.4 Does the EMR Have Medication Integration in Place? ....... 53
4.1.5 What Are the EMR Tools for Clinical Decision Support?... 55
4.1.6 Does the EMR Provide Electronic Documentation Tools
for Providers?....................................................................... 56
4.1.7 How Do Charges Drop Through Orders
and Documentation? ............................................................ 56
4.1.8 Is There a Content Process for Order Sets
and Documentation? ............................................................ 56
4.1.9 How Do Providers Maintain Problem Lists? ....................... 56
4.1.10 How Will Providers Co-sign Verbal
and Telephone CPOE Orders? ............................................. 57
4.1.11 Testing of the CPOE System................................................ 58
4.1.12 Critical Success Factors for CPOE Pilot(s) ......................... 58
4.2 Key Points........................................................................................ 59
5 Change Management............................................................................... 61
5.1 Key Events of the Change Management Plan ................................. 64
5.2 CPOE Change Readiness Assessment............................................. 64
5.3 Executive Preparation Call .............................................................. 65
5.4 Executive CRA Workshop............................................................... 66
5.5 Leadership Interviews...................................................................... 66
5.6 Organizational Culture Survey ........................................................ 67
5.7 Leadership Workshop...................................................................... 68
5.8 Change Manager Activities ............................................................. 69
5.9 Communication Assessment ........................................................... 69
5.10 Learning Assessment....................................................................... 70
5.11 Stakeholder Analysis....................................................................... 70
5.12 Retention Assessment...................................................................... 70

xix
Contents
5.13 Key Roles and Project Champions .................................................. 71
5.14 Stakeholder Engagement................................................................. 72
5.15 Communication ............................................................................... 75
5.16 Training............................................................................................ 78
5.17 Workflow ......................................................................................... 79
5.18 Performance Management............................................................... 81
5.19 Employee Impact............................................................................. 84
5.20 Knowledge Management................................................................. 84
5.21 Executive and Leadership Coaching ............................................... 85
5.22 Patient/Community Engagement..................................................... 86
5.23 Physician Engagement..................................................................... 86
5.23.1 Physician Champion Characteristics.................................... 86
5.23.2 Physician Champion Skills .................................................. 87
5.23.3 Physician Champion Responsibilities.................................. 87
5.23.4 CMO/Medical Director........................................................ 87
5.24 Key Points........................................................................................ 88
6 CPOE Change Readiness Assessment.................................................... 91
6.1 The Executive CRA Workshop........................................................ 92
6.2 CRA Change Management Activities ............................................. 98
6.3 The Denison Organizational Culture Survey................................... 103
6.4 Examples of Organizational Culture ............................................... 104
6.5 Key Points........................................................................................ 108
7 Building Momentum................................................................................ 111
7.1 Physician Engagement..................................................................... 112
7.2 Physician Training........................................................................... 115
7.3 Staff Engagement ............................................................................ 122
7.4 Key Points........................................................................................ 123
8 Avoiding Common Pitfalls....................................................................... 127
8.1 Budget Assumptions for Planning for CPOE at a Facility.............. 127
8.2 Estimating Physician Liaison(s) to Support CPOE......................... 129
8.3 Characteristics of a Successful Physician Liaison........................... 130
8.4 Care and Training of Your Physician Liaison(s) ............................. 131
8.5 Shields and Phasers ......................................................................... 132
8.6 Watering Down Medical Decision-Making..................................... 133
8.7 The Impaired/Disruptive Physician................................................. 134
8.8 The Slow-Adapting Physician......................................................... 135
8.9 “I’ll take my business and go elsewhere” Physician ....................... 135
8.10 Blaming the EMR for All Problems................................................ 135
8.11 Missing the Opportunity to Drive Performance Improvement........ 136

xx Contents
8.12 Giving Some End-Users a Pass on Training.................................... 136
8.13 Having Adequate Devices at Activation.......................................... 137
8.14 Ensuring Physician Remote Access ................................................ 138
8.15 Training Physician Office Staff ....................................................... 138
8.16 Leadership Absences at Activation ................................................. 138
8.17 Key Points........................................................................................ 139
9 Implementation ........................................................................................ 143
9.1 Activation Meetings......................................................................... 145
9.2 Other Activation Opportunities ....................................................... 146
9.3 Chart Audits and Activation Metrics............................................... 147
9.4 Key Points........................................................................................ 148
10 Stabilization and Optimization............................................................... 151
10.1 Stabilization..................................................................................... 151
10.2 Optimization.................................................................................... 155
10.3 Improve Access to Patient Lists ...................................................... 157
10.4 Enhance the Admission Process...................................................... 158
10.5 Improve Medication Reconciliation ................................................ 158
10.6 Improve the Transfer and Discharge Processes............................... 158
10.7 Improve the Order Catalogue .......................................................... 159
10.8 Provide Enhanced CPOE Content................................................... 160
10.9 Improve CDS................................................................................... 160
10.10 Improve Electronic Documentation................................................. 161
10.11 Develop CPOE Dashboards............................................................. 161
10.12 Report Physician-Specific Performance.......................................... 162
10.13 Key Points........................................................................................ 162
11 Putting It All Together............................................................................. 165
11.1 What Healthcare Has in Store ......................................................... 166
11.2 New Payment Models...................................................................... 169
11.3 The Four Principles Revisited ......................................................... 171
11.4 Key Points........................................................................................ 175
Appendices........................................................................................................ 177
Appendix A: Roles and Responsibilities of CPOE Champions................. 177
Appendix B: Example of Knowledge Transfer Agreement ....................... 181
Appendix C: Employee Retention Plan...................................................... 182
Glossary ............................................................................................................ 183
Index.................................................................................................................. 187

1
P.A. Smith, Making Computerized Provider Order Entry Work,
Health Information Technology Standards,
DOI 10.1007/978-1-4471-4243-0_1, © Springer-Verlag London 2013
Chapter 1
Why the Concern for CPOE
Abstract This chapter briefly covers the origin of Computerized Provider Order
Entry (CPOE) and how the 2009 American Recovery and Reinvestment Act (also
known as the US Stimulus bill) provided funds to acceleration CPOE adoption. The
author introduces Four Principles to guide clinical IT (information technology)
projects.
The more things change, the more they stay the same
– Jean-Baptiste Alphonse Karr (translated from French)
In June of 1973, a group of pioneers from Lockheed-Martin brought a new clinical
computer system live at El Camino Hospital in Mountain View, California. This
system would replace the doctors’ handwritten orders with orders entered directly
into a computer the birth of what the industry would later call computerized pro-
vider order entry or CPOE. By 2008, about 10 % of U.S. hospitals had adopted
computerized provider order entry,1
and systems now include not only ordering, but
also the inclusion of clinical decision support (CDS). Based on other technology
adoptions2
like radio, television and personal computers, one might predict that it
would take another 35 years for 90 % of hospitals to adopt CPOE. Despite 92 % of
the published articles on CPOE touting benefits to patient safety, quality and out-
comes,3
CPOE adoption was still creeping along with only a few hospitals activat-
ing full CPOE annually. In addition, Rand Corporation published a study in 2005 on
the potential reduction of costs through wide adoption of healthcare IT.4
CPOE and
EHR adoption needed a catalyst.
1
Though the original name for CPOE was computerized physician order entry, today most refer to
computerized provider or prescriber order entry to acknowledge mid-lever providers/prescribers
such as physician assistants and advanced practice nurses.
2
Dent HS Jr. The roaring 2000s: building the wealth and life style you desire in the greatest boom
in history. New York: Simon and Schuster; 1998.
3
Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technol-
ogy. A review of the recent literature shows predominantly positive results. Health Aff. 2011;30:3,
464–71.
4
Girosi F, Meili RC, Scoville R. Extrapolating evidence of health information technology savings and
costs. Santa Monica: RAND Corporation; 2005. http://www.rand.org/pubs/monographs/MG410.

2 1 Why the Concern for CPOE
With the stroke of the pen in February 2009, United States President Barack
Obama signed into law the $800 billion American Recovery and Reinvestment Act
of 2009 (ARRA)5
While the “stimulus bill” had numerous provisions for federal
investment in infrastructure projects, it also represented a huge commitment to
healthcare information technology (HIT) under the section now known as ARRA
HITECH. With billions of dollars of federal incentives available, hospitals and phy-
sicians are attempting to demonstrate “meaningful use of certified EHR technol-
ogy.” This has become the burning platform needed by many hospitals and physician
offices to pursue CPOE and other aspects of electronic health records.
While ARRA HITECH is also providing grants for new clinical IT training
programs, industry leaders report that there is currently a deficit of trained clinicians
capable of implementing these new initiatives. In addition to CPOE, HITECH
will push automation of clinical outcomes, electronic physician documentation,
e-Prescribing, and Health Information Exchanges (HIE).
As too few experienced persons pursue too many projects, the industry may see
an increase in project failures, which will send ripples throughout healthcare IT,
leading to confusion, pushback, or even slowing/cancellation of major projects.
This book may provide some ideas that can help professionals think through the
steps toward project success.
1.1 Four Principles
As I have worked with physicians on large, complex health care projects these past
20 years, I have devised four principles that have consistently guided successful
projects. Let me explain each of them:
1. Every day, every person in health care comes to work planning to do their best
for the patients.
2. Every day, every person in health care comes to work listening to the same radio
station, WII-FM (“What’s in it for me?”).
3. Automating broken processes gets you to the wrong place quicker.
4. Today’s problems were yesterday’s solutions.
These four principles have been both a barometer and a checklist for me over the
past two decades. Taken together, these principles can keep you on track as you navi-
gate the dangerous waters of major projects from design, activation and adoption. So
let us take them one at a time and better understand what they mean. Then we can
apply them throughout the book as we tackle the major steps to project success.
Every day, every person in health care comes to work planning to do their
best for the patients.
People get into healthcare because they have a passion to make a difference. This
is the principle of “higher calling”. Almost every doctor, nurse, therapist, technician
5
For more information on ARRA, visit www.hhs.gov/recovery.

3
1.1 Four Principles
or any other healthcare worker strive to make a difference in the lives of their
patients. You see it in their commitment, in their faces and in their work ethic. They
study hard, they work hard, and they understand the high stakes of dealing with life
and death issues. No one comes to work wanting to commit an error, omit some
treatment, or to do less than his/her personal best. Yet each human being is capable
of making an error, even on a good day. Fortunately, harm rarely occurs from a
single person making a single error.
Most harm, in our experience, occurs when a cascade of errors occurs, processes
are lax, and/or end-users do not follow recommended procedures. Health care has
made great strides in the past 20 years to create better systems, to simplify pro-
cesses, and to provide error trapping (e.g., alerts and clinical decision support). One
thing is clear: people in healthcare suffer a personal, emotional cost whenever an
error occurs, especially if patient harm is the result. The person who does set out to
do harm, is a very rare exception to the norm. From this principle arises two impor-
tant points: (1) Don’t ever communicate that you are engineering a new process to
make it “idiot-proof”, and (2) While patient safety and great outcomes are important
to everyone in healthcare, principle #2 below often trumps this principle.
People do not make mistakes because they are idiots. They make mistakes
because we are human, and because our systems have not yet matured to accom-
modate the natural course of human behavior. So communicating “idiot-proof”
solutions only implies contempt for the basic truth of this principle. Any person
thinking he/she can design and implement idiot-proof solutions probably has not
been doing it for very long. In fact, the story below illustrates that you can never
predict what others are thinking.
I learned very early in my career that physicians often believe that what they have
been doing since medical school and residency always represents the best practice.
When new evidence recommends that we change the techniques or medications
that we use, many physicians have a natural resistance to change. On more than
one occasion, I have had a physician, in a defensive tone, reply, “You mean you
are telling me that I’ve been doing it wrong all these years?” Now that same physi-
cian is probably performing laparoscopic surgery for a procedure that he learned
to do by open incision, but he misses that connection in his defensiveness.
At that moment, we must overcome the defensiveness and process the evi-
dence openly. As the physician calms down and begins to consider the evidence,
he/she begins to acknowledge the patient safety aspect and becomes more open
to discussion. By having patient safety as our ultimate outcome, the project team
is able to move CPOE forward with less resistance.
While patient safety and great outcomes are always an overall objective, there
are frequently distractions that seem to get in the way. Principle #2 explains the
phenomenon.
Every day, every person in health care comes to work listening to the same
radio station, WII-FM.
WII-FM of course is the abbreviation for “What’s in it for me?” While everyone
in health care is passionate and committed to a good patient outcome, it is important

to realize that every new advancement and process must add some personal benefit
to the person expected to adopt it. Typically, a person will take the “path of least
resistance” in his/her day, unless some new process can add some personal value.
For physicians, that value typically comes as more time, more money or more peace
of mind. In addition, unless we internalize the value of a new process or procedure,
we will fall back to our old ways with resistance, work-a-rounds, or even outright
rebellion. As we adopt new processes and new technologies, it is critical we clearly
communicate what the benefit will be to the individual who must make the change.
This might include a more efficient process, new cues, less effort, or incentives, to
name a few. Of course, each person in health care comes to work with principle #1.
However, it is principle #2 that smoothes adoption and creates lasting change. You
may refer to Principle #2 as the “law of self-interest”.
I encountered a hospital recently where the main CPOE message was, “We are
doing CPOE to collect the Meaningful Use dollars.” The doctors were upset that
the hospital was disrupting their daily work patterns to collect “millions of dol-
lars, while they are turning us into secretaries.” Once this becomes the stated
driver for CPOE, you experience more resistance from the medical staff, and
ultimately the staff follows suit.
Failing to find and state value for your doctors and nurses is lazy and creates
“ill-will” that takes much effort to overcome. Physicians realize that CPOE is
hard and will take much effort on everyone’s part to be successful. However, they
also need to hear from leadership the direct value to the physician from CPOE.
Just like the hospital expects a return on investment from CPOE, the medical
staff looks for time, money or peace of mind. You should have a clear value in
mind for each of your major stakeholder groups, especially your physicians.
Automating broken processes gets you to the wrong place quicker
Many think that new technology is often the solution to things that are no
longer working in an organization. Take automating clinical processes as an
example. Many clinical processes are inherently inefficient and needlessly com-
plex. Often there is no acknowledgement of this because the process crosses the
paths on many different individuals in many different locations or departments.
In fact, flowcharting the process often reveals issues that have persisted for years.
Often, the person in the midst of the complex process knows primarily what they
do, and a little bit about what the people immediately before and immediately
after them do in the process. Yet there may be five or more hand-offs before the
process is completed.
The workflow team in the Emergency Department (ED) at one pre-CPOE hospi-
tal identified a process that involved the registration clerk photocopying the visit
encounter notes following every ED visit, stapling them together and putting
them in an “out basket.” No one knew why the copying was necessary; they had
repeated this ritual for several years. A volunteer would pick up these copies and
hand-carry them across the hospital and deposit them into an “in basket” in the
Pharmacy. Once the pharmacist got to the “in basket”, he would drop the encoun-
ter record into the shredder bin for destruction. When our analyst asked why this

5
1.1 Four Principles
process was occurring, the pharmacist replied, “We had reviewed all the ED
records manually in the past, but now do this electronically in the EHR. We have
told the ED to quit sending these up, but they continue to send them anyway.”
The hospital CEO stopped this unnecessary process that day, well in advance of
CPOE and immediately challenged his team to identify other examples of waste
or duplication. All of us are familiar with the old adage, “That’s just the way we
have always done it around here.”
Another error is not thinking through how to leverage automation to eliminate
unnecessary or inefficient steps in the process – automating the paper processes as
a result. Using lean techniques, designers can often eliminate several steps and
remove sub-processes that are “non-value” added. As the designer provides “trans-
parency” around the process, the end-users can begin to identify opportunities to
streamline workflow and minimize wasted steps. It is critical that the design engage
the actual end-users in this stage of the process. The designer should document
decisions and frequently asked questions as well as identify the value statements
important to the end-users. The project team then leverages this information to
achieve buy-in and adoption of the new processes.
An example of this at AHS was the discharge process. Prior to CPOE, a doctor
would tell the patient that he/she would be “discharging them that day and please
have your family come in to take you home.” Prior to CPOE, however, the nurses
reported that it would take about 4–6 h to gather all the information together and
complete the discharge. This would greatly frustrate the family member who
took off work, only to sit for several hours waiting. As discussed later in the
book, the team at AHS redesigned the CPOE discharge process. As a result, the
patient typically left the hospital within 30 min of the doctor writing the dis-
charge order. The patients, nurses and doctors have all seen this as a benefit of
the new process. However, some units have held on to their old discharge process
and not seen this benefit.
Commonly, the team’s initial efforts of automation may result in flaws or miss
sub-processes and situations (i.e. “use-cases”) that they did not plan or consider.
Fortunately, the end-users tend to identify many of these during training or during
the first 30 days post implementation. The design team may experience embarrass-
ment at this result; however, a mature team will see this as an opportunity. The team
humbly can address the deficiencies and thoughtfully work through these sub-
processes and determine a solution to validate. While the first attempt may not be
the final solution, it allows the team to work together and builds confidence and
assurance that no matters what happens, the team will address and overcome the
immediate challenges.
In addition, this principle reminds us that we must properly manage expectations
for the project. The phrase, “under promise and over deliver” helps us to keep the
proper perspective as we communicate to the end-users as well as to the facility
leadership. This is the “law of managing expectations.”
Moreover, CPOE implementation may expose areas in which the hospital may
improve accountability. The largest area, in our experience, has been in clearly

defining the difference between clinical processes and medical decision-making.
The author will address that in more detail in a later chapter.
Today’s problems were yesterday’s solutions.
I started using this phrase over 30 years ago while in college and it has always
kept me humble (I honestly do not know if I coined it or heard it back then.). While
principle #3 deals with immediate cause and effect, principle #4 deals with long-term
consequences. It is important to recognize that in one’s efforts to fix some obvious
issue or problem, a new (not so obvious) problem often results down the road, and a
more complex one at that. As Einstein said, “We cannot solve our problems with the
same thinking we used when we created them.” Always recognize that in the rush to
solve problems, one may create unintended consequences, which may not even be
apparent for some time. Therefore, look for iterative solutions to complex problems.
Do not expect solutions to come easy or be simple. Moreover, do not expect to have
all the answers up front. Do your initial analysis, move forward cautiously, then
identify where sequential adaptations and improvements (enhancements) need to
occur. Two points of danger occur: analysis paralysis, in which you never move for-
ward until you have everything perfectly figured out; and foolhardy implementation,
rushing in with your “perfect” solution, only to find that you are in over your head
with an unworkable solution. This is the “law of unintended consequences.”
Most of us in clinical IT have seen this play out in the area of “hard-stops” in the
EHR. The concept is that you engineer some required documentation that must
occur in the workflow in order for the nurse or physician to proceed to the next
step. These rarely work out, since for every “rule” in healthcare, we eventually
find an “exception.” In addition, the exception may be in midst of the physician/
nurse providing some life-saving care. Typically, we design alerts or “soft-stops”
for these scenarios. We provide some type of warning to alert the user, but then
give them the option to proceed, with or without some reason for overriding.
CPOE, itself, presents some new “unintended consequences.” One may design a
system to promote safety, and inadvertently drive their end-users to select the wrong
meds, wrong doses or wrong routes of administration. For more on this topic, one
should familiarize himself with the work of the Physician Order Entry Team (POET)
at the Oregon Health and Science University.6
To apply these four principles, one should look at current or past project chal-
lenges to examine how a team might gain insights from them. From the analysis, the
team may find new opportunities for discussion that may prove helpful. Then, the
team will be able to utilize them to anticipate issues or proactively prevent problems
during future projects.
Moreover, the hospital of the twenty-first century should focus on three core
competences: healthcare delivery, information management, and sound financial
management. CPOE provides a wealth of data and information that help hospitals to
achieve improved clinical, operational and financial outcomes. Hospital executives
6
This excellent resource is at www.cpoe.org. This site presents the results of research by the
Physician Order Entry Team (POET) at Oregon Health & Science University.

7
1.3 Fingernails on the Chalkboard
should view CPOE as a strategic initiative. As they access better real-time data, they
can make more-informed decisions in these areas and make early course directions
when they do not achieve the results they expected. The author will discuss this
further in later chapters.
1.2 Key Points
ARRA HITECH has become a catalyst for EHR/CPOE adoption
•
Assume healthcare workers have a high-calling for patient care
•
Assume everyone responds to self-interest
•
Automating broken processes will get you the wrong result quicker
•
New solutions will generate new problems down the road
•
My “red flags” on these topics occur with the following comments/observations:
“
• Let’s do CPOE this year so that we can collect the Meaningful Use
dollars!”
Your employees and doctors do not see value in disrupting their days and
workflow so that the hospital can collect a government incentive. In fact, this can
often become the motto of resistance for a CPOE project as physicians claim that
you are only doing CPOE for the money. Your strong vision for the project also
needs to generate value to your stakeholders, namely your Board, your employ-
ees and your medical staff.
“
• We are putting in the new EHR to catch all the mistakes our doctors/nurses
are making.”
Doctors and nurses feel great about the care they delivery and become defensive
when you make such comments. Yet we all know the even on our best days, we
all overlook information and make less than optimal decisions. It is critical to
come to your team with specific data on where opportunities exist and how we
plan to improve our patient care processes. Armed with data, your team will see
opportunities to improve the patient care process through your CPOE project.
“
• Get on board with the project, or you will be looking for a new job.”
No one gets excited about a project that begins with threats. Sell the value to your
team up front and they will come along with you. This is important with posi-
tions, such as unit clerks/secretaries (noted below), who will experience a major
change in their daily activities once you implement CPOE.
“
• We are doing this to cut costs for the hospital”
While everyone supports cutting costs, that often means cutting jobs. You can
make a case for helping everyone be more productive and efficient through new
processes as we free up bandwidth and resources.

“
• We are doing CPOE to eliminate the unit clerks.”
Unit clerks have the ear of both the nurses and the doctors. They will derail a
CPOE project if they believe that you are trying to eliminate their job. Instead,
you must actively engage them early and help them understand the opportuni-
ties they will have as you bring CPOE live. There will be more on this topic in
Chap. 5.
“
• Our nurses/doctors don’t have the time to participate in design sessions.”
It is sometimes a challenge to engage doctors and nurses, and it ensures a
disaster if you do not engage them. We will discuss this in depth in chapter 7.
“
• Just figure it out, and we will make the nurses follow the new processes!”
Part of the success of CPOE is designing leaner processes that create new
efficiencies and improved patient care. When the front-line nurses get involved
in designing the new workflows, they will be more likely to actually follow them,
rather than work around them. You will avoid implementation rebellion when
nurses have “skin in the game” up front.
“
• Let’s not worry about that now, since CPOE will solve that problem.”
You can leverage your CPOE project as a great opportunity to better understand
your current inefficiencies and design a better workflow(s) that you can imple-
ment either before, with, or after CPOE activation. Rarely does CPOE fix prob-
lems that existed unless you give them special attention in the process. Typically,
you will accelerate problems once CPOE goes live.
• When you see a lack of committed resources to train new employees/doctors
and ensure ongoing competencies of end-users.
As you go live with CPOE, it is a 1-day event. The real work is in stabilizing your
new system and then finding opportunities to optimize your processes. Therefore,
you must keep your training materials and trainers up to date on these new pro-
cesses. As new doctors and employees enter the system, you must train them on
how you do business today, and not on what you were teaching when you first
brought your system live. Otherwise, you will be discouraging your newest users
and losing the benefit of your optimization processes.
• Beware, if you have no plan for optimization of processes following imple-
mentation and stabilization.
The end-users using your EHR are your best sources of understanding where you
must focus your efforts to achieve improved clinical, financial and operational
outcomes. Often, post activation, the design and implementation teams are
already working on subsequent projects or not involved in seeing how your end-
users are using the EHR/CPOE. If you fail to staff your optimization efforts, you
are failing to reap the full benefits of your automation efforts.
• Plan to fail if you do not have doctors contributing to your project.
Though most doctors will choose not to participate on your project, you will
need physicians who will commit time for review and feedback during several
key points in the process.

9
Chapter 2
Vision: How You Start
Abstract This chapter explains the importance of vision for successful CPOE
projects. The author provides a structure for developing and managing order set
content for a CPOE project. In addition, he discusses how to one plans the initial
scope of their CPOE project. The author stresses that patient safety is the best reason
for a hospital or health system to pursue a CPOE project.
Where there is no vision, the people perish:
– Proverbs 29:18 (Bible, King James Version)
Why start with vision? Because if you do not get vision right, you are doomed to
failure. Whether you are tackling CPOE or any other large-scale initiative, vision is
what determines what you are actually trying to accomplish and why.
Over the years, I had multiple opportunities to assess projects that had failed,
were failing, or seriously stalled. Each time, I have observed a lack of clear vision
from the senior leadership. Typically, the IT department has an idea why the project
is proceeding, but not the CEO and senior executives. The worst case occurred in
the early 2000s, when the senior executives, 1 month prior to CPOE activation, did
not even know that CPOE meant that physicians would be entering orders into the
computer and no longer writing them. It was news to their medical staff as well. Yet
the project team had built the platform and was ready to execute! I was unpopular
when I recommended that they were months away from being able to activate
CPOE. Fortunately, the CEO did get involved and many months later saw a very
successful implementation.
At the Adventist Health System (AHS), “Deploying clinical information systems
and having CPOE well under way” was the leading statement for the 2010 Vision
Statement. The senior leadership made it clear from the beginning that our EHR and
CPOE were corporate initiatives and not just IT initiatives. This visibility places it
in the annual report, before the Board, and at the front and center of strategic discus-
sions. Senior leadership determines whether CPOE is the highest priority, or just
another project only affecting a small group within the system.
Why is this important in the case of CPOE? First, CPOE affects almost every
workflow in the hospital. Therefore, it requires every department and unit of
the hospital to understand how CPOE affects them and how to leverage it for
improved efficiency. In addition, CPOE changes the physician’s workflow from one

10 2 Vision: How You Start
of viewing information and handwriting orders to total interaction with the EHR.
Handwritten orders have been the norm for years, so having the doctors perform
computerized order entry is a major change for their workflow. Moreover, each
CEO, in the community hospital, has physician satisfaction as a core responsibility.
The hospital does not employ these physicians or award academic appointments.
The CEO and medical staff form a relationship that depends on mutual trust and
benefit. Therefore, getting physicians on board and participating with this change is
critical. The CEO does not want, and cannot afford, to alienate the medical staff in
the process.
Coupled with the Vision Statement, AHS clearly identified CPOE as an opportu-
nity to improve patient safety while creating a consistent platform to deliver clinical
best practices and evidence-based medicine recommendations to the end-users. This
conclusion came after 10 years of medical staffs utilizing these pathways as paper-
based order sets on only about 40 % of qualifying patients. The ultimate vision has
always been to “hard-wire” evidence-based medicine into the physician’s “path-of-
least-resistance” workflow.
After the first two pilot hospitals went live with CPOE, Don Jernigan, the AHS
chief executive officer (CEO), validated the vision through strong messages to the
hospital CEOs at the annual meeting, saying, “Seeing CPOE go live at these two
hospitals represented some of the proudest moments of my career.” Dr. Jernigan’s
message, coupled with the 2010 Vision Statement, created a clear mandate to the
CEOs and their hospitals that would follow the pilots. One cannot put a price tag on
your CEOs public support.
Once you cast your vision, then all the fun work begins. What will the project
encompass (i.e. What is the scope)? What is the roadmap? How do we begin? How will
we make decisions? You will find detailed answers to these important questions in the
subsequent chapters. I always like to start with Stephen R. Covey’s1
analogy of filling
a bucket with rocks, gravel, sand and water – always start with the “big rocks” first.
2.1 Building Up from the Vision
The “big rocks” for AHS were how to achieve the vision of “hard-wiring” evidence-
based medicine and promote patient safety. While the author had seen other health
systems and hospitals use other approaches, it was obvious how to set up the program
at AHS.
From the evidence-based medicine aspect, it became clear that while there are
regional differences in how our hospitals operate and in the level of resources avail-
able (i.e., local variation), AHS wanted to fully leverage clinical guidelines and best
practice for diseases and conditions for which evidence exists. For example, the
American College of Cardiology regularly updates its guidelines on the treatment of
1
Covey SR. The seven habits of highly effective people. New York: Fireside; 1989.

11
2.2 Managing Order Set Content
acute ST-elevated myocardial infarction2
(acute STEMI, or heart attack). This then
becomes the standard of care that we expect physicians to follow regardless of
whether they practice at a large hospital in Florida or at a small critical access hos-
pital in Wisconsin. This meant a move from “experience-based medicine” in which
decisions on order set content for acute STEMI rests in the hands of the local medi-
cal staff, to a more universal approach, of deploying a common “evidence-based”
order set at a corporate level, that would be shared by all. The common phrase by
AHS Chief Medical Officer Dr. Loran Hauck became “we are not advocating a
standardized approach to the practice of medicine by our physician, but rather that
they practice to a standard.” This was a change in approach to the paper order set
days, when the Office of Medical Affairs sent an Acute STEMI template to each
hospital for local revisions and printing, to a common electronic order set shared by
all AHS hospitals.
The challenge then was to solve two issues. How does one provide the infra-
structure to keep corporate content up to date, and how does one deal with the
difference in resources available to hospitals of varying sizes, structure and mar-
kets? Fortunately, the Chief Medical Officer had recently expanded his depart-
ment from an Office of Medical Affairs, into the AHS Office of Clinical
Effectiveness (OCE). This proved a timely change that helped to drive the solution
to our infrastructure issue.
AHS tackled content first, since they already had a Corporate Physician Committee
(CPC) to review and develop evidence-based content and a relationship with Zynx
Health,3
a provider of evidence-based content. However, we knew the volunteer
army of community physicians, nurses and clinical pharmacists could not manage
the volume of content needed to implement CPOE. Previously, the CPC had devel-
oped and maintained content on about ten conditions, diseases, and operations
through monthly meetings and a few workgroups. In assessing what they needed,
they looked at all discharge diagnoses for the prior 2 years and determined what
represented the top 85 % of conditions/diseases that they were managing in the
hospitals. In addition, they identified 64 common presentations of signs and symp-
toms for the Emergency Department and several dozen protocols such as anticoagu-
lation management. All told, this represented a need for about 550 order sets to have
a robust catalogue. The principle for these order sets was that they were universal
and the hospitals would not modify locally. As a comparison, the author has done
CPOE projects with as few as 35 order sets and as many as 2,000.
2
ACC/AHA. ACC/AHA guidelines for the management of patients with ST-elevation myocardial
infarction. J Am Coll Cardiol. 2004;44:671–719.
3
www.ZynxHealth.com.

For admitting patients to the hospitals, AHS realized the hospitals varied in size,
structure and resources, so committed to build a localized admission order set for
each type of unit by hospital. The team called these order sets “Admit to Venue”,
and named them for the unit to which they applied. So in the case of Florida Hospital
Zephyrhills (FHZ), the Admit to Venues included:
Admit to Med/Surg/Telemetry FHZ
•
Admit to ICU FHZ
•
Admit to Labor FHZ
•
Admit to Peds FHZ
•
Admit to Behavioral Health FHZ
•
To promote local collaboration on the Admit to Venue design, the hospital’s
Medical Executive Committee, which governs the Medical Staff, became the
approving group of the content for the local Admit to Venues. The OCE team would
serve as content editors, to ensure that identified outmoded practices did not make
it into these order sets.
Knowing that the content would have to be solid for over 9,000 community phy-
sicians to accept, they decided that the OCE would be the owner of all corporate
order set content. This proved to be a wise decision.
In previous CPOE projects, a physician associated with the IT team, such as the
CMIO or a medical director, would own content for all order sets. They would then
have endless meetings with physicians by specialty and try to iron out the best order
set to meet the needs of that group. While the author has observed some skilled
physician consultants in my career facilitate these “rapid order set design sessions,”
the more likely result is that these sessions derail from local politics and opinions.
Typically, one or two outspoken physicians will dominate the session with his/her
“expert opinion” often overriding even the strongest evidence, and shut down all
other collaboration. An example brings clarity to this concept.
The setting was a 2-day, rapid order set design session for the Department of
Orthopedics at a multi-hospital system (around 2002). The group included a
couple of orthopedic surgeons, nurses, surgical technicians and unit clerks. By
the second day, the group had designed three order sets, including total knee
replacement, total hip replacement, and hip fracture. They were finishing up with
post-operative recommendations for dosing two blood thinners, enoxaparin and
warfarin, and had concluded that “mini-dose heparin” was no longer an
evidence-based alternative to prevent the post-operative, life-threatening compli-
cation of blood clots (today VTE, or venous thromboembolism). As the group
was ready to leave, after two hard nights of work, a lone unit clerk raised her
hand and brought the process to a screeching halt, “Dr. Jones (name changed)
does half the orthopedic surgery at my hospital, and he only uses mini-dose
heparin on his patients.”
It took about 5 min for the group to capitulate on the evidence, and agree
to add mini-dose heparin to the new “evidence-based” order sets. Moreover,
Dr. Jones did not even show up to participate in the process.

13
The physician leading content design must be a person of influence and an excel-
lent facilitator. The result is that the process completely consumes the physician
responsible for content, who then has no time left to contribute to other aspects of
the project, while disenfranchising all other physicians in that specialty who are
now silent. There is one principle that one should honor if you decide to pursue
order set design sessions: “Always begin a design session with a draft order set for
discussion. Never start with a clean slate.” Through the years, the author has sat
through many order set design sessions to watch a consultant start the session with
a blank sheet of paper. The sessions are very painful, drawn out, and the participants
rarely come to quick consensus. It is much more productive to know the evidence
surrounding the topic, look at what the physicians are already doing, point out where
they already agree and use the collaboration time to tackle a few areas where expe-
rience-based medicine has kept them from following the evidence. In addition,
feeding doctors at these events always seems to make them work out better.
In reviewing the work ahead at AHS, they planned for OCE to hire a full time
medical director over content, to work with a team of a project manager, three
nurses, a part-time clinical pharmacist, and a librarian. Dr. Paul Garrett, from Florida
Hospital Orlando, the flagship hospital, accepted this position. In addition, the two
other physicians in OCE, Dr. Hauck and Dr. Doug Bechard, chief quality officer,
would round out the corporate infrastructure. Overall, ten content committees were
formed in the process to include practicing community physicians with subject mat-
ter expertise. These included:
Emergency Department
•
Pediatrics
•
Neonatology
•
Anesthesiology
•
Surgery and Orthopedics
•
Neurology and Neurosurgery
•
Gastroenterology
•
Internal Medicine and Interventional Radiology
•
Psychiatry
•
Cardiology and Cardiovascular Surgery
•
Initially AHS contracted and paid for the community physicians’ time on these
committees as they developed initial content. Today, most have continued to serve
as volunteers. Through the years, the author has seen similar structures with more
committees at academic centers and pediatric hospitals. Community hospitals may
only need Medicine, Surgery, Emergency Department and Obstetrics. The impor-
tant point is to have a structure, not only for order set creation, but also for the physi-
cians’ ongoing review and maintenance of the content.
Each AHS committee reviews their content at a minimum of biannually, and
whenever new clinical guidelines appear. The most active has been cardiology,
with major revisions at least every year. Within the CPOE electronic order sets,
physicians have an active email link in which to submit immediate feedback or
questions on the content. These emails automatically log a change control request

assigned to the OCE for review and follow up with the physician. The end-user
providers have seen hundreds of changes and enhancements that have originated
through this feedback loop. The owner of any CPOE content should make sure that
they have a long-term plan for ongoing order set maintenance.
2.3 Plug and Play
Knowing that patients frequently arrive at the hospital with more than one disease/
condition, AHS devised an approach to order set design named “plug and play.” In
the paper world, admission order sets for heart failure, for example, would have all
the orders to register the patient, as well as to define diet, activity, code status and
vital signs. This worked fine until you admitted a patient with pneumonia and heart
failure. If the physician used an admission order set for heart failure along with one
for pneumonia, then the unit clerk ignores the duplicates on paper as she enters
these orders into the EHR. In the CPOE world, however, the ordering provider must
deal with the duplicates on the front end, prior to electronic signature.
Therefore, the team determined that a provider could electronically order the
Admit to Venue order set and one or more “disease/condition” order sets to cover
the needs of the patient. While a change in how physicians previously ordered on
paper, this proved a rapid way to enter initial orders on a patient with multiple co-
morbidities, such as diabetes and heart failure in addition to pneumonia. They des-
ignated the disease/condition-specific order sets as “core content.”
In addition, AHS formulated a partnership with other similar “faith-based,” com-
munity health systems that were pursuing CPOE on a similar timeline and EHR.
This group has since worked with Zynx Health as the Care Collaborative,4
which
now provides order set content to a significant number of hospitals in the U.S.
Through this collaboration, they developed a Style Guide for the order sets to facili-
tate ease of communication and tested various concepts for how best to deploy the
content. The most powerful achievement, however, was gathering a large number of
neonatologists, neonatal nurses and advanced practice nurses to formulate a com-
plete library of order sets for the critical care of infants in the first month of life.
The final comment on order sets for this chapter is that one must have a formal
process for change control. Changes arise through factors such as evolution of EHR
system design, workflow changes, new clinical guidelines, new medications or dis-
continued medications, new service lines, and new technologies. At AHS, the OCE
works very closely with the clinical IT team to ensure that each reviews any changes
prior to implementation.
4
Original members of the Care Collaborative were Ascension Health, Adventist Health System,
Catholic Healthcare West, Cerner Corporation, Trinity Health and Zynx Health. Today, the Care
Collaborative includes Ascension Health, Adventist Health System, Catholic Healthcare West
(nowDignityHealth)andZynxHealth.http://www.zynxhealth.com/News/Press-Releases/2010/05/
Care-Collaborative.aspx.

15
2.5 Project Plan and Scope
2.4 Visual Anchor
The visual anchor is an image that provides a clear representation of the problem. In
the case of CPOE, the author likes to use two images: one of an illegible set of
handwritten orders, the other the same orders clearly displayed in the EMR via
CPOE. Every patient, Board member, and caregiver can relate to this image and the
dangers it represents:
Medication delays
•
Medication errors
•
Patient harm or even death
•
Liability
•
Lack of immediate clinical decision support
•
The image must be very strong and stand independently to represent why one is
doing CPOE. While physicians and other may resist CPOE publicly and privately,
it is hard for them to deny the impact of illegible orders.
To further this image, the team should have stories that relate actual benefits of
CPOE orders over handwriting. At one CPOE site a physician admitted his patient
to the hospital from the office, 2 days into CPOE. The story relates how she arrived
at the hospital and the nurse activated her planned admission orders, only to see
everyone in her care working in concert rather than in a delayed, fragmented man-
ner. The decisive moment, however, came when the CEO asked her what she
thought of her experience as one of the first CPOE admissions, and she stated, “I
felt like the whole hospital was on call for me!” That story left an impression on
everyone, from the patient, the caregivers, the administration, and the entire CPOE
project team. The anchor gives an emotional assurance to the leadership and to the
all involved. The author has included the visual anchor (Fig. 6.2) for the AHS proj-
ect in Chap. 6.
Once executive leadership determines the vision, the project sponsor must work to
define the scope of the project, begin the formal project planning, and determine
resources and the timeline. It is important that the leadership of the organization
translate the vision of their project into a statement of scope that allows them to
achieve the vision.
The author has seen many organizations through the years fail to take the time to
define a full statement of scope that will fulfill the vision. As a result, the project
team may determine that CPOE, i.e. having physicians place orders electronically,
defines the scope of the project. They then turn it over to a project manager, who
appropriately attempts to manage the scope around merely the electronic ordering
processes. Later the project predictably stalls while physician resistance increases.

The project team creatively attempts to overcome the resistance as the project man-
ager sounds the alarm of scope creep. Moreover, if the scope of the project is too
narrow at the start, then any adjustments will require the team to either extend the
timeline or commit more resources.
The author recommends that you really understand the vision of the project, and
that CPOE is really a process that will help you achieve your vision and goals.
However, CPOE may only address the first principle in Chap. 1. Without thoughtful
planning, the organization may miss the opportunity to serve the second principle as
well, i.e. the “What’s in it for me?” principle. The result might be that you activate
CPOE, but lose sustainability as the physicians see a drop in personal productivity.
One may avoid this pitfall by considering the first two principles simultaneously.
Would it not be preferable to increase patient safety and help the physicians achieve
higher personal productivity? Instead of seeing CPOE as the lone goal, one should
likewise seek to improve physician efficiency. While CPOE activation is a project
objective, we see automating the physician workflow to achieve improved efficiency,
effectiveness and patient safety as the overarching goal.5
Once the organization commits to the goal of automating the physicians’
workflow during their CPOE process, they can begin to focus on more than just
orders and the medication process. For each workflow, teams need to document the
current state processes. It is important that current state documentation reflect actual
workflows, and not a manager’s opinion of what the processes should be. These are
also great opportunities for an organization to perform pre and post-CPOE metrics.
We recommend that the scope include the following processes:
Admission processes
•
This includes admission from office to hospital, Emergency Department to
–
hospital, post surgery to hospital, and transfer from another facility. For
CPOE, we recommend that nurses own the key components of obtaining and
documenting allergies, height, weight, medication history including patient
compliance and last dose, and an admission assessment dataset (e.g. vital
signs, history of current presentation, family and social history). The physi-
cians should own: determination of intensity of services (e.g. critical care vs.
non-critical care), admission diagnosis, admission orders, admission medica-
tion reconciliation of home (or prior venue of care) medications, and an
admission History and Physical. In addition, the initial registration process
becomes critical path since nurses and physicians must have an electronic
encounter on which to document and order.
At AHS, the team noted extreme variation in the pre-CPOE metric of time
–
between a decision to admit until nurses and doctors complete all admitting
processes. They measured cycle times at each hospital and worked prior to
CPOE activation to improve both quality and expediency of the nurse admission
5
Amusan AA, Tongen S, Speedie SM, Mellin A. Time-saver: a time-motion study to evaluate the
impact of EMR and CPOE implementation on physician efficiency. J Healthc Inf Manag. 2009;22:4.

17
process with tremendous improvements. One should remember Principle #3
from Sect. 1.1, and improve the process prior to CPOE. We would like to see
the provider complete the orders and medication reconciliation for the CPOE
admission process in 3–5 min.
Transfer processes
•
There are several transfer processes to consider, and the components of regis-
–
tration, nursing and provider workflows. Transfers typically include: critical
care unit to non-critical care units and vice-versa, post anesthesia care to nurs-
ing unit, change in attending or medical service, and transfers (i.e. discharges)
to other facilities (e.g. other acute care hospitals, tertiary care hospitals, long-
term acute care or rehabilitation hospitals.). Both nurses and providers should
document hand-off procedures, orders reconciliation, and registration events.
One would ideally like the physician to complete a transfer within the facility
in 1–3 min.
Discharge processes
•
The discharge process represents a huge opportunity for improving patient
–
safety/satisfaction as well as nurse and physician efficiency at the time of
discharge. The discharge process begins with the physician’s decision to dis-
charge the patient from the hospital, and includes all processes through the
patient actually leaving the hospital. The author discusses this in a later chap-
ter in detail. However, he has seen many CPOE projects stumble as they fail
to give appropriate attention to the discharge process. The physician owns all
medical decision-making steps in the process: decision to discharge, order to
discharge, discharge reconciliation of medications to determine a list of home
medications, diet, activity, follow-up plan for medical care and instructions
regarding the primary procedure or diagnosis. All of the physician’s decisions
should flow seamlessly to the patient’s discharge instructions in lay terminol-
ogy. The physician should also review the completion of any ordered inter-
ventions and comment on any exclusions for regulatory requirements (Such
as why discharge plan excludes any evidence-based interventions such as
daily aspirin following a heart attack). The nurse should return valuables,
review the discharge plan for patient/family comprehension, educate accord-
ing to the interdisciplinary plan of care, and ensure that there are no red flags
such as lack of safe transport to the next venue of care or inability to under-
stand the discharge instructions.
The discharge metrics should include current state for discharge to home,
–
transfer to another acute care facility, transfer to other location (nursing home
or assisted living facility), and in-hospital mortality (need for autopsy, release
of body, and preliminary cause of death).
The reason for paying attention to the discharge process is that it is the last
–
experience the patient has with the hospital and often is inefficient and inap-
propriate. Many a patient has had a doctor tell him that “you can go home
today,” only to have their loved ones arrive at the hospital and wait 4–6 h until

the actual discharge occurs. This is mainly due to nurses trying to track down
the physician to obtain all the information necessary for a safe discharge. We
recommend that you take the time to design a CPOE discharge process that
permits a measureable improvement in time from discharge order until the
patient leaves the facility. We believe that 30 min is an average goal that one
can achieve. The physician part of the discharge process, exclusive of dictat-
ing or completing a discharge summary document, should take 3–5 min on
average.
Medication reconciliation processes
•
Medication reconciliation (med rec) actually represents several sub-processes,
–
all centered around the goal of the physician giving consideration to the
patient’s home medications each time a change in venue occurs. In the author’s
opinion, med rec is an essential process for patient safety and should be a
physician responsibility for all CPOE projects.
Online medication reconciliation tools must be able to provide the providers
–
with the ability to perform and reconciliation during admission, during trans-
fers and at the time of patient discharge. The tools must permit the physician
from distinguishing home medications from any inpatient medications.
Admission medication reconciliation must allow the provider to continue a
patient’s home medications as inpatient medication orders. In addition, admis-
sion med rec should already be a physician-led process prior to CPOE.
However, some facilities, in preparation for CPOE, discover that they have
not established clear accountability and metrics for getting the attending phy-
sician to complete it in a timely fashion. The author recommends that you
establish your meds rec process and ensure physician accountability well in
advance of CPOE activation. In addition, one must provide ongoing monitor-
ing and optimization ever after.
Another variation that one must understand is the concept of multi-physician
–
meds rec. The author will discuss that further in Chap. 3. However, a facility
should be clear on the scope of meds reconciliation for their project.
CPOE in the Emergency Department
•
The Emergency Department is the front door for most acute care hospitals in
–
the United States, and CPOE creates many opportunities. Many facilities uti-
lize the ED as a pilot unit for CPOE, since it has a defined set of providers and
typically starts from a paper MAR (medication administration record). In
regards to scope, “Will the ED be the pilot unit for CPOE?” is an important
consideration for the executive team. In addition, if you do pilot in the ED,
what about admitting doctors who come to the ED?
Moreover, the ED physicians should have few verbal orders and no telephone
–
orders. The hospital typically contracts with them, and can incorporate CPOE
into their performance metrics. However, the team must provide appropriate
order set content for the management of ED patients and an efficient ordering

19
process. Important metrics for the ED include the time from patient arrival to
physician engagement, patient arrival to discharge home, and patient arrival to
admission if inpatient care is the result.
Patient summary views
•
When doing CPOE, physicians like to be able to see a quick snapshot of their
–
patients. The current EMR may already have one or more summary views that
bring various elements together onto one view. One should assess whether the
current views available will be sufficient for physicians doing CPOE.
Typically, the EMR vendor can provide suggestions based on other clients
who have already implemented CPOE.
Ordering processes
•
– Scope of CPOE orders: The author once consulted on a project in which the
client wanted to have the physicians do inpatient CPOE only for laboratory
and radiology and not for medications and other orders. This would have cre-
ated a process in which physicians would be constantly moving between the
paper and online chart as they place orders. While this actually might improve
throughput in the short term in the ED setting, we would not support frag-
menting workflow in this way for inpatients. We believe that one should be
giving physicians context during the ordering process and fragmenting the
orders does not seem consistent with that effort, or useful to achieving long-
term CPOE success. The author passed on this project, as he believes that
CPOE should be an all-out effort to create seamless ordering processes with
very few exceptions that he will discuss.
– Non-formulary meds: While patients may be taking any of the numerous
medications on the market, the hospital pharmacy may have a limited formu-
lary available for its inpatients. Therefore, the team will need to understand
how to display only formulary items for inpatient orders, as well as a strategy
to allow physicians to convert non-formulary home medications into active
hospital orders. Most EMR also provide reference tools online for many
medications.
– Telephone and verbal orders: Since telephone and verbal orders are a reality
of hospital care, the project must include processes to allow telephone and
verbal orders. We will discuss these further in the next Chap. 3.
– Co-signature of orders: The EMR should have some mechanism to ensure
that doctors can subsequently sign orders that they give verbally or over the
phone. Ideally, this should be an electronic signature with the system “push-
ing” orders to sign to the physician. Therefore, the CPOE project needs to
include a mechanism for electronic signature in its scope. A CPOE metric
would be the percentage of telephone/verbal orders with physicians sign
within 24 and 48 h, depending on local medical staff bylaws requirements.
– TPN (total parenteral nutrition): TPN orders are complex and the physician
often customizes them for each patient on a daily basis. Modern day CPOE
systems should be able to provide solutions for ordering TPN online. Some

medical staffs delegate TPN orders to the pharmacy department, while others
keep TPN on preprinted forms.
– Prescription writing/e-Prescribing: As physicians discharge patients from
the Emergency Department or following an inpatient stay, they will need to
provide prescriptions to the patient. Project scope should indicate whether
physicians will handwrite patient prescriptions, or the project team will pro-
vide an electronic solution. The project team should spell out if prescription
printing and/or e-Prescribing will be in scope for the CPOE initiative. The
Emergency Department is often an ideal place to start prescription printing
and e-Prescribing due to the volume of new prescriptions.
– Special Orders and Chemotherapy: The project team should understand
how the CPOE system manages orders such as dialysis and chemotherapy.
While most EMR vendors will accommodate hemodialysis and chemotherapy
protocols, they may require add-on modules or additional design and build
time. Therefore, it is advisable that the team make this decision early as to
whether physicians will place such orders from pre-printed order sheets or in
electronic format. The author would not recommend allowing physicians to
handwrite them without some pre-printed template.
Physician documentation in ED and inpatient
•
Many CPOE projects have not included electronic physician documentation
–
within their scope. The author has found, to the contrary, that physicians adopt
online documentation very rapidly when coupled with the CPOE activation.
However, there is a strategy that will increase success, and accounted for phy-
sicians voluntarily doing over 1.5 million electronic notes at AHS in 2011.
The author has found that structured electronic documentation empowers
–
physicians as long as they have the ability to personalize their experiences. He
recommends two major elements that will increase your success for physi-
cians voluntarily adopting online notes: grow it virally and combine it with
near-time scanning of the paper chart. Since we mentioned AHS above, we
will use it as a case study.
Long before Meaningful Use, the team believed that physicians could gain adop-
tion of electronic notes by using a viral marketing approach: find some early adopt-
ers to build the business case around personal efficiency then let organic growth
occur. Therefore, the they introduced structured electronic notes in October 2008,
prior to the initial CPOE pilots in May and June 2009. They utilized our vendor’s
templates, and added some custom-coded smart templates to add auto-population
of data elements that the physicians were already using in their daily Progress
Notes. This included Tmax
(the highest temperature in the past 24 h), latest vital
signs (while maintaining one-click access to all vital signs from within the note),
lists of problems and diagnoses, and laboratory results including bedside blood
sugars. Over the past few years, the team has added imaging “Impressions,” micro-
biology summaries, pathology reports, and I & Os (intake and output calculations).
Physicians can save pre-completed templates and utilize personal macros as well.

21
In areas like the ED, the team created “required fields” for the visit diagnosis,
which ensures that the visit note meets profession and billing requirements. In
the ED, they started with templates based on presenting complaints, and have
done little modification to these. They did allow the optional use of speech rec-
ognition software, though few use it today. However, one may make the case that
it provides a more narrative result than templates for items such as History of
Present Illness, Impression and Plan. A handful of ED’s do utilize scribes, but
this does often delay the completion of the notes rather than enhance them (and
creates the need for clear policy as discussed in Chap. 3). We find it quite humor-
ous today now that all of the AHS emergency department documentation is elec-
tronic. Previously, the ED physicians were very committed to their paper
templates, which allowed them rapid documentation and billing efficiencies,
while creating a visit record that other physicians could barely interpret. Today,
many of our ED physicians report that it is quicker and easier for them to see a
patient that returns to the ED, since they, themselves, can better understand the
story of the prior visit from the electronic note than the older paper templates.
AHS added near-time scanning of the paper record as part of the scope of CPOE
and it proved a critical success factor for the project as well as for moving physi-
cians to electronic documentation. In addition, it helps the physicians to increase
their personal efficiency. The author will discuss the mechanics of this below.
However, the goal is to have the entire chart digitalized so that the physician has
a complete picture of the patient, whether at the bedside, or viewing the EHR
remotely. The efficiency comes as physicians no longer spend time looking for
charts, competing with others for the chart, and can review scanned paper notes
more quickly than even flipping through pages. Moreover, when the physician no
longer goes to a paper chart for any information, it becomes easier to complete
an online Progress Note than to look for a paper form to complete. This effec-
tively makes the electronic note the “path-of-least-resistance.”
Today, AHS brings new hospitals live from completely paper-based physician
workflow to CPOE and electronic documentation with much less physician resis-
tance. They do not prohibit handwritten notes, but the physicians quickly see the
benefits of electronic documentation not only for efficiency, but also for more
effective physician-to-physician communication and handoffs.
In addition, we teach both ED and inpatient physicians to place orders from within
their documentation. This creates valuable timestamps within the notes, and allows
all users to get a clear picture of the physician’s medical decision-making process.
There can be a downside, however, to electronic templates, as they reveal the heart
of some providers. Once live, the HIM (Health Information Management) team
and the medical staff should police the process of physicians copying each other
notes, using excessive documentation of needless words, or creating inaccurate
documentation through mindless use of macros and canned phrases. A real exam-
ple from several years ago was the description of a patient pharmacologically
paralyzed, on a ventilator, and in a drug-induced coma. The physician’s canned
phrase read, “The patient is alert and oriented.” Always remember, the problem is
the heart of the documenter and not solely problem with the technology.

Speech recognition software
•
If the project team determines to include online documentation in scope, then
–
they should consider the option of speech recognition software as well. In the
case of physician documentation, the “history of present illness” within the
History and Physical Examination report as well as the “hospital course”
within the Discharge Summary both lend themselves to narrative structure.
While the providers should use structured elements for the Diagnosis and
Problem lists as well as orders, there are also opportunities for providers to
add narrative commentaries to the Assessment and Plan of documents. The
combination of structure and speech recognition can allow providers to add
more contexts to their documentation.
Transcription
•
Since most hospitals already offer transcription with dictation for documents
–
such as History and Physical, Consultation Reports, Operative Reports and
Discharge Summary, the consideration for CPOE is around whether physi-
cians will move these reports to structured documentation, and whether pro-
viders may dictate daily progress notes. In addition, hospitals now have the
option to add “back-end” speech recognition (i.e. provider dictates, voice rec-
ognition software transcribes draft document, and transcriptionist performs
final edit) to their transcription system. This will only cut costs if that organi-
zation negotiates better transcription fees with their transcription vendor, or
can perform more transcription per employee if in house.
Scanning of paper records into EMR
•
As mentioned above under physician documentation, hospitals should strongly
–
consider adding near-time scanning to the scope of their CPOE project. If the
paper chart no longer contains orders, physician documentation or nursing/
ancillary documentation, then scanning the remaining paper will allow the
providers to manage their orders remotely with no gaps in critical results or
documentation. The author recommends that one support this by also remov-
ing all chart binders and using a clipboard with a front cover, once you start
scanning. This serves as another visual anchor to remind the users to go to the
EMR and not the paper chart. He also recommends that one use the clipboard
only as a location for patient labels, consents that have not yet been fully
completed, and forms that remain on paper (e.g. Living Wills, chemotherapy
orders, ambulance sheets) until the facility scans them. Moreover, the hospital
unit clerk (HUC) should no longer place blank order forms and Progress Note
forms on the clipboard. The hospital should avoid printing anything (e.g. lab
or imaging reports) that is already in the EHR. This is the time to get all end-
users going to the EMR and not the clipboard.
At AHS, the team brought near-time scanning live 2 weeks prior to the CPOE
–
go live. Because orders and progress notes were still on paper, the HIM
(Health Information Management) department typically had 26 pages of
m

23
paper to scan daily for each patient. Depending on the unit, they would scan
two to four times a day. While the HIM department owns scanning, most sites
put scanners on each nursing unit and direct the HUC to scan, with HIM staff
overseeing the quality of scanning through audits. Once CPOE went live, the
typical scanning volume fell to zero to two (0–2) pages per patient per day as
order sheets and Progress Notes went electronic except for orders still on
paper (e.g. hemodialysis, chemotherapy) and the occasional handwritten
Progress Note.
Handwriting a Progress Note requires the physician to get the form, write the
–
note, and then place it on the clipboard. The physician still needs to access the
electronic record to review orders, results and others’ notes. Therefore, many
physicians quickly move to online documentation.
The other benefits of starting scanning 2 weeks before CPOE activation are
–
less obvious, but valuable. First, it makes a clear statement to all end-users
that CPOE is moving forward. Second, it gets all the users on the EMR and
assures that they can log on and navigate through the EHR. Thirdly, it deter-
mines if you have deployed enough devices on the clinical units to accom-
modate all the users during the peak rounding times. The facility should be
able to see an ROI (return on investment) of moving users to the electronic
chart and minimizing pages of the patient’s record that HIM (Health
Information Management department) must collect, scan, index and perform
quality assurance. The facility must include the cost of scanners and should
acquire some temporary workers to help with scanning during the transition
from initial scanning through the first few days of CPOE activation. A metric
for scanning is the number of pages of paper per patient per day.
Clinical decision support
•
The author will discuss clinical decision support (CDS) in later chapters.
–
However, he recommends that the team determine the number of CDS alerts
that they will include in the initial scope. He recommends that they under-
stand major patient safety opportunities and select six to ten CDS alerts that
will get providers engaged in understanding alerts, without over-taxing them
early in the process. Some common alerts that physicians understand are
around the avoidance of digoxin in the face of electrolyte imbalances, poten-
tially lethal drug combinations, use of anticoagulants in the face of excessive
anticoagulation, and warning on certain renally excreted drugs in the face of
acute or chronic renal failure. Metrics include number of CDS medication
alerts per 100 medication orders and the percentage of alerts in which provid-
ers cancel, modify or supplement an order rather than override the alert.
Code Blue and Rapid Response Teams
•
Code Blue is a common term US hospitals use for sudden cardiopulmonary
–
arrest while rapid response teams typically respond to patients who are dete-
riorating and are at risk for arrest. The author recommends that the project
team examine workflows for each, including early warning techniques (such

as rules and alerts), and include these in the scope of CPOE. On typically see
Code Blue orders as documentation and allow these to remain on paper or as
electronic forms. An organization may want to measure the incidence of Code
Blues or inhospital mortality as CPOE metrics.
Anesthesia Information Management System
•
Anesthesiologists have managed their intra-operative documentation for over
–
a century on paper. Their intra-operative records include:
Common operating room events:
°
Anesthesia start time,
Anesthesia induction time,
Incision time,
Surgery stop time,
Time out of the operating room, and
Arrival to the post anesthesia care unit/PACU;
Physiological monitoring (e.g. vital signs, oxygen saturation),
°
Intravascular fluid and blood administration,
°
Induction medications, and
°
Anesthesia administrations:
°
Oxygen and nitrous oxide flows, and
Delivery of IV/inhaled anesthesia/analgesia agents
The paper record is often a silo for important information and data such as
–
normally found on the eMAR (electronic medication administration record)
and the ongoing calculation of the I & O’s (intake and output volumes).
Most U.S. hospitals do not have an electronic Anesthesia Information
–
Management System, and therefore remain on the paper Anesthesia Record.
When they do, medication and I & O’s should flow seamlessly into the appro-
priate portions of the EMR.
If the Anesthesia Record remains on paper for the CPOE project, the author
–
recommends that you still keep pre-operative and PACU processes in scope
for CPOE. That means that anesthesiologists will need to utilize CPOE for
their pre-operative orders as well as for all the orders in the PACU following
surgery. He also recommends that if the anesthesiologist is administering the
pre-operative antibiotics, that he documents it on the inpatient eMAR. This
will allow better timing for the nurse administering any post-operative antibi-
otics 8–12 h later.
Problem List maintenance
•
The Problem List is an excellent communication tool within the EHR, enhanc-
–
ing physician documentation, communication and for helping to optimize
clinical decision alerts. The author recommends that physician own the
Problem List and its maintenance, and not nursing. Physicians should be able

25
2.6 Key Points
to view and update problems during the ordering and documentation pro-
cesses. While CDS may suggest to the physician, the inclusion of new prob-
lems (such as adding diabetes if the patient is on insulin or has persistent
hyperglycemia), the author does not recommend that one automatically add
problems as a byproduct of the use of order sets, or other schemes that do not
require a physician’s confirmation. Otherwise, one will be building long prob-
lem lists with no motivation for physicians to review and maintain them. The
author does recommend that you utilize CDS to remind physicians when they
have not addressed that Problem List during the hospital stay. A metric for
Problem List would be percentage of charts in which physicians have docu-
mented active problems, or the absence of problems.
Incentives and CME
•
A final consideration for scope is to include incentives for physicians to adopt
–
CPOE. This could include CME for review of evidence-based content, for
attending CME presentations and for training that leads to adoption of evi-
dence-based order sets. The hospital must provide any incentives to all mem-
bers of the medical staff equally. Planning must occur to offer CME or to
budget for other incentives.
As the hospital leadership determines scope of the project, the project manager
will work to determine an appropriate timeline and resources. Whether you imple-
ment CPOE at one hospital or many hospitals, you will need to have a defined
project plan to implement successfully. Fortunately, at AHS, the team had a dedi-
cated project manager, and used a repeatable process to implement multiple times.
Chapter 4 will address this topic with more detail.
2.6 Key Points
Provide a clear vision statement/concept for the project
•
Articulate the vision at every event/opportunity
•
Use a visual anchor to communicate the vision
•
Use the vision for all course corrections
•
Wear the vision on your sleeve
•
Build an effective plan to fulfill the vision
•
Have a content team separate from the IT team
•
Define a change control process for managing content
•
Allow physician review of order set content at every juncture
•
Consider scope that automates physicians’ workflow rather than only the
•
ordering process.
Consider opportunities to move behavior in multiple areas, not just orders.
•
Use pre and post-CPOE metrics to demonstrate value and define success.
•
k

• Lack of a central, unifying vision
You need to have a vision you can articulate at every level of the organization and
with enough authority to overcome the noise of competing priorities. An execu-
tive, preferably the CEO or Board, must own and communicate it.
• Vision statement that only provides value to the organization and not the
end-users
The vision must provide a strong business case at every level. End-users, includ-
ing physicians, will act on what provides them value, and are not as strong in
their support of projects that value the organization without providing some per-
sonal value. Patient safety alone cannot drive the adoption. The end-users also
need to see new efficiencies (or similar reward) for their efforts.
“
• The Joint Commission (or CMS, Corporate, etc.) is making us do this!”
Organizations that do not provide a clear vision with defined value statements
will move into the victim role as its end-user repeat any of these mindless mantra
that fail as effective motivators.
• Absence of a visual anchor
A visual anchor, tied to the vision, provides a simple reminder to all of the impor-
tance of seeing the project completed. CPOE is a complex project, so a visual
anchor helps to keep everyone focused on the reason we are going through this
massive change.
• Absence of a statement of work (scope)
Without a clear statement of work on the front end, the organization will not
complete the project on time, on budget, or with significant benefit. By clearly
defining scope at the start, the team can better project the timeline and resources
for success and avoid costly scope creep later.
• Senior executives not leading the project
Organizations always have competing projects. All projects have risks and chal-
lenges. The project with the highest level of senior support will always receive
priority when competing interests arise, as they always do. CPOE is a major
change initiative for an organization, affecting almost every person in a hospital.
Having the CEO lead at every occasion sends a clear message of the importance
of the project and the commitment for project success.
• Senior executives multi-tasking or absent during project meetings and
major events
As in any other leadership, the team watches what the senior leadership does. If
the senior leaders lack full engagement, the rest of the team loses its confidence
of their support. The executive, who is distracted, such as reading e-mail during
a CPOE meeting, sends a conflicting message that this project does not have high
priority at the facility.
• Having the IT team own content
CPOE teams chronically underestimate the amount of effort to complete the content.
Leaders tend to draft CPOE implementation timelines in stone and not recognize the

27
importance that content be complete and up to date. It is always best to have a
dedicated content team that works independently of the implementation team
and are not distracted by last minute IT issues as the activation date approaches.
• Not having identified physician resources with the time to participate
Most CPOE teams have an identified physician, but few have a physician with
the time to commit to project success. I have seen many failing CPOE projects
that have a roster of physicians on the project who are essentially unengaged.
The other risk is the partially engaged physician, who is making recommenda-
tions with only peripheral knowledge of the project.

29
Chapter 3
Leadership and Governance
Abstract The author discusses the importance of developing a leadership structure
for your CPOE project. He also lays out the many policies and procedures that a
hospital should contemplate as they prepare for their CPOE deployment. The hos-
pital should determine early in their project as to whether to require physicians to
comply with mandatory training and CPOE use.
Effective leadership is not about making speeches or being liked;
leadership is defined by results not attributes.
– Peter Drucker1
Leadership expert John C. Maxwell2
teaches, “Everything rises and falls on leader-
ship.” The leadership and governance of a project like CPOE determines how you
execute against the vision as well as how you manage obstacles along the way.
While many different governance models are possible, you will need to select one
that will work with your organizational culture to achieve results. Whenever possi-
ble, do not recreate the wheel, but rather use existing structures that you know have
worked in the past for success. However, in many cases, this is an opportunity for
you to introduce a new model in order to minimize obvious risks.
In the early 2000s, the author assessed an academic hospital that not only wanted
to do CPOE, but also had plans to build a new hospital in the subsequent 5 years.
The executive team had a decision-making model that each of the C-Suite lead-
ers individually confessed was not working for them. In seeking further clarity,
the team discovered that they would tackle big decisions with a consensus-driven
mindset, and often process a major decision for 4–5 months, at which time the
CEO would commonly step in and make a unilateral decision. It was apparent
that one could not drive a 10-month CPOE project with their model of decision-
making. They needed a leadership and governance model in which they could
process options, make decisions and move on rapidly.
1
Drucker P. BrainyQuote.com, Xplore Inc. 2011. http://www.brainyquote.com/quotes/quotes/p/
peterdruck121706.html. Accessed 10 Aug 2011.
2
John C. Maxwell, author of numerous books on Leadership. www.johnmaxwell.com.

30 3 Leadership and Governance
As a result, the project team designed a governance model that would lever-
age existing committees, build momentum and have the leadership make difficult
decisions on a biweekly basis. Three existing committees, IT (technology team),
clinical advisory (nursing and ancillaries) and physician advisory (medical staff),
would meet separately on a biweekly basis and to ensure they were hitting the
milestones on the project plan. On the opposite week, the CPOE Cabinet would
meet, review the project and resolve any outstanding decisions or issues arising
from the three committees. The executive sponsor chaired the Cabinet, whose
membership included the C-Suite executives and two members of each commit-
tee. The Cabinet had one guiding principle: the Cabinet would resolve any issues
or conflicts arising from any of the three committees in the preceding 2 weeks. If
the Cabinet could not come to a decision during the course of the meeting, then
the executive sponsor (and Chair) would make a final, binding decision at the
conclusion of the meeting.
The Cabinet structure kept the team and the project moving forward. At the
first meeting, the executive sponsor had one decision to make. Subsequently, the
committees or the Cabinet made the remaining decision. The leadership team
was able to move the project forward and move from an unsuccessful consensus
model to one of decisive leadership, not only for CPOE, but also for their later
building project.
For a multi-hospital health system, the AHS team had to build a governance
model that would allow input from each hospital, while keeping the project on track.
The health system already had an existing Corporate Clinical Council and the
Corporate IT Council as decision-making boards in their respective areas (Fig. 3.1).
The need therefore was to develop leadership groups that could quickly move
executive-level decision-making on a monthly basis between the quarterly councils’
meetings.
The Corporate Chief Information Officer (Corporate CIO), Corporate Chief
Medical Officer (CMO), Chief Medical Information Officer (CMIO), Chief Clinical
Information Officer (CCIO) and Chief Information Officer (CIO) made up the
CPOE Steering Committee. Non-voting members included the Project Manager,
Medical Director and Clinical Applications Director. This was a new committee for
the organization. The Steering Committee owned project timeline, scope and
resourcing, and met monthly. The CMIO authored the initial charter that clarified
the vision, methodologies and assumptions for the project and served as executive
sponsor. The Steering Committee served as the mastermind group for the project. It
was important that all members contributed to the product.
The Corporate IT Council serves as a governance board over IT operations and
approves the overall budget. This was not a new group for the project. It includes the
IT executive team as well as regional and divisional CEOs. The CMIO provides
monthly updates to this group.
Through the years, the author has found that the actual components of the gover-
nance structure are not as important as the various functions that need to occur. In a
single hospital organization, the structure is simpler, though the decisions are just as

31
3.1 CPOE Policies
complex. There needs to be a commitment to timeline, resources and a commitment
to a defined scope. With a single hospital or small multi-hospital system, the author
recommends that you include more local physician participation in the process. In
the larger health system, you may need to be creative in your physician engagement
plan. If you require physician participation from each hospital, the group becomes
too large and unwieldy.
Regardless of size and complexity, the organization should commit to a mini-
mum of specific policies that help avoid confusion in key areas. It is advantageous
that you address and formalize your policies before the physicians place their first
CPOE orders. Once live on CPOE, you will likely find new opportunities to address
other processes with specific policies and procedures.
3.1 CPOE Policies
Through the years and many prior projects, the author has experienced issues with
hospitals and medical staffs agreeing to best practices on the front end, then decid-
ing not to follow them once the system is live. Moreover, if dealing with more than
one facility, one can anticipate there will be processes that you will need to stan-
dardize in order to be successful across multiple facilities. While single facilities
may be able to leverage existing structure to create new policies and procedures, a
larger system should establish a CPOE Governance Committee to fulfill this role.
Typically, one should include the voting members of the CPOE Steering Committee
in addition to one C-Suite Executive (CEO, CFO, CMO, CNO or COO) represented
each of your hospitals. The purpose of this group is to originate draft policies that
all the hospitals would agree to follow – those that are non-negotiable. The group
would then forward their approved draft policies to the corporate committee or
structure, which owns clinical processes, for review and approval before moving
them on to the CEO/Board for final signature.
Corporate clinical council Corporate IT council
CPOE steering
committee
CPOE Governance
committee
CPOE Project team
CPOE Sub-project teams
Clinical
policies
Fig. 3.1 Example of a CPOE
governance model

32 3 Leadership and Governance
Typically, the members of the CPOE governance group take their role seriously.
They actively discuss, debate and approve multiple policies and procedure that may
address the following questions:
Is CPOE mandatory?
•
Is training mandatory?
•
When is CPOE required, and what are the exceptions?
•
When are verbal or telephone orders appropriate?
•
What is the process for entering verbal or telephone orders?
•
What is the role of rounding nurses or scribes?
•
What is the process for the reconciliation of the patient’s medications (i.e. Meds
•
Rec)?
Moreover, the reader will find that the answers to these questions allow the lead-
ership to determine and reinforce the guiding principles of a CPOE initiative.
3.1.1 Is CPOE Mandatory?
The author recommends beginning with an overall policy that doctors taking care of
inpatients at our hospitals must use CPOE and the scenarios during which physi-
cians could give orders verbally or over the phone to a nurse. This is where the
health system’s vision determines the process. With patient safety the reason for
CPOE, it would not be reasonable to allow physicians to opt-out of it and continue
to hand write their orders. In addition, the author’s research of prior CPOE sites
compared sites that had gone all at once (“big bang”) versus unit by unit or a few
physicians at a time. He saw that the hospitals that had deployed in a “big bang”
model had rapid adoption and minimal physician resistance, while the latter model
created a precarious model of dual processes with some orders on CPOE and some
orders on paper. With the latter case, leadership often reports the many risks of
important orders falling through the cracks. Moreover, once the leadership accepts
voluntary CPOE as the norm, they experience more resistance from the medical
staff when they ask them to set the bar higher.
However, if you are putting in a completely new system, you might consider
starting with a pilot in a single nursing unit, such as in the Emergency Department
(ED) as a “small test of change,” in addition to the validation of your system design
and build. The benefit of the ED is that it is mainly a self-contained unit with well-
defined users. There you can implement CPOE orders, perfect stat turn-around
times for lab and radiology, and implement an electronic medication administration
record (eMAR). Moreover, you will have a great laboratory for implementing your
change management plan, overcoming resistance and negativity, and fine-tuning
your content and key workflows. The author’s experience has also been that the high
volume of the ED leads the doctors and nurses to rapid adoption and competency.
Every encounter includes orders, a medication history and interventions. The users
will be highly motivated to help iron out the medication administration process and
other key workflows.

33
3.1 CPOE Policies
One caution, however, is that there are nursing units in hospital that one should
avoid as potential CPOE pilots. The medical/surgical (med/surg) unit has too much
fluctuation in patient flow and physician participation. Even though a hospital may
dedicate such a unit to a service line such as orthopaedics, there will still be multiple
doctors contributing to orders through consultations. One should avoid a situation in
which nurses are managing similar orders across two platforms – paper and elec-
tronic. The main consequences are nurses dealing with duplicate orders across the
two, as well as missing orders in the confusion.
The other unit to avoid as a pilot is behavioral health or psychiatry. While this
represents a unit with minimal fluctuation in users, it typically is not a credible
example for the rest of the hospital. This unit has unique individuals and workflows.
The author’s experience is that it often is slow at adoption and sets a poor example
for initial CPOE success.
3.1.2 Is Training Mandatory?
In his career, the author has seen both mandatory training in addition to various
combinations of prescribed/suggested schemes. His observation is that physician
acceptance and efficiency is often directly proportional to the physician’s training
effort. In other words, if you like to see physicians struggle with CPOE after go live,
then do not have them train to a level of competency. However, the author will dis-
cuss more on training in a later chapter.
3.1.3 When Is CPOE Required, and What Are the Exceptions?
Early in the project, an entity needs to have frank discussion about when CPOE is
required, and when it is optional. The author typically works through this exercise
to determine this by venue, by process and by context:
Which units will be doing CPOE, both during pilots and once deployed?
•
Will the Emergency Department (ED) physicians do CPOE?
•
Will the ED nurses chart mediation administration on an electronic medication
•
administrative record (eMAR) or on paper?
Will physicians order outpatient tests/labs using CPOE?
•
Will surgeons place Pre-Admission Testing (PAT) orders using CPOE?
•
Will surgeons place Pre-Operative orders (i.e. the orders necessary to prepare a
•
patient for an operation on the morning of surgery) using CPOE or on paper, and
if the latter, whose responsibility is it to enter those orders into the EMR?
What is your process for accepting “direct admission” orders, for patients com-
•
ing directly from another location such as physician office, urgent care clinic or
other health care facility when the admitting doctor is initiating that transfer/
admission and bypassing the ED?
Will the behavioral health or psychiatric physicians enter orders using CPOE?
•
Who will enter/record intra-operative orders?
•

Another Random Scribd Document
with Unrelated Content

not known that Mr. Pendarves, the head of the family, knew nothing
of this intended marriage, Seymour would have been convinced it
was a fact himself.
My mother's tears now fell silently down her cheek, and in spite of
herself she pressed her forehead on the head of Seymour, as it still
rested on her knees. Certain it is, that she loved him with much of a
mother's tenderness—loved him also because he resembled his
father and mine—and loved him still more because he was all that
remained to her of her ever-regretted friend. The opposition to our
union, therefore, was the strongest proof possible of the strength of
her principles, and of her affection for me; for, though she thus
loved, she rejected him, because she was sure that he was not likely
to make her daughter happy.
My mother was the first to break silence. In a voice of great feeling,
she said, "Seymour! unhappy young man! why do I see you here,
infringing college rules? and why do I see you thus? Have you been
ill long? have you had no advice?" It was now quite day; and, as he
raised his head, the wild wanness of his look was terrible to us both,
and it was with difficulty that I could prevent myself from sobbing
audibly, while I anxiously expected his answer.
"Spare me! spare me!" cried he mournfully, "a painful confession of
follies."
"Did not business carry you to London, Seymour?"
"No—nor kept me there. It was the search of pleasure; and I have
scarcely been in bed for three nights. Yet no; let me do myself some
little justice: I was unhappy, and I am unhappy. By denying me all
hope of Helen, you made me desperate, and I fled to riotous living,
to get away from myself; therefore, do not reproach me; I am quite
punished enough by seeing before me the intended wife of the
Count de Walden—curses on the name! Tell me," cried he wildly,
seeing that my mother hesitated to speak, "am I not right? Is not
my Helen, as I once thought her, betrothed to De Walden?"

"Oh, no—no!" cried I, eagerly, and I caught my mother's eye rather
sternly fixed upon me; but I regarded it not, for I felt at the very
bottom of my heart the sudden change from misery to joy which
Seymour's face now exhibited. He could not speak—his heart was
too full; but leaning back, overcome both with physical and moral
exhaustion, he nearly fainted away. He was soon, however, roused
to new energy by the indignation with which he listened to what my
mother felt herself called upon to say. I shall not enter into a detail
of her observations; suffice, that she candidly told him her
objections to his being allowed to address me remained in full force,
as did her ardent wish that I should marry De Walden, who had
offered himself as my lover, and who (she was certain) would as
surely make me happy in marriage, as he would make me miserable.
When she had ended, he thanked her for her candour, but coldly
reminded her that he had always said he would never take a refusal
from any lips but mine—and he retained his resolution.
"And now," said he, "the opportunity is arrived. Helen! such as I am
—not worthy of you, I own, except as far as tender and constant
love can make me so—I offer myself to your acceptance. Speak—Yes
or No—and speak as your heart dictates!"
I remained silent for a minute; then faltered out, sighing deeply as I
spoke, "I have no will—can have no will—but my mother's."
"Enough!" replied he, in a tone and with a look which seemed to me
to be the climax of despair. "Hark!" cried he, "the Oxford clocks are
striking six—why do I linger here? for here I am sure I have no
longer any business!"
He let down the glass, and desired the postilions to stop, while the
footman rode up to the door. This little exertion seemed too much
for him, and he sunk back quite exhausted, while my mother tried to
take one of his hands.
"Pshaw!" cried he, throwing her hand from him—"give me love or
give me hate; no half-measures for me; nor hope, when you and

your daughter have given me my death-blow, that I will accept of
emollients. I thank you, madam, as I would a stranger, for your
courtesy in admitting me here, and I wish you both good morning."
Again his strength failed him, and he was forced to wipe the dews of
weakness from his forehead.
"Go, I must—even if I die in the effort!" he then exclaimed.
I could not bear this; and while my mother herself, greatly affected,
held me back, I tried to catch him by the arm; and, in a voice which
evinced the deep feeling of my soul, I exclaimed, "Stay, dear
Seymour! you are not fit to go—you are not, indeed!" But I spoke in
vain: he mounted his horse, assisted by the servant, while I broke
from my mother, and stretched out my clasped hands to him in
fruitless supplication; then giving me a look of such mixed
expression, that I could not exactly say whether it most pained or
gratified me, he was out of sight in a moment, while I looked after
him till I could see him no longer; and even then I still looked, in
hopes of seeing him again. I did see him again, just as we had
entered Oxford, and were passing Magdalen; he stood at the gate;
he had, therefore, seen my long, earnest gaze, as if in search of
him; and though I felt confused, I also felt comforted by it. In
another moment we were near him, and his eyes met mine with an
expression mournful, tender, and I thought, grateful, too, for the
interest which I took in him. He kissed his hand to me, and then
disappeared within the gates.
"Helen!" said my mother, "I meant to have stopped here, to refresh
the horses and ourselves; but after what I have seen this morning, I
shall proceed immediately."
She left the footman, however, behind, to bring us word the next
day how Mr. Pendarves was. Oh! how I loved her for this kind
attention! But then she was a rare instance of the union of strong
feelings with unbending principle.

Methinks I hear you say, "I hope you were now convinced that
Seymour's attachment as well as Ferdinand's, was founded on too
good a basis to be shaken by your altered looks."
No, indeed, I was not; for so conscious was I that my looks were
altered, I never once lifted up my veil before Pendarves. I dare say,
both he and my mother imputed this to the wish of hiding my
emotion, whereas it was in fact only to hide my inflamed eyes, and
my ugliness. But what a degrading confession for a heroine to make!
to plead guilty of having bad eyes and a plain face! It is as bad as
Amelia's broken nose. But n'importe: my eyes, like her nose, will get
well again; and, like her, I shall come out a complete beauty, when
no one could expect it.
We awaited with great impatience the return of the servant, from
whom we learnt that Mr. Pendarves had been seized with an
alarming fit on leaving the chapel, and was pronounced to be in an
inflammatory fever.
"O my dear mother!" cried I, wildly, "he has no one to nurse him
now that loves him!"
"But he shall have," she replied; and in another hour we were on our
road to Oxford. My mother insisted on being admitted to the bedside
of the unconscious sufferer, who in his delirium was ever blaming the
cruelty of her who was now watching and weeping beside his pillow.
Long was his illness, and severe his suffering: but he struggled
through; and the first object whom he beheld on recovering his
recollection, was my mother leaning over him with the anxiety of a
real parent. Never could poor Seymour recall this moment of his life
without tears of grateful tenderness.
He was too much disappointed, however, to find that her resolution
not to allow him to address me remained in full force; for the
circumstances on which it was founded were added to, rather than
diminished. Nor could his assertion, that his dissipation was owing to
the despair into which she had plunged him, at all excuse him in her

eyes, for she could not admit that any sorrow could be an excuse for
error.
This, indeed, far from its being a motive to move her heart in his
favour, closed it the more against him; as it proved she thought that
from his weakness of character he never could deserve to be
intrusted with the happiness of her child.
Bitter, therefore, was his mortification, when, on expressing the
hopes to which her kindness had given birth, she assured him that
her sentiments remained unaltered.
"Then, madam," cried he, "why were you so cruel as to save my
life?"
"Young man," she gravely replied, "was it not my duty to try to save
your life, that you might try to amend it? Were you prepared to meet
that terrible tribunal from which even the most perfect shrink back
appalled?"
On his complete recovery, my mother and I proceeded to the house
of my uncle, now become our property; and thence we returned
home. The following vacation Seymour finally left college, and again
went abroad.
He wrote a farewell letter to my mother, as eloquent as gratitude
and even filial affection could make it: she wept over it and
exclaimed,
"Oh, that the generous-hearted creature who wrote this should not
be all I wish him! He is like a beautiful but unsupported edifice, fair
to behold, but dangerous to lean against!"
There was one part of the letter, however, which my mother did not
understand: I fancied that I did, though I did not own it. He assured
her, that in spite of everything he carried more hope away in his
heart than he had ever yet known: hope, and even a precious
conviction which he had never known before, and which he was sure

his cousin Helen would wish him to possess, as it would be to him
the strongest shield against temptation.
"My dear," said my mother, after long consideration, "how stupid I
have been not to understand this sooner! He certainly means that he
is become very religious: and that this hope, this sweet conviction,
are faith and another world. Dear Seymour, I am so glad! for though
I do not choose you should marry a Methodist, and one extreme is
to me as unpleasant as another, still I believe Methodists to be a
very happy people; and I hope Seymour, for his own sake, will not
change again."
I smiled, but said nothing; for I put a very different interpretation on
his words. As it appeared to me, his hope and conviction were that
he possessed my love, and that my compliance with my mother's will
was wholly against my own; for I recollected the tone in which I had
replied to his question concerning my engagement to De Walden,
"Oh, no! no!" and also my scream of agony in spite of his alarming
weakness when he persevered in leaving us, and the anxiety with
which I looked at him at the gates of Magdalen. Yes, when we
exchanged that look, I felt that our hearts understood each other,
and I was sure that the shield to which Seymour alluded was his
conviction of my love.
But alas! he was absent—De Walden was present. He came to us at
the beginning of the long vacation, and was to remain with us till he
returned to college.
My mother now urged me to admit the addresses of De Walden,
showing me at the same time a letter from his uncle, in which he
expressed his earnest desire that his nephew should be a successful
suitor, and offering to make a splendid addition to his fortune
whenever he should become my husband. In short, could the
prospect of rank and fortune, could manly beauty, superior sense,
unspotted virtues, and uncommon acquirements, have made me
unfaithful to my first attachment, unfaithful I should soon have
become; but though the attentions of De Walden could not

annihilate, they certainly weakened it. No wonder that they should
do so, when I was so little sure of the stability of Seymour's
affection, that I was fearful it would be weakened by any change in
my external appearance, and as I had often heard him say, he did
not admire tall women, I own I was weak enough to be uneasy at
the growth consequent upon my fever; and I was glad, when we
met in the coach, not only that my veil concealed my altered looks,
but that, as I was seated, he could not discover my almost may-pole
height.
De Walden, on the contrary, admired tall women; and declared that I
had now reached the exact height which gave majesty to the female
figure without diminishing its grace; and as I really thought myself
too tall, his praise (for flattery it was not) was particularly welcome
to me. Whatever was the cause, whether I liked De Walden so well,
that I liked Seymour so much less as to cease to be fretted by his
absence, I cannot tell; but certain it is that I recovered my bloom,
and that from the increase of my embonpoint, my mother feared I
should become too fat for a girl of seventeen: my spirits too
recovered all their former gaiety, so that October, the time for the
departure of De Walden, arrived before I was conscious that he had
been with us half his accustomed time.
My mother now naturally enough augured well for the success of his
suit; and I owned that I was no longer averse to listen to his love,
but that I would on no account engage myself to him till I was quite
sure I had conquered my attachment to Pendarves.
This was certainly conceding a great deal, and De Walden left us full
of hope for the first time; while I, who felt much of my affection for
him vanish when I no longer listened to the deep persuasive tones
of his voice, should have repented having gone so far, had I not
seen happiness beaming in my beloved mother's face.
At Christmas De Walden came to us again, and I then found that in
such cases it is impossible (to use an expressive phrase) "to say A
without saying B;" I had gone so far that I was expected to go

further; and but for the secret misgivings of my own heart, and the
firm dictates of my own judgment, De Walden would have returned
to college in January my betrothed husband. But, though we had not
received any tidings from Pendarves, and my mother felt assured of
his inconstancy, I persevered firmly in my resolution not to engage
myself till I had seen him again, and could be assured, by seeing
him with indifference, that my heart had really changed its master.
You will wonder, perhaps, how a man of Ferdinand's delicacy could
wish to accept a heart which had been so long wedded to another,
and that other a living object. But my mother had convinced herself,
and had no difficulty in convincing him, that I was deceived in the
strength of my former attachment; that she had originally, though
unconsciously, directed my thoughts to him; that, like a romantic
girl, I had thought it pretty to be in love, and that my fancied
passion had been irritated by obstacles; but that, when once his
wife, I should find that he alone had ever been the real possessor of
my affections.
It is curious to observe how easily even the most sensible persons
can forget, and believe, according to their wishes. My mother had
absolutely forgotten the proofs of my strong attachment to Seymour,
which she had once so much deplored. She forgot my illness, which
if not caused was increased by his letter of reproach; she forgot the
tell-tale misery which I had exhibited on the road to Oxford, and she
did not read in the firmness with which I still persisted to see
Seymour again, a secret suspicion of still lingering love.
But the crisis of our fates was fast approaching: I received an
invitation to spend the months of May and June in London, with a
friend who had once resided near us, and who had gone to reside in
the metropolis.
I felt a great desire to accept this invitation; and my mother kindly
permitted me to go, but declined going herself, saying that it was
time I should learn to live without her, and she without me.
Accordingly, for the first time we were separated. But this separation

was soon soothed to me by the charms of the life which I was
leading. I was a new face: I was only seventeen, and I was said to
be the heiress of considerable property. This, you know, was an
exaggeration; my fortune was handsome, but not very large:
however, I was followed and courted, but none of my admirers were
in my opinion at all equal to Seymour or De Walden: they gratified
my vanity, but they failed to touch my heart.
One day at an exhibition, I met a newly-married lady, who when
single had been staying in the neighbourhood of my mother's uncle
during our last visit, and was much admired both by my mother and
myself. This meeting gave us great pleasure, and she hoped I would
come and see her at her lodgings. I promised that I would.
"But there is nothing like the time present: will you go home with
me now, and spend a quiet day? You must come again when my
husband is at home and I have a party; but he dines out to-day, and
I shall be alone till evening."
"But I am not dressed."
"Oh! I can send for your things and your maid; and such an
opportunity as this of telling you all about my love and my marriage
may never occur again."
I was as eager to hear as she was to tell; my friend consented to
part with me, and I accompanied her home.
In the afternoon while we were expecting two or three ladies of her
acquaintance, and were preparing to walk with them in the park, my
friend received a little note from her husband.
"That is so like Ridley," said she. "However, this is an improvement;
for he often goes out and invites half-a-dozen people to dinner
without giving me any notice: but now he has only invited one man
to supper, and has sent to let me know they are coming. His name I
see is the same as yours, Seymour Pendarves: is he a cousin of
yours?"

"What!" cried I, almost gasping for breath, "Seymour Pendarves in
England, and coming hither!"
"Yes; but what is the matter, or why are you so agitated?"
"If you please I will go home, I had rather go home."
Mrs. Ridley looked at me with wonder and concern, but she was too
delicate to ask me for the confidence which she saw I was not
disposed to give. She therefore mildly replied that if I must leave
her, she would order her servant to attend me.
A few moments had restored my self-possession: and I thought that
as the time was now arrived when I could, by seeing Pendarves,
enable myself to judge of the real state of my heart, I should be
wrong to run away from the opportunity.
"But pray tell me," said I, "when you expect Mr. Ridley and his
friends?"
"Oh not till it is dark, not till near supper-time."
Immediately (I am ashamed of my girlish folly) I had a strong desire
to discover whether Seymour would recognise my person, altered as
it was in height and in size; and I also wished to get over the first
flutter of seeing him without its being perceived by him. In
consequence I told Mrs. Ridley that Seymour was my cousin, but
that he had not seen me standing since I was grown so very tall;
and I had a great wish to ascertain whether he would know me.
"Therefore," said I, "do not order candles till we have sat a little
while."
Mrs. Ridley smiled, fully persuaded that, though I might speak the
truth, I did not speak all the truth. I was at liberty in the mean time,
during our walk in the park, to indulge in reverie, and to try to
strengthen my agitated nerves against the approaching interview.
But concerning what was I now anxious?—Not so much to ascertain
whether I loved him, but whether he loved me. Alas! this anxiety
was a certain proof that he was still the possessor of my heart, and

that of course I ought not to be and could not be the wife of De
Walden.
Just as we stopped at the door, on our return from our walk, Mr.
Ridley was knocking at it, accompanied by Seymour. I felt myself
excessively agitated, while I pulled my hat and veil over my face: to
avoid a shower, we had crowded into a hackney-coach. Luckily I had
not to get out first; but judge how I trembled when I found
Seymour's hand presented to assist me. My foot slipped, and if he
had not caught me in his arms, I should have fallen. Mrs. Ridley,
however, good-naturedly observed, that she had been nearly falling
herself, the step was so bad, and her friend Miss Pen was also very
short-sighted. I now walked up stairs, tottering as I went.
"Fanny," whispered Mr. Ridley to his wife, "who is she?" She told him
I was a Miss Pen, and she would tell him more by and by.
"Pray, Fanny, when do you mean to have candles?" said Mr. Ridley.
"Not yet; not till we go to take off our bonnets. I like this light, it is
so pleasant to the eyes."
"Yes, and so cheap too," replied her husband. "But I wonder you
should like this sort of light, Fanny, for you are far removed yet from
that period of life when le petit jour is so favourable to beauty: you
are still young enough to bear the searching light of broad-eyed day,
and so I trust are all the ladies present; though I must own a veil is
always a suspicious circumstance," he added, coming up to me.
"Yes, yes," said his wife, "I always suspect a veil is worn to conceal
something."
"But it may be worn in mercy," he added; "and perhaps it is so here,
if I may judge of what is hidden by what is shown: if I may form an
opinion indeed from that hand and arm, on which youth and beauty
are so legibly written, I—"
Here, confused and almost provoked, I drew on my gloves; and Mrs.
Ridley, who loved fun, whispered her husband,

"Do not go on; she is quite ugly, scarred with the confluent small-
pox, blear-eyed, and hideous: you will be surprised when you see
her face."
She then begged to speak to me; and as I walked across the room
in which we sat to join her in the next, I saw Ridley whisper
Pendarves.
"May be so," he replied: "but her figure and form are almost the
finest I ever saw."
"And yet I am so very tall," said I to myself with a joy that vibrated
through my frame.
The conversation now became general; and on a lady's being
mentioned who had married a second husband before the first had
been dead quite a year, Pendarves, to my consternation, began a
violent philippic against women, declaring that scarcely one of us
was capable of a persevering attachment; that the best and dearest
of husbands might be forgotten in six months; and that those men
only could expect to be happy who laid their plans for happiness
independently of woman's love.
It is strange, but true, that the indignation which this speech excited
in me enabled me to conquer at once the agitation which had
hitherto kept me silent. Coming hastily forward, I exclaimed, while
he rose respectfully,
"Is it for you, Mr. Seymour Pendarves, to hold such language as this?
Have you forgotten Lady Helen, your own blessed mother, and her
friend and yours?"
So saying, while he stood confounded, self-judged, and full of
wonder, for the voice and manner were mine, but the height and
figure were no longer so,—I left the room; and a violent burst of
tears relieved my oppressed heart.
Mrs. Ridley then rang for a candle and considerately left me to
myself.

Oh! the flutter of that moment when I re-entered the drawing-room,
which I found brilliantly lighted up! Seymour, who had I found now
doubted, and now believed, the evidence of his ears in opposition to
that of his sight, was standing at the window; but he turned hastily
round at my entrance, and our eyes instantly met.
"Helen!" exclaimed he, springing forward to meet me, while my hand
was extended toward him; and I believe my countenance was
equally encouraging. That yielded hand was pressed by turns to his
lips and his heart; but still we neither of us spoke, and Seymour
suddenly disappeared.
Mr. Ridley, who was that melancholy thing to other people a
professed joker, to my great relief (as it enabled me to recover
myself,) now came up to me bowing respectfully, and begged me to
veil my face again; for he saw that my excessive ugliness had been
too much for his poor friend, and he hoped for his sake, as well as
that of the rest of mankind, I would conceal myself from sight.
I told him, when his friend came back I would consider of his
proposition, and if he approved it I would veil directly.
Before Seymour returned, I asked Mr. Ridley whether he suspected
who his presuming monitor was.
"Pray, madam," he archly replied, "say that word again. What are
you to Mr. Pendarves?"
"I said 'Monitor.'"
"Oh—monitor! I thought you were something to him, but did not
exactly know what. No wonder he was so alarmed at sight of you,
for monitors, I believe, have a right to chastise their pupils; and I
begin now to fear he will not come back. Do you use the ferule or
the rod, Miss Pendarves?"
"You have not yet answered my question, sir!"

"Oh! I forgot. 'Heavens!' cried he, as you closed the door, 'is it
possible? Could that be my cousin, Helen Pendarves? Yes, it could be
no other; and yet'——Is that like him, madam?"
"Oh! very!"
"'Well,' I, in the simplicity of my heart, replied, 'your cousin she may
be; but my wife told me her name was Pen.'
"'Oh yes, it must be Helen—it was her own sweet voice and
manner!'
"'She is given to scolding, then—is she?' said I.
"'Oh!' said he, 'she is!' But I will spare your blushes, madam; though
I must own that I could not believe you were the lady in question,
because my wife told me you were hideous to behold, and he said
you were a beauty: besides, when he last saw you, he added, you
were thin and short; but then he eagerly observed, that a year and a
half made a great difference sometimes, and you had not met during
that period. But here comes the gentleman to answer your questions
himself. What I further said did not at all please him."
"No! what was it, sir?"
"That, if you were indeed Miss Helen Pendarves, you were a great
nuisance, for that you had won and broken at least a dozen hearts;
but that it was a comfort to know you would soon be removed from
the power of doing further mischief, as you were going to be married
to a Swiss gentleman, and would soon leave the kingdom."
"And you told him this?" cried I, turning very faint.
"Yes, I did; and he had just turned away from me, when you made
your appearance."
Seymour now entered the room; and I was, from this conversation,
at no loss to account for the gloom which overspread his
countenance, while he hoped Miss Pendarves was well.

"My dear Fanny," said Mr. Ridley, who must have his joke, "I hope
you will make proper apologies to this gentleman and me, for having
exposed us to such a horrible surprise as the sight of that lady's face
has given us. Pray, was this ungenerous plan of concealment Miss
Pendarves's or yours?"
"Her's, entirely."
"But what was her motive?"
"She wished to see whether her cousin would know her through her
veil."
"Oh! she was acting Clara in the Duenna; you know she plays Don
Ferdinand some such trick."
"True; but Ferdinand and Clara were lovers, not cousins."
"Cannot cousins be lovers, Fanny?"
Here the entrance of the servant with supper interrupted the
conversation, and Seymour and I sat down to it with what appetite
we could.
"It is astonishing," said Mr. Ridley, "what use and habit can effect; I
have already conquered my horror at sight of your friend's face; and
I see Mr. Pendarves has not only done the same, but I suspect he is
meditating a drawing of it, to send to the Royal Society, as a lusus
naturæ."
In spite of himself, Seymour smiled at this speech, and replied, while
I looked very foolish, that he was gazing at me with wonder, as he
could not conceive how I had gained so many inches in height since
he saw me.
"I grew several inches after my fever," I replied.
"Fever? When—where—what fever, Helen? I never heard you were
ill."

"Oh yes, I was—and my life was despaired of."
"You in danger, Helen, and I never knew it!"
"It was really very unkind," said Ridley, "to keep such a delightful
piece of intelligence from you."
"But when was it, dear Helen?"
"When I saw you on the road to Oxford, I was only just recovered."
"Only just recovered! You did not look ill; but I remember you had
your veil down, so I really did not see your face."
"So, so; wearing her veil down is a common thing with her—is it? I
am glad she is so considerate."
These jokes, however, had their use; for they tended to keep under
the indulgence of feelings which required to be restrained in both of
us, in the presence of others.
"But, when were you first seized, Helen? and what brought on your
fever?" said Seymour, as if urged by some secret consciousness.
You will not wonder that I blushed, and even stammered, as I
answered, "I was not quite well when I saw you in the church—and
—and——"
"And what?"
"I was seized that night, and when my mother returned, she found
me very ill indeed!"
"That night!" Here he started from his seat.
"Ah Fanny!" cried Mr. Ridley, "you would buy them! I always
objected to them."
"Buy what, my dear Ridley?"

"These chairs; I always said they were such uneasy ones, no one
could sit on them long—you see Mr. Pendarves can't endure them."
I was very glad when Seymour sat down again; when he did, he
leaned his elbows on the table, and gazed in my face as if he would
have read the very bottom of my soul. But hope seemed to have
supplanted despair. Mr. Ridley now suddenly rose, and holding his
hand to his side, cried, "Oh!" in such a comic, yet pathetic manner,
that though his wife really believed he was in pain, she could not
help laughing; then, seizing a candle, he went oh-ing and limping
out of the room, leaning on her arm, and declaring he believed he
must go to bed, if we would excuse him.
There was no mistaking his motive, and Seymour was not slow to
profit by the opportunity thus good-naturedly offered him.
"Helen!" he exclaimed, seating himself by me, and seizing my hand,
"is what I heard true—am I the most wretched of men—is this hand
promised to De Walden?"
"No—not yet promised."
"Then you mean to give it to him?"
"Certainly not now."
"Why that emphasis on now?"
"Because I am sure I do not love him sufficiently."
"And since when have you found this out?"
I did not answer; but my tell-tale silence emboldened him to put his
own interpretation on what I had said; and now, for the first time,
unrestrained by any unwelcome witness, he passionately pleaded
the interests of his own love, and drew from me an open confession
of mine. Nor was there long a secret of my heart which was withheld
from him; and while he rejoiced over the certainty that his rival's
hopes were destroyed by this interview, I rejoiced in hearing that

the conviction he had received of my affection for him, had
preserved him from temptations to which he would probably
otherwise have yielded.
"But they are returning," cried he; "tell me where you are, and
promise to see me to-morrow, my own precious Helen! Never, never
was I so happy before."
"Nor I," I could have added; but I believe my eyes spoke for me,
and I promised to see him the next day at eleven. He had just time
to resume his chair when Mr. and Mrs. Ridley returned.
"I have been very unwell," said Ridley, "and am so still; but I would
come back, as she would not leave me, because I was sure, what
with the uneasy chairs, and Miss Pen's ugly face, you would be so
fretted, Mr. Pendarves, that you would never come hither again.
"'But then, my dear,' said Fanny, 'you forget they are relations, and
must love each other.'
"'That I deny,' said I, 'if they are not both loveable.'
"'And then,' says she, 'they have not met for so long a time, and
have so much to say.'
"'I don't believe that,' says I: 'if so, they would have taken care to
meet sooner'——but pray what has happened to you both since we
went away? Well, I declare, such roses on cheeks, and diamonds in
eyes! and, I protest, Miss Pen has learnt to look straight-forward,
and is all dimples and smiles! and this, too, when, for aught you
both knew, I might be dying!"
Seymour and I were now too happy not to be disposed to laugh at
any absurdity which Ridley uttered; and never before or since did I
pass so merry an evening. Seymour was as gay and delightful as
nature intended him to be: you will own that the word "fascinating"
seemed made on purpose to express him; and I, as he has since
told me, appeared to him to exceed in personal appearance that
evening (animated as I was with the consciousness of loving and

being beloved) all the promises of my early youth; nor could he help
saying—
"Really, Helen, I cannot but look at you!"
"That is very evident," observed Ridley.
"Yes, but I mean that I look at her because—because——"
"You cannot help it, and it requires no apology. I have a tendency to
the same weakness myself."
"But I mean you are so surprisingly altered—so grown—so——"
"Say no more, my dear sir," cried Ridley, interrupting him, "for it
must mortify the young lady to see how much she has outgrown
your knowledge and your liking! and she is such a disgrace to your
family, that it is a pity there is no chance for her changing her name,
poor thing! those blear eyes must prevent that. I see very clearly,
indeed, she is likely to die Helen Pendarves."
This observation, much to Ridley's sorrow, evidently clouded over
the brows of us both; for we both thought of my mother, and I of
poor De Walden. But the cloud soon passed away; for we were
together, we were assured of each other's love, and we were happy.
—Nor did we hear the watchman call "past one o'clock," without as
much surprise as pain. However, Pendarves walked home with me,
and that walk was not less interesting than the evening had been.
But, alas! my mother's image awaited me on my pillow. I could not
help mourning over the blighted hopes of De Walden, nor could I
drive from my startled fancy the suspicion that I had committed a
breach of duty in receiving and returning vows unsanctioned by her
permission, or satisfy my conscience that I had done right in
allowing him to call on me the next day. But I quieted myself by
resolving that I would instantly write to my mother, tell her what had
passed, and see Seymour only that once, till she gave me her
permission to see him more frequently.

He came at eleven, and I told him what I meant to do. He fully
approved, but declared he would not consent to meet evil more than
half way, and give up seeing me. On the contrary, he was resolved
to see me every day till she came; and as Mr. Pendarves our uncle
was just come to his house in town, he meant to tell him how we
were situated, and he was very sure that he would approve our
meeting as much as possible. On leaving me he proceeded to lay his
case before our uncle, while I sat down to write to my mother. It
was a long letter bathed with my tears; for was I not now pleading
almost for life and death? If I loved Pendarves when my affection
was not fed by his professions of mutual love, how must that flame
be now increased in fervour, when I had heard him plead his cause
two days successively, and had enjoyed with him hours of the
tenderest uninterrupted intercourse! Wisely had my mother acted in
forbidding us to meet, as she wished to annihilate our partiality; for
absence and distance are the best preventives, if not the certain
cures of love.
My letter, which was full of passion, regrets, apologies and pity for
De Walden, was scarcely finished, when I was told that a gentleman
who was going immediately into Warwickshire, and would pass close
by my mother's door, would take charge of it. I foolishly confided it
to his care; I say "foolishly," because the post was a surer
conveyance. However, I could not foresee that this gentleman would
fall ill on the road; that he would not deliver my packet till ten days
after it was written; and that I was therefore allowed to spend many
hours with Pendarves unprohibited; for my uncle approved our
meeting, and desired our union, declaring that he had always
thought my mother severe in her judgment of his nephew, and that
while considering the fancied interests of her own child, she had
disregarded his.
"Besides," added he, "I am the head of the family, and I command
you to meet as often, and to love as much, as ever you choose."
Alas! I obeyed him only too well, though my judgment was not
blinded to the certainty that he had no rights which could invalidate

those of my mother; and though I rejoiced at not receiving her
command to cease to receive Pendarves, I was beginning to feel
uneasy at her silence, when a letter from her reached me, saying,
she was on her road to London, where she would arrive that night,
and should take up her abode with our friend Mr. Nelson.
Never before had I been parted from my mother, and till I met
Pendarves I had longed for her every day during my stay in London;
but now, self-reproved and ashamed, I felt that a yet dearer object
had acquired possession of my thoughts and wishes, and the once
devoted child dreaded, rather than desired, to be re-united to one of
the best of mothers.
She came; and we met again, as we had parted, with tears; but the
nature of those tears was altered, and neither of us would have liked
to analyze the difference.
Long and painful was the conversation we had together that night,
before we attempted to sleep. I found my mother fully convinced
that there was a necessity for my not marrying De Walden, a
necessity of which he was now himself convinced; for she had gone
round by Cambridge, in order to see him: but she was not equally
convinced that there was a necessity for my marrying Pendarves, as
all her objections to that marriage remained in the fullest force.
The next morning she opened her heart on the subject to Mrs.
Nelson, who was Seymour's warm advocate, and assured her, that if
she made proper inquiries, she would find that the character of
Pendarves was universally spoken of as unexceptionable; and that
whatever might have been the errors of the youth, they were
forgotten by other people in the merits of the man.
"Ay, but a mother's heart can't forget them," she exclaimed, "when
her child's happiness is at stake!" and she begged to have no private
conversation with Seymour till the next day. In consequence, she
saw him only in a party at my uncle's, where she was struck with the
great improvement both of his face and person, for both now wore

the appearance of health; and the countenance which, when she
last surveyed it, bore the stamp of sickness and sorrow, now
beamed with all the vivacity of youth and hope.
The party was a mixed one of cards and dancing; and as she gazed
on Pendarves when he stood talking to me, he recalled forcibly to
her mind the image of my father, as she first beheld him in a similar
scene, four-and-twenty years before.
The next day Seymour obtained the desired interview with my
mother. She brought forward his former errors in array against him,
his debts, his dissipations, and his love of play; and though she
expressed her readiness to believe him reformed, still, as he
ingenuously admitted that his improvement was chiefly owing to my
influence over him, she could not deem it sufficiently well-founded to
obviate her objections; and he was still pleading, and she objecting,
when Mr. Pendarves insisted on entering. Mrs. Nelson and I
accompanied him.
"I tell you what, niece," said he, "you do not use this young man
well: you bring up a parcel of old tales, and dwell upon the
naughtiness of them, as if he was the only young man who ever
erred. I know all his sins; he has made me his confessor. In the
affair to which you allude he was much more to be pitied than
censured, and yielded at seventeen to temptations which might have
overcome seven-and-thirty. Since then he has distinguished himself
at college: he has paid all his old debts, and incurred no new ones;
he has steered clear of the quicksands of foreign travel, shielded (as
he says) by the hopes of one day possessing Helen, and by the idea
that he was the object of her love; and what would you have more?
Besides, Helen tells me he once saved her life."
"I did so," cried Seymour, eagerly seizing her hands, "I did so, and
you promised to be for ever grateful!"
"How was it, my dear nephew?"

"I will tell you, sir," cried I, gathering hope from my mother's
agitation. "It was at the Isle of Wight, soon after we came to
England: he and I were playing on the shore, and I, not knowing the
tide was coming in, paddled across a run of water to what I called a
pretty little island, and there amused myself with picking up sea-
weed, when the sea flowed in, and he saw that I must perish; no
one was near us. Luckily, he spied a boat on the dry land, which,
with all his boyish strength, he pushed off to my assistance, and
jumped into it. In one minute more it floated towards me, just as my
cries had reached the ears of my mother, who was reading on the
rock, and who now saw my situation."
"Helen! Helen!" cried my mother, "I can't bear it—the scene was too
horrible to recall." But I persevered.
"Seymour seized my hand just as I was sinking, and dragged me
into the boat; but in another moment the waves came swelling
round us, and, without oar or help, I and my preserver were both
tossed to and fro upon the ocean."
"Helen!" cried Seymour, with great feeling, and clasping me fondly to
his heart, "I could almost wish we then had died, for then we should
have died together!"
"Go on," said my uncle, "I hope you will live together yet!"
"I have not much more to tell, except that my mother's screams had
now procured assistance, and a boat was sent out to follow our
uncertain course. When we were overtaken, they found Seymour
holding me on his lap, and crying over me in agony unutterable, for
he thought that I was dead, and he had come too late. Who can
paint my mother's transports, when she received me safe and living
in her arms?"
"And how she embraced me, Helen," cried Seymour, "and called me
her noble boy—the preserver of her child! (for she saw all I had
done;) and how she owned she should ever love me as her own
child—and vowed her gratitude should end but with her life!"

"It never will end but with my life!" cried my mother, throwing
herself on Seymour's neck. "But is your having saved my child's life
an argument for my authorizing you to risk the happiness of that
life?"
"Julia, Julia, I am ashamed of you!" cried my uncle. "Was there ever
a better or more devoted wife than yourself? Yet, what did you do at
Helen's age? You ran away from your parents, out of an
ungovernable passion for a handsome young man."
"But is my error an excuse or justification of his?"
"No; but you are a proof that error can be atoned for and never
repeated, as you have been a model for wives and mothers. But
beware, Mrs. Pendarves, of carrying things too far; beware, lest you
tempt Helen and Seymour to copy your example, rather than
conform to your precepts."
"Ha!" cried my mother, clasping her hands in agony.
"Now, then," said Seymour, with every symptom of deep emotion,
"the moment is come when I am authorized to obey the commands
of the beloved dead, and fulfil the last injunctions of my mother."
A pause which no one seemed inclined to break, followed this
unexpected observation; and Seymour, taking a letter from his
bosom, kissed it, and presented it to my mother.
"'Tis Helen's hand," cried she.
"And her seal, too, you observe," said Seymour: "the envelope, you
perceive, is addressed to me, and I have therefore broken it; the
other is entire."
My mother read the envelope to herself, and these were its
contents:—
"My conscience reproaches me, my beloved son, with having
too lightly surrendered your rights, and probably your wishes, in

giving my friend back her promise to promote your union with
her daughter, as I know Julia's ability to act up to her strict
sense of a mother's duty, even at the expense of her own
happiness, and risk of her child's safety. But I have given up
that promise, which might have pleaded for you, my poor child!
when I was no more, and ensured to you opportunities of
securing Helen's affections, which may now, perhaps, be for
ever denied to you. However, I may be mistaken; therefore, if
Helen's affections should ever be yours—avowedly yours, and
her mother still withhold her consent, give her the enclosed
letter, and probably the voice of the dead may have more power
over her than that of the living.
"For your sake I have thus written, with a trembling hand, and
with a dying pulse; but value it as a last proof of that affection
which can end only with my life.
"Helen Pendarves."
The letter to my mother was as follows:—
"I speak to you from the grave, my dearest Julia! and in behalf
of that child on whom my soul doted while on earth. But this
letter will not be given you till he is assured he possesses the
heart of your daughter; and when, if your consent is denied to
their union, nothing but an act of disobedience can make them
happy in each other. Are you prepared, Julia, to expose them to
such a risk, and thus tempt the child you love to the crime of
disobedience? that crime which, though it dwelt but lightly on
your mind, weighed upon mine through the whole of my
existence, as it helped to plunge my mother in an untimely
tomb. Perhaps you flatter yourself that Helen's education has
fortified her against indulging her passion at the expense of her
duty. But remember, that your precepts are forcibly
counteracted by your example.

"Anxious, however, as I am that Helen should not err, I am still
more anxious that my son should not lead her into error, as I
feel that he is doubly armed against her filial piety, by the
example of her mother and his own.
"And must my crime be thus perpetuated by those whom I hold
most dear? must the misery of my life be renewed, perhaps, in
that of her whom I have loved as my own child? and must my
son be the cause of wretchedness to the dearest of my friends,
through the medium of her daughter?
"Forbid it Heaven! I conjure you, my beloved Julia! by our past
love—by tanta fede, e si, dolce memorie, e si lungo costume,
listen to this my warning, my supplicating voice; and let your
consent give dignity and happiness to the union of our children.
"Helen Pendarves."
My mother, after having read this letter, covered her face with her
hands, and rushed out of the room. It was in a state of anxious
suspense that we awaited her return. When she appeared, her eyes
were swelled, but her countenance was calm, her look resigned, and
her deportment, as usual, dignified. Her assumed composure,
however, failed again, when her eyes met those of Pendarves.
"My son!" cried she, opening her arms to him, into which Seymour
threw himself, as much affected as she was; then, beckoning me to
her, she put my hand in his, and prayed God to bless our union.
Little of this part of my life remains to be told. My mother had given
her consent, and in two months from that period we were MARRIED.
Here ends my narrative of a Woman's Love. When next I treat of it, it
will be as united to a Wife's Duty.

[1] See a volume of Sermons written by the Rev. P. Houghton.
[2] Is it not permitted in England?
[3] Oh! I comprehend: you do not like any should laugh in your
presence. Alas! beautiful Helen, one must laugh while one can,
when one has the happiness of being in your society; for one runs
the risk of crying very soon, and perhaps for life.
[4] But what did you mean with your 'Is it possible?'
[5] For holidays, no: they never came to me every day, till I came
hither; but now, all days are holidays to me, and my saint is Saint
Helen.
[6] But what are you seeking? let me look for it. Tell me.
[7] Oh, let them go away entirely! These are not the sentiments
with which I wish to inspire you.
[8] In pity tell me, which of these two characters pleases you the
most; but pray do not tell me that I offend you less as a
philosopher, for who that is near you can long remain a
philosopher?
[9] You agree then to the justice of my proposition, that near you
no one can remain a philosopher?

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