Embedded coaches lead to CPOE victory: Northwestern Memorial Hospital designs a system to bring point-of-care expertise to physicians as they adopt computerized order entry in everyday work.

As one of Northwestern Memorial Hospital's physicians used the new computerized physician order entry (CPOE) system for the first time, he reached that moment of puzzled hesitation that tests every new system. What he did next has helped make Northwestern Memorial a model of CPOE success. Instead of circumventing the new system by reaching for a pen to write a paper order, or asking a nurse to handle the situation for him, he did something far easier: He turned to the specialized CPOE coach beside him and asked, "So what do I do next?"

As low physician acceptance continues to bedevil many CPOE systems, these "embedded" coaches--training assistants who either do rounds with doctors or are strategically located where doctors are most likely to need help--have provided the necessary level of convenience that has made it easy for physicians to quickly learn and accept Northwestern Memorial's new CPOE program. Today, all 1,060 physicians introduced to the system so far have fully integrated it into their work, with 78 percent of all medication orders written electronically by physicians.

Inside the Embedded Coach Method

The basic premise behind embedded coaches is to give physicians immediate access to coaching at the moment questions arise. If help is further than a few steps away, physicians are most likely to revert to old, familiar habits, and may soon decide the new system is more of a hindrance than an improvement.

Recognizing that physician acceptance is one of the most critical factors in CPOE success, First Consulting Group (FCG) jointly developed the embedded coach concept with Northwestern Memorial Hospital, a 750-bed Chicago-based academic medical center. The goal was to make it more convenient for physicians to use the automated system than to revert to old methods during the rollout.

The CPOE implementation was part of a larger and foundational initiative. FCG and Northwestern Memorial have been collaborating since 1999 to automate all patient documentation, a project that will reach completion next year. Implementation of the electronic health record, including CPOE, was recommended by the medical staff as a key infrastructure element to improve quality and patient safety. This larger initiative has allowed the hospital to build on its successes with each new phase.

Regardless of the specific advantages or disadvantages a particular hospital may have, the embedded coach method can benefit any institution if executed properly. There are five main factors that can help make the embedded coach method--and, ultimately, a CPOE implementation--a success. Northwestern Memorial now has experience with all five factors.

Laying the Groundwork for Successful Coaches

Poor systems design can undermine any approach, because even the most effective coaches will never sell physicians on an overly complicated or flawed system. Well before embedded coaches took to the hospital floor, FCG and Northwestern Memorial collaborated on systems design.

In the interest of patient safety and physician-friendliness, order sets, or standing orders, were the most obvious candidates for automation. Building the order sets into the system eliminated the need for physicians to write common orders repeatedly, and reduced the potential for error in a large number of orders. Additionally, Northwestern Memorial reduced the amount of paper distributed over time, resulting in online clinician review of patient data. For example, the practice of printing and routing lab results to the nurses station was discontinued prior to the introduction of CPOE.

To specifically address physicians' needs, the system was designed to offer options for common dosages and typical methods of administering the drug, so physicians could make choices quickly with as few clicks as possible. To address safety issues, no assumptions were made about existing paper order sets. Quality committees reviewed all order sets thoroughly to ensure that each met standards and protocols and were evidence-based.

This planning and design phase took 12 months for Northwestern Memorial, since the hospital also was planning for the automation of patient documentation. Preparation for the CPOE implementation alone normally would have required nine to 12 months.

Selecting and Training Coaches

Making the right choices in selecting and training coaches is nearly as important as the decision to use the embedded coach method. In Northwestern Memorial's case, coach selection and training were completed within 90 days.

Coaches were recruited from diverse departments throughout the organization. Coaches were chosen from areas as varied as the residency program, physical therapy and physician relations. The selection process relied upon formal interviews to screen applicants.

Each applicant had to make a minimum commitment of 90 days and needed to be flexible enough to accommodate odd hours and weekend work. Also, the applicant's home department had to agree to let the individual rotate into the coach role to support the system implementation. Interviewers also looked for candidates who showed a genuine interest in the project and its goals. Finally, the program sought individuals who seemed able to handle a fairly heavy workload and who had personalities that would allow them to interact well with busy physicians.

Because Northwestern Memorial rolled out its physician documentation and CPOE systems simultaneously, coaches were trained in both areas during an intensive, one-week course of 40 hours. In addition to covering documentation and medication orders, training included physician workflows, coaching instruction and guidance on training adult learners. Of the 40 hours of training, CPOE training accounted for a smaller portion of classroom time, compared to documentation training.

Starting With a Pilot

At Northwestern Memorial, we chose hospitalists for the pilot because they were highly supportive of the initiative and had routine schedules, with seven of them on duty at all times. In addition, the hospitalists at Northwestern Memorial are technology-savvy and very enthusiastic, which indicated they would provide ample feedback. Finally, because medicine had been identified as the most complex area for the CPOE implementation, the related work of hospitalists served as a good sample of any challenges to come.

The pilot took two weeks and provided plenty of feedback that improved both training and the system itself.

A Phased Rollout Approach

A phased approach allows a small number of coaches to serve multiple areas of the hospital. In addition, each phase builds on the previous ones, as coaches gain experience, and additional feedback helps improve the system incrementally.

Northwestern Memorial's rollout was scheduled over a period of 12 months, with the majority of the physicians online within the first seven months. Prior to each department's phase, physicians attended four hours of training that covered both the documentation and CPOE systems. During training, doctors were introduced to their coaches, who served as support to the instructors.

The rollout began in medicine, following the hospitalist pilot. Because medicine had complex needs that overlapped with other departments, subsequent phases benefited from the progress made in medicine. Coaches encountered their greatest challenges in early phases, making later phases relatively easy.

In addition, once residents from medicine had completed training, they were also available as supplemental coaches for other departments. Their medical experience was very useful in situations such as assisting surgical residents on rounds. Using residents to train other residents provided the social benefit of peers helping peers, as opposed to nonclinician coaches doing all the training.

Adapting Coaching Strategies to Workflows

Coaching tactics must be modeled on physician workflows. Since Northwestern Memorial is an academic medical center, physicians in medicine work in teams. When the rollout began in medicine, one coach accompanied each team of doctors throughout their workday for a full week. The following week, coaches were available to physicians by pager.

As the rollout moved to other areas of the hospital, training was adapted to suit each department's workflow. In areas where physicians did not work in teams, coaches were strategically placed so doctors never had to look for assistance. In surgery, for example, coaches were placed in pre- and post-op, as well as in the surgical suite. Coaches also were placed in the nursing unit while surgical physicians did their rounds. Like the rollout in medicine, coaches were available on site for one week and by pager for a second week.

Beyond Embedded Coaching

The strategy of embedded coaches worked well not just because of the five factors outlined above. While careful planning, judicious coach selection, pilots and phased implementation are all critical, one overarching factor has helped all these strategies work.

The one element that can help any institution get the most mileage from these five factors is executive and hospitalwide support for a CPOE implementation. Just as coaches were selected from diverse areas of the hospital, and not simply from the IT department, Northwestern Memorial had the vision to make the CPOE rollout more than an IT initiative.

Even the effective techniques of embedded coaches will have difficulty overcoming the resistance clinicians often harbor against initiatives that are perceived as purely IT concerns. By highlighting the real purposes of CPOE implementations--patient safety and quality of care--and following the five key factors behind embedded coaching, institutions can go a long way toward their own CPOE success.

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Julie L. Creamer, M.S., R.N., is vice president, operations and quality, with Northwestern Memorial Hospital, Chicago.

Paula Elliott is implementation director with First Consulting Group, Chicago. Contact her at [e-mail]