Even though healthcare professionals who have made the switch to computerized physician order entry would not return to using paper charts, the actual transition can be a daunting task, particularly for oncology nurses who have years of experience working with the paper-based system.
Though some may describe a phobia as an intense irrational fear, try telling that to Charmaine Anthony, a pediatric oncology nurse at the Afl ac Cancer Center of Children’s Healthcare of Atlanta. Her bout of technophobia, or fear of technology, during the center’s implementation of computerized physician order entry (CPOE) was as real as it gets. “My first thought was, ‘My God, I have to give up my paper!’” Anthony recalls. “Nobody likes change. It was extremely scary. It was tense.”
One of the reasons could stem from a lack of informatics training. A study published in the Journal of Nursing Education (February 2007) found that nursing students “received limited informatics exposure and may not be adequately prepared to use information technology.” Oncology nurses, faced with regular exposure to technology tools, including bar code and radio frequency identification (RFID) scanners, electronic charting, and ‘smart’ intravenous pumps, certainly have their share of fears to hurdle. But, hurdle they must. “You have to think positively, have an open mind, and embrace challenges,” says Anthony. “Once you do that, there’s really nothing you cannot do.”
Anthony, who has been a nurse for 18 years, says that she can navigate around a computer fairly well, but by no means would she consider herself tech-savvy. In fact, she admits that prior to attending graduate school, she didn’t know how to use e-mail. Imagine her fear when informed she would have to give up her paper and pencil and learn to use CPOE.
“To think that you’re going to be doing all your orders, all your notes on a computer, and not be able to see where it goes, that was extremely scary,” says Anthony, who drew on her years of experience to get over the initial hurdle. “I’ve been around long enough to remember when the Pyxis machines came. We freaked out, and we wanted our keys back. Now, looking back, Pyxis is the best thing that ever happened.”
Anthony also took classes off ered by the cancer center, and spent ample time in an ‘online playground’ that she could remotely access from home to practice everything she was learning about CPOE in the classroom. When the system went live in June 2008, Anthony was still scared, still apprehensive, but at least she felt prepared.
“The classes were really important, because they gave us an idea of what to expect when the system went live,” Anthony says.
Still, there were challenges. Anthony recalls that using the system’s discharge navigator was the most tedious aspect of learning CPOE. The first discharge she had to process took her 90 minutes—a lot longer than it should have, she admits. Today, she handles three discharges in that time period. Forcing herself to practice, she says, was the key to overcoming the challenge, and the fear.
“I was doing it every day, and then it started to become easier,” she recalls. “It’s like anything else. Once you do it over and over, it becomes a part of you.”
Joining the team
In 2001, Montefiore Medical Center in the Bronx, NY, introduced CPOE to its inpatient units. Susan Sakalian, RN, BSN, OCN, a nurse in the center’s ambulatory oncology unit, recalls the stress her colleagues endured during the transition.
“It seemed like a very daunting task,” Sakalian says. “It seemed overwhelming. We, in the outpatient setting, felt a little safe and sheltered that we were still using paper and pencil.” That safe feeling lasted a few years, but in 2006, the oncology unit became the medical center’s fi rst foray into the ambulatory setting. “We couldn’t imagine how that could possibly work in our setting. We were defi nitely very scared about transitioning to that process.”
Sakalian, with 15 years of oncology nursing experience, was placed on the committee of clinicians and information technology specialists who worked on the transition to the CPOE system. That, she recalls, was the best thing that could have happened, because she was able to experience the transition step by step.
“The fear with anything like this is they’re just going to throw it in your lap and walk away,” Sakalian says. “Once we realized it wasn’t going to be that way, that nursing had a voice in this and it wasn’t just the technology people putting something in place and saying ‘Okay nursing, fi gure it out,’ it was a great experience. We had a lot of support from the technical side. They had people here with us for almost a month answering questions and helping the nurses navigate the system.”
Sakalian says it was also important that she and her colleagues were there for each other. Any time a problem cropped up, they were quick to share it with each other and work to develop a solution. They also drew on their experience as a unit that handled a lot of phase I testing of investigational drugs, and developed the same mindset that they were working with something new and needed to fi gure out how to use it safely. Th ere were challenges along the way, and a learning curve to overcome, but after about eight weeks of working with CPOE, it became second nature.
“We likened the process to being right-handed and learning how to write with your left hand,” Sakalian says. “You know how to do what you need to do. It’s just a matter of getting through the process.”
Old dog, new tricks
Peggy Guenther has been a registered nurse for 44 years, but she hadn’t been in a hospital setting for nearly 20. Still, after a brief experience as an outpatient at the James Cancer Center at Ohio State University four years ago, she felt she could tackle the terrain once again.
“It was very challenging,” recalls Guenther, explaining that she was not familiar with the intravenous pumps used to regulate how much fluid a patient receives, or the patient control analgesic pumps patients use to control the amount of pain medication they receive. “It had been 20 years since I had even attempted to start an intravenous. Medications and patients’ orders are entered into computers. I was totally unfamiliar with doing any kind of charting or checking off of orders that way. I never took typing in high school, so I had to learn how to use a computer. I was very uncomfortable.”
Guenther took an oncology class off ered at the hospital and recalls sitting at lunch with a classmate and asking, “‘What have we gotten ourselves into?’ I didn’t know the names of the drugs, and I knew nothing about chemotherapy. Now, four years later, we laugh about it, and we say, we never thought we would make it this far.”
She made it because she was not afraid to ask questions of her fellow nurses, and because she kept telling herself that it was important to learn new technology so that she could help patients feel comfortable with the treatments they were undergoing. To this day, she keeps the same mindset. “I rely a lot on my coworkers,” Guenther says. “I don’t want patients to feel like ‘I don’t think she knows what she’s doing.’ I can’t not do things because I’m hesitant. But I’ve always said, you can teach an old dog new tricks, and I was defi nitely the old dog.”
John Berry Jr. has been a nurse for 25 years. Currently, he’s a charge nurse with Dubuis Health System in Houston, TX, working in both palliative and hospice care. He says one of the biggest problems for any nurse, especially an oncology nurse, is staying current on medication information.
“It’s exasperating, especially as a fl oor nurse, to watch all these doctors with all their specialized medicines, and knowing that within moments of the publication of any nurse-based book, it’s out of date,” Berry says.
In the late 1990s, Berry began exploring handheld computers as a way to keep current with new medications. He also explored available software, and Epocrates Essentials for Oncology was the “only product I found early on that off ered a simple solution on a common platform where you could access the Web for periodic updates.”
Today, Berry uses Epocrates software on his iPhone platform but says there was a lot of trial and error that occurred along the way. “Computers are diffi cult,” Berry acknowledges, “but they can provide us with a lot of information. You just roll up your sleeves and dig in. Once you select a mobile platform, then it’s just a matter of practice and becoming somewhat profi cient in communicating between your base system and your mobile platform.”
Berry is active in helping his coworkers extinguish their technology fears. He says the key is to take their focus away from the fear of the technology, and he does so by handing them his iPhone and allowing them to “play with it,” and become comfortable with the program. But he admits, old habits—and fears—are tough to break.
“There really are a lot of anti-technology mindsets out there,” Berry says. “Most of the physicians I work with are familiar with Epocrates on many levels, but it’s the nurses I’ve been working on, trying to get them to commit to using personal digital assistants as a way to keep from making medication errors, which have always been recognized as one of the greatest dangers that patients face in a hospital. I’ve always had this passion that I want to learn new technology to prevent problems for my patients, but it’s tough to get people to come over to that side.”
The big picture
Anthony says that what helped her overcome her fears of the CPOE system was thinking about the benefi ts going forward. Th e system “has made my life a little easier in the comfort of knowing that even if I get home and I forgot to add something on a progress note, I can go into my home offi ce, log on, and put it in,” she explains. “Everything we do now is in real time. I think for patient safety and patient satisfaction, it’s a wonderful thing.” Sakalian echoes those thoughts. “Looking at the big picture really does help a lot,” she says. “Knowing that if we treat a patient today and, God forbid, the patient ends up in the emergency department in the Montefi ore system this evening, those practitioners have access to the drugs, the dosages, and an assessment that was done on the patient earlier that day. That kind of turnaround is so benefi cial to our patients.”
Ed Rabinowitz is a veteran healthcare reporter based in Bangor, PA.