Original Contributions

Mobile Physician Order Entry Alan Ying

A B S T R A C T Because both computerized physician order entry (CPOE) systems and mobile technologies such as handheld devices have the potential to greatly impact the industry’s future, IT vendors, hospitals, and clinicians are simply merging them into a logical convergence — “CPOE on a handheld” — with an expectation of full functionality on all platforms: computer workstations, rolling laptops, tablet PCs, and handheld devices. For these trends to succeed together, however, this expectation must be revised to establish a distinct category — mobile physician order entry (MPOE) — that is different from CPOE in form, function, and implementation.

K E Y W O R D S Computerized physician order entry (CPOE) Mobile physician order entry (MPOE) Adverse drug events (ADEs) Handheld Mobility Medical errors PDA software applications

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Historically, successful mobilization of comprehensive, stationary systems — such as stereos and telephones — resulted from intentionally limiting their functionality on portable implementations, as with the ubiquitous Walkman® and cell phones. Consistent with this model, widespread adoption of MPOE in the healthcare market will be driven by easy-to-use, intelligently limited, high-yield functions that do not merely mimic comprehensive CPOE systems onto smaller devices. With industry emphasis on mobility and error reduction only beginning to intensify, MPOE will become indispensable as both a stand-alone solution and a complementary system in hospitals’ order entry strategies.

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Irresistible Force I: CPOE After over 30 years of CPOE availability, only 3 percent1 of hospitals have successfully implemented enterprise-wide CPOE systems. However, countless factors, such as the following, have increasingly pressured the healthcare industry to widely implement CPOE systems. Publicity. With the issuance of the 1999 Institute of Medicine (IOM) report “To Err is Human,” CPOE was launched to the forefront of the nation’s consciousness. The report concluded that preventable medical errors caused as many as 7,000 deaths each year in U.S. hospitals, and singled out CPOE as a way to significantly reduce these errors. In fact, there are more deaths in hospitals each year from preventable medical mistakes than there are from vehicle accidents, breast cancer, or AIDS.2 A study by David Bates, MD, chief of general medicine of Boston’s Brigham and Women’s Hospital, illustrated a reduction in medical error rates achieved with CPOE by 55 percent.3 The study attributed the prevention of errors by CPOE’s computerized, structured orders and medication checks.4 The Leapfrog Group estimates that CPOE would prevent approximately 522,000 serious medication errors each year in the U.S.5 Industry. Subsequent to the Institute of Medicine’s report, “To Err is Human,” organizations such as the Leapfrog Group, the National Patient Safety Foundation, and the National Alliance for Health Information Technology, called for meaningful reform of healthcare IT — with CPOE as a specific priority. In particular, the Leapfrog Group has taken the initiative to develop a coalition of more than 100 public and private organizations that provide healthcare

Original Contributions benefits with the shared goal of reducing preventable medical errors. The group’s strategy consists of mobilizing employer purchasing power to create improvements in healthcare safety, and to equip consumers with information to make more informed hospital choices. The Leapfrog Group outlines three specific error-reducing recommendations, including computerized physician order entry (CPOE). Leapfrog specifically asserts CPOE systems can automatically warn caregivers against the possibility of drug interaction, allergies, or over-dosage, and remove the confusion over handwritten physician prescriptions or notes. Current estimates are that more than 2 million cases of prescription errors are caused by poor handwriting annually.6 Legislation. According to a May 2002 report from the National Academy for State Health Policy,7 an increasing number of states are enacting laws aimed at reducing the incidence of medical errors — 11 states in 1999 and 2000, and 12 states in 2001. For example, Senate Bill 1875 in California calls for a medication error reduction strategy that includes the use of CPOE systems. Massachusetts’ senate passed a similar law, “Bill 571: An Act to Provide for the Payment of a One-time Bonus to Health Care Providers for Implementation of Medical Error Reduction Technology,” which encourages a wide range of healthcare facilities to implement systems designed to identify, track, and prevent medical errors, including computerized medication order entry. Financial. According to the 2001 Leapfrog Group report, “Leapfrog Patient Safety Standards, Economic Implications,” CPOE could save hospitals $180,000 to $900,000 annually from reduced medication errors alone. With improvements in resource utilization and reductions in duplicate lab testing and imaging, some hospitals could save $5 million annually by implementing CPOE. Over half of serious medication errors result in preventable adverse drug events (ADEs). Each of these ADEs adds an average of $2,000 to hospitalization costs.8 These expenditures add up to hospital costs of at least $2 billion per year nationwide.9 Significant consequences beyond human lives also result from preventable errors including the expense of additional care required, lost income, decreased

household productivity, and disability. It is estimated that these additional consequences cost hospitals up to $29 billion a year nationwide.10 Interestingly, the mistakes that account for these problems are, for the most part, not due to workers’ inabilities, but to hospitals’ inadequacies in system, process, and workflow management that encumber the identification of potential errors. However, despite vendors’ and healthcare organizations’ efforts to implement efficacious solutions to address these market pressures, the industry is struggling with how to integrate these CPOE solutions into other technology trends.

“With industry emphasis on mobility and error reduction only beginning to intensify, MPOE will become indispensable as both a stand-alone solution and a complementary system in hospitals’ order entry strategies.”

Irresistible Force II: Handheld Devices Handheld devices and other mobile technologies, in contrast to CPOE, have followed a significantly steeper adoption curve in healthcare. According to a Harris Interactive poll, about 18 percent of the nation’s physicians reported using a personal digital assistant (PDA) as an integral part of their professional duties. This poll also estimates that physician usage of PDAs will reach nearly 50 percent by 2005.11 Even more indicative of mobile devices’ high user adoption is the Mobile Healthcare Association’s (MoHCA) estimate that physician usage of all wireless applications — including pagers, cell phones, and PDAs — is currently over 95 percent.12 Also important are handheld software offerings that stimulate adoption through

valuable application functions. For example, the Gartner Group estimated that as of May 2001, more than 75 percent of physician deployments of PDA-based software products were for ePocrates™, a popular drug reference guide.13 Additionally, Harris Interactive reports that usage of PDAs among physicians for billing applications tripled from 1999 to 2001.14 Other mobile healthcare applications presently available for end-users include prescription writing, lab order entry, results reporting, clinical documentation, alert messaging, clinical decision support, medication administration, and inpatient care solutions. Ultimately, the end-user demand for these time-saving handheld applications will drive the trend towards mobility from the grassroots level up to become a priority at the hospital executive level. Further fueling wireless adoption is the increased penetration of standards, such as the 802.11b wireless protocol, and the decreasing costs of wireless infrastructure. In 1999, the Wireless Ethernet Compatibility Alliance (WECA) was formed to certify interoperability of wireless Local Area Network products based on 802.11 specifications. Currently WECA has 147 member companies from around the world, and 306 products have received 802.11b certification since certification began in March 2000.15 The 802.11b wireless networks are faster than broadband solutions — like DSL or cable modems — and are now more affordable than when they were first introduced. For example, a wireless infrastructure implementation can cost a small business (with coverage of a few thousand square feet) less than $2,000.16 Additionally, as any technology does after successfully gaining user adoption, handheld devices have come down in price over the past two years. In July 2002, Palm announced that is was cutting prices by up to 34 percent on five of its six handheld lines.17 These recent decreases in consumer barriers, coupled with the overall growth of handheld devices, have the industry struggling to integrate handheld devices and wireless networking into hospitals’ clinical and IT strategies as quickly as most users want. When Irresistible Forces Meet... The hospital IT industry is just

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Original Contributions beginning to understand how to combine CPOE functionality with handheld device technology. With the penetration of handheld devices growing along with the demand for CPOE, the obvious conceptual integration is to implement full CPOE functionality on handheld devices. Upon in-depth analysis, however, this approach is fundamentally flawed. Clearly, despite CPOE’s recent prominence, the industry is having a hard time achieving adoption with CPOE on computer workstations. Even among the nation’s “Most Wired Hospitals,” 86 percent of the facilities ordered fewer than 20 percent of medications electronically.18 As published statistics support, and industry participants will confirm, CPOE systems are complex and require substantial user training for appropriate use. Even with all the CPOE-relevant benefits of computer workstations (i.e., large screens, keyboards, fast processing power, mice, comfortable chairs), and time-intensive training initiatives, the adoption rate is quite low. It seems unreasonable, then, to expect sudden, enthusiastic industry adoption by replacing CPOE-friendly computer workstations with the tiny screens, slower processing power, and reduced connectivity of mobile devices — while maintaining all the complexities of full-function CPOE. Yet this is exactly what the industry is growing to expect and demand. Lessons Learned: The Walkman® and the Cell Phone The growth of portable stereos and cell phones over the past 30 years demonstrate that migration of only the most vital functions from stationary, fullfeatured systems to smaller devices is the formula for successful mobile products. The consumer stereo market began to explode in the 1970s, and the status quo was large systems with numerous knobs and dials. Sony introduced its firstgeneration Walkman® — the Soundabout — in 1979. Sony believed that most consumers desired ease-of-use and mobility, not the advanced features appealing to a small population of users. For example, people wanted to listen to music anywhere, often in noisy environments such as parks, subways, and gyms, so there was no need for a

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10-band graphic equalizer to finely balance the sound. Inside the company, Sony’s chairman, Akio Morita, had to defend why the device could not record sound: “Well, a car tape deck doesn’t record, either,” he said, explaining his dedication to basic functionality. By the end of the first month of availability, less than 3,000 units had been sold, but by the end of the second month the entire first production run of 30,000 Walkmans was sold in Japan. By 1989, 10 years after the product’s introduction, Sony had manufactured more than 50 million Walkmans®.19

“According to a Harris Interactive poll, about 18 percent of the nation’s physicians reported using a personal digital assistant (PDA) as an integral part of their professional duties.” The success of this approach is selfevident, as the ubiquitous portable music player — now of countless technologies — remains successful because of its focus on limited functionality, ease of use, and mobility. Cell phones present another familiar example of limited features in portable devices. This technology ushered in the age of mobile communication by offering productivity for “on-the-go” business people and instant access for social purposes. But cell phones moved from luxury to necessity primarily because they were easy to use and did not require consumers to learn a new system. The business telephone system boomed in the 1980s, and the status quo was PBX-style phone systems with dozens of functions and features. Motorola introduced its first cell phone in 1983, and because of limited hardware capacity, users could only place and receive calls. The phones did not permit call waiting, three-way calling, or even voice mail — they were

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simply a mobile implementation of an existing, familiar technology. In January 1985, two years after Motorola first offered commercial cell phone service, there were only 96,000 cell phone subscribers — a number that grew to 340,000 by the end of that year, according to the Cellular Telecommunications and Internet Association (CTIA). As adoption grew, cell phone ownership jumped from 5.2 million in 1990 to nearly 110 million in 2000.20 This widespread adoption can be attributed to focused and limited functionality within an easy-to-use, mobile form. High-Yield Orders + Simple Interface + Mobility = MPOE The lesson for the healthcare industry in these historical examples is clear: take only the most useful, high-yield functions from CPOE systems and make them easy to use on mobile devices. Presuming that such logic is acceptable, formidable questions still exist for vendors, hospitals, and industry regulatory groups wishing to successfully mobilize CPOE: What are the most useful, high-yield functions in CPOE systems? What are the features that make systems “easy to use”? How can a system integrate rapidly changing mobile technologies? High-yield Orders. Over time, healthcare has naturally developed processes to facilitate high-yield orders. For example, hospitals group together commonly ordered tests, because using such groupings is high-yield for operational efficiency. Physicians can then order “Coags” (pronounced “KOags” — several tests that measure blood thinness) or a “Liver Panel,” instead of ordering each lab test individually. Another example is a “care map order set,” which groups together multiple orders around common clinical profiles. Physicians can then choose “Post-CABG” (Coronary Artery Bypass Graft) orders for patients undergoing heart surgery instead of repeatedly entering the same group of orders for different patients. The Leapfrog Group confirmed the importance of high-yield orders in its December 2001 report titled “CPOE: A Look at the Vendor Marketplace and Getting Started,” by stating: “It is important to differentiate basic...functions that are relatively easy to implement but provide immediate value because they

Original Contributions apply to a large percentage of the orders written, from those that expand the scope of coverage to lower volume, highly specialized orders or add refinements to the delivery of decision support.” Simple Interface. Over time, vendors have adopted these high-yield orders as the “most useful” functions to be presented in CPOE systems. For MPOE, these must be further pruned down to orders that should be accessible via mobile devices and orders that are specific for that particular user. Even after identifying these high-yield orders, vendors must reengineer their display from workstation-based CPOE systems to accommodate the mobile form factor. Given that simplicity is the key to handheld use in any hospital environment, physicians are not likely to click through 15 screens on a 2” PDA display to make one precise order. According to Gartner Research’s Vice President of Research and Development Ken Kleinberg, intuitive completion of frequent orders and context-sensitive menus will help simplify order entry on handheld devices. Ultimately, users will judge ease-of-use success by demonstrating adoption while standing at the patient’s bedside, walking down corridors, or while eating in the lounge. Mobility. With the significant penetration of various portable devices and connectivity solutions, the healthcare user market has clearly preferentially adopted some mobile technologies. Leveraging highly adopted mobile technologies will facilitate integration of CPOE into this user market. One of the clear winners in clinician user adoption is the PDA. Importantly, the most successful PDA solutions have avoided trendy new mobile technologies, sticking with the tried-and-true “fat client” implementations with “intermittent connectivity.” In fact, such healthcare implementations have been cited as the “right” way to use mobile technologies to other vertical industry sectors.21 The wars will continue to rage between operating systems, connectivity standards, and devices — but successful systems will mobilize CPOE by migrating high-yield orders on simple interfaces that function on highly adopted consumer devices. Systems that successfully implement such a compromise will lead the way in the

industry in these historical examples is clear: take only the most useful, high-yield functions from CPOE systems and make them easy to use on mobile devices.”

the right time. Even a very limited MPOE system, if available to practitioners during their rounds, could increase workflow efficiency, shorten billing cycles, and — above all — improve the quality of patient care. High-Tech Hospital. The “high-tech” hospital has invested millions of dollars in its computing and data communications infrastructure. Clinicians already have CPOE systems and “bluetooth” enabled laptops. Nurses have wireless phones with ear buds and can talk to anyone in the hospital while they’re entering patient data into rolling laptop workstations. Even in this advanced hospital, MPOE can supplement CPOE by allowing physicians to enter simple orders that they use most frequently — such as care map order sets — when laptop or desktop workstations are not conveniently accessible. Practitioners don’t need a desktop computer to select the initial care map; a physician can use their handheld device to quickly choose from care maps in each discipline and transmit their selections in real-time over the wireless network. Even at the most technologically advanced hospitals, MPOE will be customized to facilitate high-yield orders. Physicians do not expect their handheld devices to have all the functionality of their sophisticated, desktop-based CPOE systems. Instead, they will want MPOE to deliver the flexibility to quickly enter these high-yield orders, such as care map selection, during or just after a patient visit.

Patient care can be jeopardized and millions of dollars can be lost each year simply because consults are not entered and billed in a timely manner, if at all. The critical order type that this hospital desires to automate — particularly through a MPOE system — is consults. If physicians could enter consult orders on handhelds, orders could get transmitted to the consulting practitioner and the relevant departments, enabling primary physicians to receive notifications and lab reports more timely. Medicare could also be notified on time and hospitals would know to appropriately bill for primary and consulting practitioners. At this hospital, “high-yield” means capturing consult orders and delivering those orders to the right departments at

Addressing Wireless Security Considerations Three essential ingredients — encryption, authentication, and data integrity — make up the recipe for a no-fail wireless security initiative, according to Ali Ersheid, vice president of Ecutel Inc.22 Encryption allows for the scrambling of data flowing between two data end points, thus making the information unreadable without specific decoding software. The industry standard calls for 128-bit encryption. This level of encryption provides a significantly greater amount of cryptographic protection than 40-bit encryption and is the standard used by the online banking industry. Authentication ensures that individuals

inevitable rise of mobile physician order entry (MPOE). Practical Examples of High-Yield MPOE What constitutes a high-yield order will change from one hospital to another, requiring vendors to fully understand and respond to the environment at each customer site. By considering two hypothetical hospitals, each one on different sides of the spectrum in terms of investment levels and technology experience, we can begin to see how MPOE systems can be adapted to play a critical role in regard to high-yield orders. Low-Tech Hospital. The “low-tech” hospital has a modest computer system created from old and new technology from many different vendors. Interdepartmental data flow is still the most significant issue.

“The lesson for the healthcare

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Original Contributions accessing wirelessly transferred data are permitted users. It requires users to register with the organization, be assigned an encryption key, and enter a valid personal identification number (PIN) when logging on to their handheld device. After users register with the organization from which they will be receiving data, an encryption key “opens” the encrypted data that is received from this organization’s server — allowing the receiver to view decoded data after a successful PIN log-in. Data integrity guarantees that the data stays reliable and accurate. Data integrity can be achieved by implementing encryption software; authorization controls, such as password protections and PINs; automatic logoffs, rules that cause a device to terminate after a predetermined time of dormancy or a series of unsuccessful login attempts; and integrity controls, mechanisms used to ensure the validity of the information being electronically transmitted. Handheld users should also be prevented from “beaming” protected health information (PHI) to another user. Understanding MPOE’s Relationship with CPOE By recognizing the importance of MPOE as a distinct product category, hospitals can implement MPOE systems to accomplish different goals depending on the stage of their overall “order entry” strategy. In different settings, MPOE may be most effective as a stand-alone system or as a separate, complementary system to an existing CPOE system. MPOE as a Stand-alone System. Based on recent studies performed by the California Healthcare Foundation, the American Hospital Association, the Leapfrog Group, and the Institute for Clinical Systems Improvement, the average cost to implement a CPOE system is $4.4 million in upfront fees with $500,000 in annual expenses.23 Shockingly, this is the average cost for a 200-bed single hospital, not for a large, multi-facility healthcare organization. Considering this cost profile and average hospital margins of 2 percent,24 CPOE systems remain largely out of reach. With such conditions, the only options for the vast majority of hospitals, unfortunately, are to have everything... or nothing.

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Hospitals who understand the distinct value of MPOE will be able to leverage the recent penetration of mobile data delivery systems. Such data delivery systems consistently demonstrate a high user adoption rate and enhance clinical workflow while costing an average of $250,000 in upfront fees with $50,000 in annual expenses.25 By appropriately adding MPOE functionality to a solidly adopted handheld enterprise-wide system, such as mobile data delivery, hospitals can achieve the majority of essential benefits in a comprehensive CPOE system at a fraction of the cost. In such circumstances, MPOE systems can be cost-effective and valuable stand-alone systems.

“With the high user adoption of simplified order entry in MPOE systems, hospitals can likely capture the majority of high-yield orders in a more timely fashion from handheld devices than from stationary workstations.” MPOE as a Complementary System. CPOE has existed for many years — the oldest facilities report 58 million to nearly 75 million orders26 to date — with more hospitals added regularly. However, even in environments with stable and comprehensive CPOE systems, MPOE systems fill a distinct and valuable role as the penetration of mobile technologies in hospitals is increasing. Hospitals must respond to demands for MPOE systems that provide a complementary avenue to place electronic orders. In fact, with the high user adoption of simplified order entry in MPOE systems, hospitals can likely capture the majority of high-yield orders in a more timely fashion from handheld devices than from stationary workstations.

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For example, in a hospital with “care map order sets” accounting for the most common disease profiles admitted to the facility, a hospitalist physician might choose the “Pneumonia” order set and immediately transmit it from the patient’s bedside — possibly trimming hours from the order capture process. As illustrated in the table below (figure 1), the core components of an MPOE system — highyield order sets, a simple interface, and mobility — make it invaluable in complementing existing CPOE systems with such efficiencies.

• • • • •

CPOE Computer Stationary Comprehensive Medical Record Episode of Care

• • • • •

MPOE Handheld Mobile High-Yield Patient Context Point of Care

Summary Mobile technologies and order entry systems are becoming significant and enduring fixtures in healthcare. While CPOE has proven to be extremely difficult to implement successfully — even with a pervasive, existing IT infrastructure — handheld devices have proven to be rapidly adopted and powerful technology tools. Although convenient to treat them as merely smaller computer workstations, handheld devices possess a unique culture of use and adoption that is very different from full-function computers. This distinctiveness equips handheld devices with the means to provide highyield order entry functionality to the mobile physician. It is possible that the high adoption of handheld devices will accelerate the adoption of CPOE through its implementation on such devices. This will only prove true, however, if the implementation is intentionally limited to high-yield orders through a simple interface on commonly used mobile devices. If, however, CPOE is not treated as profoundly different from MPOE, the likely outcome will not be accelerated

Original Contributions adoption of order entry, but rather an inhibited adoption of handheld devices. As the industry adjusts to new mobile technologies and the demand for order entry, MPOE will emerge as one of the most consequential changes in healthcare workflow over the next

several years. When physicians can and do enter their own orders for patient care — even if such orders are a fraction of the total possible orders — hospitals will realize the cost-savings and higherquality care only possible with high adoption of such systems.

References 1 Back Beats Survey. Healthcare Informatics, March 2002. 2 Kohn, L. T., Corrigan, J. M., Donaldson, M. S. (eds.). To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine, National Academy of Sciences, National Academy Press, November 1999. 3 Bates, D. W., Leape, L. L., Cullen, D. J., Laird, N., et al. “Effect of Computerized Physician Order Entry and a Team Intervention of Prevention of Serious Medication Errors.” JAMA, 1998, 280, 1311-6. 4 Bates, D. W., Teich, J. M., Lee, J., Seger, D., Kuperman, G. J., Ma’Luf, N., Boyle, D., Leape, L. “The Impact of Computerized Physician Order Entry on Medication Error Prevention.” JAMA, 1999, 6, 313-21. 5 Birkmeyer, J. “Leapfrog Patient Safety Standards: The Potential Benefits of Universal Adoption.” Leapfrog Group Reports, November 2000. 6 “The Possibilities of Wireless Healthcare.” Air2Web White Paper, 2001. 7 Flowers, L. State Responses to the Problem of Medical Errors: An Analysis of Recent State Legislative Proposals. National Academy for State Health Policy, February 2002. 8 Classen, D. C., Pestotnik, S. L., Evans, R. S., Lloyd, J. F., Burke, J. P. “Adverse Drug Events in Hospitalized Patients: Excess Length of Stay, Extra Costs, and Attributable Mortality.” JAMA, 1997, 277(4), 301-306. 9 Bates, D. W., Spell, N., Cullen, D. J., et al. “The Costs of Adverse Drug Events in Hospitalized Patients: Adverse Drug Events Prevention Study Group.” JAMA, 1997, 277(4), 307-11. 10 See reference 2. 11 Taylor, H., Leitman, R. Harris Interactive Health Care News. 1(25), August 15, 2001.

About the Author Alan Ying, founder and chief executive officer of MercuryMD, trained as a general surgeon at Duke University. He is an active educational speaker on hospital information systems, healthcare technology, and the burgeoning mobile systems market.

Waegemann, P. Mobile Healthcare: State of the Industry. Mobile Healthcare Association, January 2002. 13 Rishel, W. Physician Order Entry on Portable Devices in 2004. Gartner Research Note #SPA-14-066, July 2001. 14 See reference 11. 15 Wireless Ethernet Compatibility Alliance Backgrounder. Wireless Ethernet Compatibility Alliance Website. http://www.wirelessethernet.org/ pr/backgrounder.asp. 16 Davidson, J. O’Reilly Network, February 14, 2002. 17 Shim, R. ZDNet News, July 24, 2002. 18 Solovy, A. “Most Wired Hospitals Survey.” Hospitals & Health Networks, July 2002. 19 Sony web site. Corporate History, 2002. http://www.sony.co.jp/ en/Fun/SH/1-18/h4.html. 20 U.S. Census Bureau. Statistical Abstract of the United States. ISBN No. 003024-08863-1, January 24, 2002. 21 Adrian, B. Healthcare Provides Lessons for Mobile Financial Services. Gartner Research Note SPA-17-0376, July 2002. 22 Joch, A. “Wireless Watchdogs.” Healthcare Informatics, July 2002. 23 Scalise, D., Lazar, C. “CPOE: An Executive’s Guide.” Hospitals & Health Networks, July 2001. 24 Lovern, E. “Reaping Healthy Profits.” Modern Healthcare, December 2000. 25 Briggs, W. “Is the Future in the Palm of Your Hand?” Health Data Management, January 2002. 26 CPOE Implementation Case Studies. The Eleventh Annual PhysicianComputer Connection Symposium, Association of Medical Directors of Information Systems, July 2002. 12

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