Computerized physician order entry systems have been around for years. Although advocates say the technology is crucial for boosting patient safety and health care efficiency, relatively few physicians seem to use it.
CPOE systems automate the process of ordering medications, medical procedures and tests. The Leapfrog Group, which promotes health care quality and safety, reported last year that only 10 percent of the hospitals it surveyed had fully installed such systems. The organization said the adoption rate had slowly progressed since 2002, when it reported full CPOE deployment among only 2.5 percent of the hospitals it surveyed.
Health information technology watchers cite a number of reasons for the slow growth, but most of them center on the sobering price tag.
However, recent developments could spark greater use. In Massachusetts, a research initiative has presented a business case for deploying CPOE systems, and payers nationwide are now seeking to link hospital reimbursements to the use of electronic orders.
Even hospitals that find a way to pay for the systems face significant workflow changes. However, they could draw on the experience of earlier adopters to ease the learning curve. For example, the Veterans Affairs Department deployed a CPOE system around 2000 as part of its Veterans Health Information Systems and Technology Architecture (VistA). Since then, VA officials said health care organizations in the United States and other countries have asked about their experience.
The financial angle The prospect of spending $1 million or more on a CPOE system has deterred some health care organizations from pursuing the technology.
“The financial concern is one of the barriers that exist to implementation,” said Mitchell Adams, executive director of the Massachusetts Technology Collaborative. “It’s not that hospitals do not have access to those funds. All hospitals have a capital budget. The problem is [that] the competition for those dollars is fierce.”
The group seeks to break down the barriers to adoption and launched the Massachusetts Hospital CPOE Initiative with that goal in mind. The program released a report in February that addresses the financial aspects of CPOE installations.
In “Saving Lives, Saving Money: The Imperative for CPOE in Massachusetts Hospitals,” researchers examined six community hospitals. They reviewed 4,200 charts and found that the average baseline rate of preventable adverse drug events was 10.4 percent. They concluded that a CPOE system, in conjunction with clinical decision support, could substantially reduce such incidents.
Furthermore, within 26 months of deployment, the average hospital could receive payback on installation costs and reduce operating costs by $2.7 million a year. That figure is based on an average upfront investment of $2.1 million and annual operating costs of $435,000.
Those results could help hospitals justify the expense of CPOE systems, Adams said.
“If you only had the safety and quality arguments — and didn’t have this very attractive payback — it’s a harder decision to make to implement,” he said. “This way, it’s not that bad. You’re going to get your money back.”
Meanwhile, payers are encouraging the adoption of CPOE systems by offering financial incentives that involve a bit of the carrot and the stick. Blue Cross Blue Shield of Massachusetts informed hospitals in February that they will be required to use CPOE systems to participate in the company’s incentive programs beginning in 2012. Adams said the incentive will amount to 10 percent of a hospital’s revenue.
To hospital officials who are still hoping to avoid CPOE adoption, Adams said: “The dollars you would leave on the table would be unacceptable. We think Massachusetts hospitals are going to be very serious now about this.”
Elsewhere, Pennsylvania’s Medicaid program has made adoption of a CPOE system or bar code medication administration tool a measure in its pay-for-performance program, according to a 2007 Commonwealth Fund report.
Implementation issues The potential for organizational disruption represents another obstacle to adopting CPOE systems. And changes in physician workflow could prove particularly thorny.
CPOE deployment “takes a lot of energy and requires physicians to do things differently,” Adams said. “That’s a tough sell.”
“Historically, what’s happened is these systems have had challenges being time-competitive,” said Dr. Don Rucker, vice president and chief medical officer of Siemens Medical Solutions’ U.S. operations.
Another obstacle is the lack of trained employees. Dr. J. Marc Overhage, director of medical informatics at the Regenstrief Institute, said few people understand physician workflows, have worked with nursing professionals and understand the technology.
The problem is particularly acute at rural hospitals, community hospitals and small physician practices. “There is nobody there who has the training [or] the time to drive that kind of change,” Overhage said.
Adams said the Massachusetts Hospital CPOE Initiative offers implementation support in the form of workshops, symposia and reports on best practices.
“Hospitals don’t have to reinvent the wheel,” Adams said. “It’s been done.”
The VistA case VA’s VistA is a case in point. Its Computerized Patient Record System includes order entry. After CPRS went live around 2000, VA began measuring the extent to which providers entered orders electronically, as opposed to writing them or phoning them in.
At the VA San Diego Medical Center, direct electronic orders hit the 90 percent range by mid-2001, said Dr. Robert Smith, the center’s associate chief of staff for health care analysis.
Gail Graham, director of health data and informatics at the Veterans Health Administration, said the 90 percent mark was eclipsed by 2004, and VA no longer tracks that performance metric because the rise to compliance was so rapid.
VA officials said a strong technical infrastructure, the involvement of clinicians and developers’ willingness to customize the system were important factors in making CPOE adoption successful. Furthermore, a hospital must have enough computers to give providers ready access to the system.
“A lot of the timeline is building the infrastructure,” Smith said. He added that the San Diego center had about 200 computers in 1997 but now has about 2,700.
Moreover, CPOE systems require significant workflow changes. The San Diego center conducted a time and motion study and found that when physicians used the first version of CPRS’ application, it took them 20 percent to 25 percent longer to enter orders electronically than manually.
Officials consulted with their provider community to refine the system. Teams of clinical application coordinators worked with various groups to shape the order-entry feature.
One tweak involved creating menus to display preferred antibiotics for conditions such as urinary and upper respiratory tract infections.
By using a collaborative approach, CPOE systems can take 20 percent to 40 percent less time than paper-based ordering, Smith said.
“Some level of customization is necessary to make it more powerful for the clinicians,” said Graham, who added that all VA medical centers now have clinical application coordinators.
The San Diego center’s deployment is an example of what all VA sites went through during the automation process, Smith said. Although the task of deploying such systems can be painful, the patient safety benefits are undeniable.
For hospitals that have yet to deploy such systems, Smith had this to say: “It’s worth the pain.”
Government Health IT presents Rick Friedman, director of the division of state systems for the Center for Medicaid and State Operations with the U.S. Department of Health and Human Services, in this recent eSeminar regarding how the federal Centers of Medicare and Medicaid Services is partnering with state Medicaid and health and human services officials to bring Medicaid into the digital age. Paul McCloskey, Government Health IT editor, moderates.
