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CMIO: Some Hospitals ‘Have No Plan’ For CPOE Implementation

September 4, 2013
by Rajiv Leventhal
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Many challenges remain for the majority of hospitals to move forward with CPOE
Delanor Doyle, M.D.

Recently, the Medical Center of Central Georgia (MCCG), a Macon, Ga.-based 637-bed, full-service acute care hospital that serves 750,000 residents in the central and southern regions of the state, tapped healthcare information technology consultant HCI Group to assist with implementing its computerized provider order entry (CPOE) project as part of its overall transition to electronic health records (EHRs).

MCCG, which is the second largest hospital in the state, initially started processing orders in the computer in 2007. They were diagnostic, not medication orders, however; the hospital began transitioning to medication orders in 2011, at which time, the conversion to CPOE began.

Prior to federal mandates coming down (Stage 1 meaningful use requires that more than 30 percent of unique patients with at least one medication in their medication list have at least one medication order entered using CPOE; Stage 2 requires more than 60 percent of medication, 30 percent of laboratory, and 30 percent of radiology orders created during the EHR reporting period are recorded using CPOE), MCCG felt that this transition would allow for fewer medical errors, ultimately increasing patient safety, says Delanor Doyle, M.D., CMIO at MCCG. “But once the laws changed, we knew we had to do it, and it became a more time-sensitive project,” Doyle says.

MCCG’s CPOE implementation plan involved completely re-building the pharmacy catalog, to ensure a smooth and successful transition. Before going live, HCI Group performed pre-optimization to prepare the system for provider use and provided on-site technical support throughout the go-live of the new technology. It has been about four months and a few weeks since the transition has been completed, and 64 percent of all medication orders are currently being electronically entered. Prior to that, the number was closer to 20 percent, says Doyle.

Unfortunately, MCCG is in the minority when it comes to CPOE adoption. A 2011 report from the Orem, Utah-based KLAS stated that at the time, between 20 and 25 percent of U.S. hospitals were live on CPOE. “That means you’ve got thousands of hospitals out there that aren’t live on CPOE, and the majority of those need to be. They don’t want to be impacted by meaningful use penalties,” said Colin Buckley, strategic operations manager with KLAS Research and co-author of the report.

“If that [20-25 percent] number is true, that is really sad,” says Doyle. “But for many health systems, I think CPOE is a big challenge. I have talked to people who have no plan for CPOE, and that’s amazing to me at this point. You will incur penalties very quickly. In this era of shrinking reimbursements and value-based purchasing, the bottom line is getting more and more difficult to maintain, so it sounds to me like organizations are making a decision to throw in the towel. That might be contributing to the [statistic] we keep hearing about— one-third of hospitals will be closing by 2018.”

Indeed, in a 2010 survey by the College of Health Information Management Executives (CHIME), more than half (52 percent) of CIOs said their biggest concern was getting clinicians to enter orders into their CPOE system to meet thresholds stipulated by meaningful use objectives. Overall, 62 percent of respondents said they expect some level of difficulty ahead regarding CPOE implementation.

The challenges with CPOE happen to overlap with a rise in the technology's use—the global market for CPOE systems is likely to reach $1.5 billion by 2018, according to a 2012 report by Global Industry Analysts, with the U.S. predicted as the fastest growing market. However, the report said usage still remains low thanks to a lack of commitment and interest from physicians. It found that sporadic incidents of errors from the CPOE systems and other user errors have affected the physicians’ trust in these systems, which threatens further increases in adoption. In addition, the report’s authors said, initial prices of these systems remain prohibitively expensive.

Doyle wholeheartedly agrees with the report’s findings, and sees these issues as tough to overcome, especially for smaller hospitals. “Some hospitals simply don’t have the resources. Small hospitals choose not to invest in IT infrastructure and training. Some of them are not electronic at all, and are still doing everything on paper except for pharmacy. You’re going to tell them that now you have to jump from [paper] to an electronic system in terms of documentation as well as order entry? Well many of them just don’t see how they are going to do that.”

These hospitals might only have a part time IT person or outsource IT to a small company, Doyle says. “But either way, they feel incapable of getting it done. They are hoping for funding, or outside help, or maybe the law will be relaxed, or maybe someone will come and buy them, allowing for access to capital. I think all of those things are in play for these smaller hospitals.”

In fact, continues Doyle, many in the industry are hoping and praying that there will be pushback or a grace period regarding CPOE requirements. “There are questions about safety and proper policing, and there are people organizing an in attempt to influence lawmakers to relax the mandates a little bit and allow for a delay. We have seen a number of initiatives that have been pushed back for a number of years,” acknowledges Doyle.

And despite the apparent benefits of CPOE systems—a 2009 study by the Massachusetts Technology Collaborative and the New England Healthcare Institute concluded that CPOE systems could save hospitals up to $2.7 million a year, compared to a cost of $2.1 million for implementation and $435,000 for annual maintenance—Doyle also agrees with the notion that there is simply not enough physician buy-in when it comes to it.

“In the physician community, there has not been significant buy-in,” he says. “It will take retirement of a number of physicians, and we do know we will lose several in the next few years to death, disability, or retirement. The average age of physicians in Georgia is 55, so we’re top heavy. The more we get physicians coming into [the industry] with computers in their hands, the better.”

At MCCG, Doyle said his strategy was to be upfront and honest with the physicians, explaining to them that nobody will work faster than they did pre-CPOE right away. Some people get back to the same level of productivity after a year, and for others, it might take 18 months, he says. “I dispelled these myths and rumors that said ‘if you’re going to make me use this, it has to be designed so I work faster.’ That part hasn’t come yet and won’t come for years down the road. You’re not going to be faster; rather, you will probably be slower. I had to tell them that. I even went to administration and told them to expect to see a decrease in revenue because we were going to be slower and it was going to take time. I think they understood it when I put it in those terms, and that’s a good thing, because ultimately, CPOE is going to have to be physician-led and physician-driven in a lot of places.”

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