The Landscape: It's not just the push to obtain federal funding under the ARRA-HITECH legislation that's driving a burst of CPOE implementation of late; it's the realization on the part of CIOs and other organizational leaders that CPOE really is foundational for progress in improving care quality and efficiency.
The Future: The image of CPOE is rapidly being transformed. Clinician leaders and CIOs see the technology as a vital tool in eliminating unnecessary and problematic variation in care, and in spurring data analysis for quality and patient safety improvement going forward. The challenge, as many hundreds of hospitals move towards CPOE in order to qualify for meaningful use under ARRA-HITECH: can they all implement successfully?
When computerized physician order entry (CPOE) was first rolled out in hospitals, it was frequently derided by many as “turning doctors into order entry clerks,” and criticized for adding precious minutes to physicians' daily tasks. But more and more, hospital leaders are recognizing the true value of CPOE - as a foundational technology for data analysis, the standardization of physician practice, and quality and patient safety improvement initiatives. In addition, in the past several years, the technology itself has steadily improved. So with hospitals nationwide scrambling to achieve meaningful use under the ARRA-HITECH Act, CPOE - a technology famously difficult to implement - is becoming an industry-wide litmus test for clinical IT implementation. And CPOE-pioneering CIOs are urging their colleagues forward.
“I think that computerized physician order entry has become an emblematic term and milestone for electronic health record adoption,” says Tim Zoph, vice president and CIO at the 873-bed Northwestern Memorial Hospital in Chicago. “That's been shored up by the Leapfrog standard, which has long maintained CPOE as a core patient safety measure. That was one of the first signals. And now Leapfrog has a measure around effective use of CPOE, such as sufficient dose-range and drug-allergy checking, to make sure you're using your system safely. So we're at one of these inflection points in the adoption of electronic records that says you've arrived.”
According to David Liebovitz, M.D., medical director for clinical information systems and associate chief medical officer at Northwestern, the benefits of CPOE are becoming clearer as hospitals move beyond implementation. “For hospitals that have successfully implemented CPOE, very little will happen without an electronic order that is very specific, with elements completed,” he says, noting that the technology has been in place at Northwestern for several years. “So already, this standardizes the entering of orders for nursing, lab, pharmacy, and so on. And once that's in place is when the real potential benefit becomes possible.” He says that involves using clinical decision support and alerts intelligently, and drilling down to enrich the features embedded in CPOE at deeper levels.
“One potential pothole along the path is assuming that if something is used, it will actually be used,” Liebovitz says. “For example, he says, an organization could develop a community-acquired pneumonia order set, while maintaining a scenario in which that order set has to be explicitly looked up. “In that situation, the physician would have to search for the specific community-acquired pneumonia (CAP) order set rather than defaulting to ad hoc ordering. So CPOE might exist, but we have to get to the next step.” So, he says, if a patient has an elevated white blood cell count from a chest X-ray, “the system should serve up the CAP order set as a first choice. The power of the system is in making sure the right orders are entered at the right time.”
The path to that level of order entry optimization is inevitably challenging, Liebovitz says. However, he notes that resources are becoming increasingly available to help facilitate the path, including Web sites offering free downloadable order sets. Specialty medical societies and numerous other groups have made order sets available in a variety of care areas as well.
What the trailblazers learned
Leaders at hospitals and health systems that have successfully implemented CPOE say there are several lessons they've learned that can benefit those in the early stages of deployment. One piece of advice is to make sure senior executives are closely involved, says Ferdinand Velasco, M.D., vice president and CMIO of Texas Health Resources, a 14-hospital, 3,700-bed system based in Dallas-Fort Worth. “Another major lesson has to do with the manner in which you engage physicians,” he says. “In a community hospital setting like ours, unlike an academic setting, you simply can't dictate to physicians to use the system. So it really involves getting the physicians on board, finding champions, and getting physicians to be partners with us.”
Once that's done, says Ed Marx, Texas Health Resources senior vice president and CIO, the challenge is to derive real benefit from the implementation. For Marx, this means harnessing the power of automated order entry to help fuel clinical business intelligence and transform care delivery. Organizations are usually very proud when they reach 30 percent of standardized order sets, Marx says. His, he adds, is somewhere north of 60 percent. “The higher that number goes, the higher the clinical quality and efficiency in the utilization of implants and other supplies.”
As for the difficulties involved in implementing CPOE in a community hospital setting, Todd Rothenhaus, M.D., senior vice president and CIO of six-hospital Caritas Christi Health System in Boston, says those may be a bit exaggerated in some people's minds. “Fundamentally, community hospitals really aren't that different,” says Rothenhaus, who in addition to his CIO duties, still devotes a small number of hours a month to practicing as an emergency physician at Caritas Christi. The bigger challenge, he says, is the variability of results when implementing commercial CPOE products in different community hospitals. “CPOE potentially has the ability in a community hospital setting to have an even greater impact on patient safety and quality,” he says, adding that having an electronic hospital allows physicians to be more attentive to the needs of the patients. “They can be in the office, and looking at the patient's chart, without having to drive into the hospital.” The same kind of logic has become apparent in the PACS space over the past two decades, he notes.
Quality improvement, turbo-charged
Like most CIOs who have implemented CPOE, Rothenhaus extols its benefits for data analysis and quality improvement. “We're looking at metrics for patients whose medications have been barcoded, and we've been looking at CPOE-entered orders and have been tracking adverse events,” he says.
At Summa Health, a five-hospital, 2,060-bed health system based in Akron, Ohio, System Vice President and CIO Greg Kall says, “CPOE is indeed a platform, and it allows you to do things you can't do as easily in a paper-based world. We view it here at Summa as a tool: there's this great marriage between information technology and quality that allows us to help move our quality agenda forward.”
Charles Ross, M.D., Summa's vice president and CMIO, says that while there are some technical aspects that are important in successful CPOE implementation, the vast majority of elements are process changes that lead to the end-point, which improved care quality. “That, to me, is much more important than checking a box and saying you've done it, and now you want your money from ARRA-HITECH,” he says firmly.
The pioneers say in the end, ARRA-HITECH legislation is only accomplishing what should have already been happening - an industry-wide acceleration in CPOE adoption. Caritas Christi's Rothenhaus says one day in the future, leaders across healthcare will understand that CPOE is an infrastructure that allows for serious and continual process improvement. “I think if you flash forward just five years from now, using paper to write orders will be an anachronism.”
Healthcare Informatics 2010 February;27(2):16-18