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Could Ten Percent Be About Right...?

July 17, 2009
by Mark Hagland
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I’m going to step out on a limb here and comment on the CPOE element of the revisions announced yesterday to the recommendations of the Meaningful Use Work Group of the ONC’s HIT Policy Committee, per the ARRA-HITECH funding (my colleague David Raths wrote an excellent blog report on the announcement of the overall revisions yesterday).

So here’s the thing: I think that whatever requirement gets set in stone regarding the 2011 requirements for CPOE as an element in meaningful use, would be criticized by one faction or another in the industry. Some will say that the 10-percent-of-orders requirement is far too weak a requirement; others, that any firm requirement for 2011 will be impossible for most hospitals to achieve.

I’m going to take a middle-of-the-road view here (or at least, what I consider to be a middle-of-the-road view!) and say that, in a situation that is going to require that we all accept imperfection to begin with (after all, this whole process is going to be like asking a thousand archers to try to hit a bull’s-eye on a moving target, I think!), 10 percent sounds more or less about right to me. Why is that?

Well, to begin with, just requiring some level of implementation of CPOE by 2011 will indeed be a rigorous demand for the majority of U.S. hospitals. For one thing, it means that, if this revised set of recommendations is solidified, the vast majority of hospitals will have to rush—and I do mean, rush—just to get their CPOE implementation to that level in time. In fact, if hospital CIOs around the country aren’t moving right now to budget for CPOE implementation and beginning at least the first stages of its planning (vendor evaluation, internal multidisciplinary working group planning and preparations, etc.), they won’t make it. And I’m talking about now, meaning this week or this month.

And yes, some might say the 10-percent requirement is too lax; but basically, what it does is to compel hospitals to get the core CPOE functionality live on at least one significant unit within a hospital. In my reporting on CPOE, I’ve found that the most common unit for hospitals to go live in is one of the ICUs, for a variety of reasons, including the smaller number of clinicians regularly working on that unit; the smaller number of patients; the close physician-nurse communications required in an ICU; and other clinical and operational reasons. In any case, if a hospital goes live on one significant unit or one floor, it means that at least an important portion of the groundwork has been laid for the ongoing rollout of a CPOE system.

What’s more, the feds will almost certainly raise that level for 2012, and thus, will be compelling hospitals forward in an important area.

My September cover story on CPOE will give HCI readers a look at what some of the CPOE pioneers have done to leverage the power of CPOE. What I can say now is that those organizations that are at least two or three years out on CPOE go-live (and thus by definition ahead of 90 percent of their peer organizations nationwide) have terrific stories to tell. All of those I interviewed for the September cover story approached CPOE not as an IT project, but as one strongly facilitative component in an overall drive towards improved patient safety, clinical care quality, and clinician workflow. And aren’t those the areas that all the purchasers, payers and policymakers want healthcare to move forward on, anyway? I’m glad that the feds are going to compel CPOE forward; and I hope they figure out a way to move the pace car forward at a reasonable pace, one that neither causes hospitals to fail through rushing nor lets hospital leaders think they have forever to get going. The right pace would also mean acknowledging the pressure that will be put on vendors and consultants to help hospitals implement so much, so quickly, en masse. There’s no perfect solution here, but with the right combination of carrots and sticks, the feds could maybe get the pacing of this whole thing just right after all.



Mark, in your September story, will you also be addressing ePrescribing? Would be great to get your input in this area too.

Thanks much for your additional excellent comments. You've read the policy committee's language more carefully than most! I agree completely with your comment (which amplified my earlier one) that most hospitals that haven't yet implemented CPOE will likely begin in the ICU. And I agree that the 10-percent-of-medicine-orders-with-EBMOS language could indeed help to provide clarity. And I also agree that this is a tremendous opportunity for content products and services vendors to prepare highly refined starter order sets. It's amazing how certain policy and payment thrusts can really move the industry forward. Thank you again!!

I still think that Ten Percent is about right.

That said, I've reviewed the matrix published by the policy committee last week and was reminded of some language:

the implication is CPOE with Evidence-Based Medicine Order Sets (EBMOS).

Achieving a CPOE start with a 10% goal of total orders, with EBMOS has planning and cost implications. I could imagine that organizations aiming for 10% would need to plan their initial CPOE around CHF patients being admitted to the ICU. A significant percentage of them will have Diabetes. I think that this focus can provide clarity. It's also an opportunity for the content products and services vendors to package very refined starter sets. At HIMSS 2009, every HIS vendor was offering the "shrink-wrapped starter set of content to get you live within 3 to 9 months of contract signing." I don't know that any of those were crafted around the goal of assuring TEN PERCENT orders as a deliberate focus.

I also readily acknowledge that the cross-HIS-vendor history of shrink-wrapped starter content has not been a pretty story. Hospital always have local needs that are not addressed by the package, be it acceptance, content completeness, of other factors. The Stimulus dollars do have the potential of providing a new kind of clarity, alignment and focus.

10 percent is far too weak.
Apparently many people still haven't heard the digital success stories at the VA and other stage 6 and 7 organizations.

It can be done, and it doesn't have to break the bank.

Ten percent could be exactly the right number ...

Three times in my career, 1996 with Cerner Classic CPOE, 1999 with Cerner HNAM CPOE, and 2002 with QuadraMed CPOE, I've worked with a team to bring up a nascent CPOE solution. In each case, the products are were not as strong as they are today.

Brining up CPOE is an orchestration. When a clinician enters orders electronically, they must be reviewed by nursing in the care unit taking care of the patient. So, there is a focused, location-specific set of things that has to happen on that location. The rest of the integrated delivery parts of the order life cycle needs to be addressed for the CPOE workflow. The amount of work to bring up and work out the kinks in one or two units is a lot of work. This could be managed with the goal of getting to 10% of a hospitals orders. It would represent a containable set of work, and much less work than the 50% or other percentage of order criterias that have been floated.

We all need to be cognizant that the subsequent rate of acceleration to get to 2015 will be significant.

So, Mark, I think there's a case. It wouldn't surprise me if those same units did concurrent work on clinical/nursing documentation in parallel. Also, it wouldn't surprise me if eRx was carved out, which means CPOE would not extend to discharge, ambulatory medications. My point is that, if we add caveats to the ten percent number, we could make it unachievable.

Green Leaves,
Thank you for your question. Unfortunately, I didn't have the space in the September cover story to cover ePrescribing specifically, but that is a topic that our publication will continue to publish articles on fairly regularly. And without a doubt, it's an extremely important subject, of course!

Joe Bormel,
Thank you very much for your extremely thoughtful comments! I think the points you bring up are very important and I think the arguments you bring forward make perfect sense. Of course, it doesn't hurt that you've supported by basic contention... :-) But one point you brought up I think really does speak to some of the thoughts I had had while developing my post, and that is that organizations bringing up CPOE over time will generally also be developing, on the same units on which CPOE first goes live, concurrent physician and nursing documentation capabilities. It only makes sense. So a gradual approach (but not a lazy one) on the part of the feds should help pull the industry along on multiple fronts, not just CPOE itself. Thank you again for your extremely thoughtful comments!