Ever since the Institute of Medicine (IOM) published "To Err Is Human: Building a Safer Health System" in November 1999, pressure has been mounting for hospitals and clinics to implement computerized physician order entry (CPOE) systems to improve patient safety. The highly publicized IOM report concluded that medical errors kill as many as 98,000 people and cause complications in one million hospital patients every year.
Ultimately, CPOE will be used for all diagnostic and treatment orders from physicians. However, most of the immediate interest in CPOE is focused on its ability to reduce medication errors.
While many agree that CPOE systems can eliminate such errors, the technology hasn't been widely adopted because it's complicated, expensive, and can take years to implement. So far, just over 3 percent of hospitals use CPOE systems, according to a recent study by The Leapfrog Group, the coalition of Fortune 500 companies and other large healthcare purchasers that has jump-started the patient safety movement.
Nevertheless, CPOE "is coming to a hospital near you," says Thomas Yackel, MD, associate medical information officer at the Oregon Health & Science University (OHSU) in Portland. "Hospitals presumably are paying lots to put these systems in, and there will be enforcement of the use of these systems."
Indeed, The Leapfrog Group found that 30 percent of hospitals plan to implement CPOE by 2004, and some hospitals are making its use mandatory. For example, when Cedars Sinai Health System in Los Angeles launched its CPOE system in mid-2002, it required doctors to demonstrate their ability to use the system or risk losing hospital privileges. And a new law gives California hospitals and clinics until Jan. 1, 2005 to eliminate or substantially reduce medication errors, implying widening use of CPOE.
Proven benefits
A study in the September/October 2002 issue of the Journal of the American Medical Informatics Association (JAMIA) concluded that CPOE can be an effective tool for improving the delivery of healthcare. The results, from Ohio State University (OSU) Hospitals and The Arthur G. James Cancer Hospital (The James) in Columbus, Ohio, determined that their CPOE and electronic medication administration record (eMAR) systems, "enhanced patient care by improving turnaround time, reducing transcription errors, and improving verbal order countersignature by physicians," along with other positive findings.
According to Hagop Mekhjian, MD, lead author of the study, "The objective was go to an electronic medical record, not for its own sake, but to meet the needs of quality care in a multi-hospital system with physician clinics and satellite centers. Integrating all parts of the medical record was essential in providing complete information for all care," he says. "One of the crown jewels was physician order entry."
The scope of CPOE
But CPOE isn't simply about replacing paper orders with electronic ones. Unlike order communication tools, which simply capture and transmit orders, CPOE uses rules-based logic to provide relevant information at the time of the order, which helps physicians make appropriate ordering decisions. That's why CPOE requires organizational restructuring that addresses existing information technology (IT), physician workflow, and integrating the processes and technologies of other entities, such as pharmacy and laboratory.
The problem, according to Don Rucker, MD, vice president and chief medical officer at Siemens Health Services, is that "typically, IT departments won't get as much doctor input as they need. IT departments need to understand that it's process engineering, not just software installation."
In most cases, physicians will be required to adopt new clinical workflow procedures and use new computer workstation interfaces, voice recognition units, or data entry units similar to personal digital assistants (PDAs). The first step toward success, Rucker says, is that physicians must agree to work online. Then they must be involved in the design, implementation, and support of the system to ensure that the CPOE application fits the clinical workflow.
To guarantee that physicians took an active role in its system design, OSU Hospitals established teams of physician consultants who signed a contract that outlined their responsibilities. In exchange, medical and administrative leadership empowered the doctors to approve system design and operational policy. The method was such a success, that other hospitals are copying it.
"We are looking to 'hire' physicians in our practice for this purpose to have dedicated time to work on the issues involved," says OHSU's Yackel. "This will likely take from two to four hours per week during the design and implementation phases of the project."
Positioned for success
In response to pressure from patient safety advocates and payers, large urban academic hospitals generally have been among the first to install CPOE systems. Most community hospitals are in the planning stages while they try to secure funding. Typically, once hospitals have their systems in place, they extend CPOE to satellite facilities and physician offices.
