CPOE is much more than computers - Managing Change - computerized physician order entry

Physician Executive, Nov-Dec, 2003 by Donald Levick, David O'Brien

IN THIS ARTICLE ...

A prominent hospital in Pennsylvania turned to CPOE to help reduce medical errors and improve patient care. Learn what steps hospital officials took to establish a successful CPOE system.

In the wake of the groundbreaking report, "To Err is Human," by the Institute of Medicine (IOM), hospitals are struggling to find ways to improve the safety of our health care delivery system.

Documenting as many as 98,000 deaths every year from avoidable medical errors, the report cites information technology as an important tool to reach the goal of cutting medical errors in half by the year 2005.

When implemented effectively, computerized physician order entry (CPOE) systems can enhance the quality and efficiency of patient care and help prevent harm. CPOE is technology that creates a non-ambiguous order, permitting integration of decision support into order generation and supporting timely order implementation. (1)

To reduce errors, CPOE must be tightly integrated into a clinical information system that provides easy access to complete patient information. The best CPOE systems also provide clinical decision support and real-time access to current medical knowledge.

IT challenges

Efforts to implement information systems in clinical settings are not always successful. (1,2,3,4)

Reed Gardner, PhD, a prominent researcher in the use of information technology (IT) in health care, says the success of a health care IT project "is perhaps 80 per cent dependent on the development of the social and political interaction skills of the developer and 20 percent or less on the implementation of the hardware and software technology." (6)

CPOE implementation is particularly challenging because it requires major change in physician workflow. Change of this magnitude is not accomplished by simply deploying the technology. (7) As a result, despite solid evidence of its benefits, CPOE is deployed in only about five percent of hospitals nationwide. (8)

CPOE is not new. Several forces that recently converged fueled intense interest in the topic. In addition to the IOM report, other CPOE drivers include:

* The Leapfrog Group

The Leapfrog Group is a consortium of industry leaders including AT&T, IBM, General Electric and General Motors that are leveraging their combined health care purchasing power to drive improvements in health care safety. Leapfrog members agreed to make health care purchasing decisions that favor organizations focused on patient safety, and placed major emphasis on CPOE. To be "Leapfrog certified" a hospital must demonstrate that its CPOE system can intercept at least 50 percent of common serious prescribing errors. (9)

* Legislative pressure

In 2000, California passed legislation requiring health care facilities to adopt a plan for reducing medication related errors by 2005, including "... computerized physician order entry or other technology that has been shown effective in eliminating or substantially reducing medication related errors." (10)

California is not alone. Since 1999, more than 100 bills addressing health care safety have been introduced in 26 states. (11)

* Cost savings

There are significant financial incentives for hospitals to deploy CPOE. Leapfrog estimated that savings from reducing preventable adverse drug events (ADEs) range from $180,000 annually for a 200-bed hospital to $900,000 for a 1,000-bed hospital--a total of $370 million for all US hospitals. (12)

CPOE implementation case study

Most studies demonstrating that CPOE can reduce errors have been performed in academic medical centers. In these settings, the house staff who enter the vast majority of orders are residents and interns dependent on the institutions to complete their training. Use of CPOE is a condition of employment.

By contrast, in a community hospital where most of the physicians are in private practices, the hospital cannot mandate compliance in the same way. Instead, community physicians who are resistant to the change can admit their patients where CPOE has not been implemented or simply refuse to use the system.

Let's take a look at a successful CPOE implementation in a community setting. Lehigh Valley Hospital and Health Network (LVHHN) is a large complex health care organization based in eastern Pennsylvania, with 720 beds across three community hospitals and an active staff of 750 non-employed physicians who enter 60 percent of all inpatient orders.

LVHHN uses information technology extensively to support clinical and administrative processes that improve the quality and efficiency of care. In planning the implementation of its CPOE program, the hospital's senior management rose to the challenge of convincing a predominantly independent medical staff to embrace CPOE.

Establishing CPOE leadership

The commitment to CPOE at LVHHN originated at the highest level of the organization. In response to the IOM report, the board of trustees instructed the CEO and administrative leadership to expand the existing patient safety program to include reducing medical errors through the use of CPOE.