Although healthcare delivery organizations have long talked about and promoted the quality of care they deliver, for the most part they have not been held directly accountable for measuring, improving and reporting that quality. Instead they have focused far more attention on reducing costs and maximizing reimbursement. Consequently most organizations have invested heavily in administrative information systems and much less so in clinical information systems.
However, this reality is beginning to reverse itself. Healthcare organizations are faced with a new era of clinical accountability-and perhaps even a future of "no outcome, no income"-in which financial reimbursement will be dependent on clinical outcome reporting and improvement.
Perhaps the best example of this shift is the rapid movement of healthcare organizations toward computerized physician order entry. CPOE represents an ongoing and perhaps permanent shift of focus in information technology toward the clinical side of the house.
It also represents a point of no return: Numerous hospitals have learned that once the computer-based approach is implemented, their staff physicians, nurses and other clinicians will not tolerate going back to the older paper-based approach.
At one time CPOE was an arcane, primarily academic undertaking without widespread application or interest among healthcare delivery organizations-or for that matter among health information technology vendors. However, despite its great cost (both for the technology and its successful implementation), CPOE is now the leading information technology initiative for many healthcare delivery organizations.
Much has changed in the world of clinical information systems as vendors race to provide properly configured and well-implemented computerized order-entry systems. When physicians write medication orders using these systems, they can receive real-time alerts regarding dangerous drug interactions, dosing adjustments and a host of other information to help them avoid writing incorrect orders.
CPOE offers other potential benefits including:
* Savings through reductions in duplicate testing.
* Closer adherence to formulary limits.
* Preferential selection of less-expensive medications.
* Increased adherence to therapeutic pathways.
* Significant time savings for nurses and pharmacists.
It is for these and other reasons that stakeholders both within and outside of healthcare are targeting industrywide implementation of CPOE as a primary objective to improve the quality of hospital care.
The Leapfrog Group, representing a coalition of employers that purchase health benefits for one out of every 10 Americans, has made CPOE one of three quality-improvement mandates that it is promoting nationally. Health insurers are increasingly focused on the Leapfrog standards including CPOE; recently a large health insurer agreed to increase reimbursement to hospitals that meet the Leapfrog safety standards, including CPOE.
Why is the use of this computer assist so low today, given its apparent value for improving the safety of drug use and reducing costs associated with adverse outcomes? Implementing CPOE is a costly undertaking; hospitals must spend millions of dollars to achieve broadly utilized, highly functional systems. But the single most important obstacle is that implementing CPOE is a monumental organizational challenge. Success requires an organizationwide commitment, including participation and championing by multiple administrative and clinical leaders.
Organizational structure and culture affect the success of CPOE. And both the operational capacity of the information systems group and the organization's current technical infrastructure have profound implications for an organization's choices and priorities when pursuing CPOE. It's not just another information systems project. It represents a fundamental shift that requires clinical leadership for success, not just clinical cooperation, which has been the sine qua non of many previous information technology projects in healthcare organizations.
The Leapfrog Group is not the only driver of this ongoing move to CPOE and clinical information technology. Indeed, a series of reports outlining the new era of clinical accountability have come from the Institute of Medicine, the medical component of the National Academy of Sciences. The IOM's reports on the quality of healthcare in America have fueled an ongoing debate about serious problems facing the U.S. healthcare system.
One of these reports, titled Crossing the Quality Chasm: A New Health System for the 21st Century, outlines strategies for attaining substantial improvements in the quality of healthcare provided to Americans in the next 10 years. It states that "information technology must play a central role in the redesign of the healthcare system if a substantial improvement in quality is to be achieved over the coming decade."
The use of information technology is advocated to support clinical processes; in particular, the report emphasizes pairing information technology and clinical process innovation and the development of new models that integrate technologies into an infrastructure that ensures system interoperability. This report outlines a new framework for measuring quality of care, which can be defined in six ways: safe, clinically effective, timely, patient-centered, equitable and efficient. These six principles will form the basis for an annual report card on the quality of healthcare in the U.S. to be produced by HHS beginning in 2003.
Akin to the index of leading economic indicators, this report will contain specific clinical quality performance metrics in each of the six categories outlined above. These performance measures are defined in the latest report issued by the IOM titled Envisioning the National Healthcare Quality Report, which outlines the government's approach to measuring the quality of care delivered in the U.S.
This latest report, which received the least attention, represents the greatest potential impact on healthcare organizations as it outlines specific performance metrics in healthcare quality that operationalize clinical accountability. Multiple avenues exist that will enforce this new reality, including: reimbursement (health insurers, employers, Medicare and Medicaid), regulation (the Joint Commission on Accreditation of Healthcare Organizations and the National Committee for Quality Assurance) and licensure (by the states).
Computerized physician order entry represents the tip of the iceberg for the emerging role of clinical information technology in helping healthcare organizations adapt to and thrive in this new era of clinical accountability. Healthcare organizations will need to invest more broadly in clinical information technology to be able to measure, track and report the detailed clinical performance metrics outlined in the IOM's National Healthcare Quality Report.
In the past, the survival of delivery organizations was based on their ability to maximize reimbursement and minimize cost. In the not-too-distant future, that survival will be based on their ability to measure, report and continually improve the quality and safety of the care they deliver.
David Classen, M.D., is a vice president with First Consulting Group, a Long Beach, Calif.-based healthcare information technology consulting firm. He is a member of the Institute of Medicine's committee charged with developing a national healthcare report card, and his research at Intermountain Health Care, Salt Lake City, was among the first to demonstrate the role of clinical computerization in systematic care improvement.