The ideal of computer-based clinical decisionmaking is alive and well. But the realities of tight money, bulging project lists and competing capital priorities are intruding more than ever on the prospects of putting the ideal into practice anytime soon.
Healthcare executives are grasping the concept of a clinical information network as a many-layered sequencing of perhaps dozens of separate IT initiatives, all building toward the goal of locking efficiency and patient safety into the processes of physician ordering and diagnostic duties.
But that long and expensive quest leading up to the clinical IT end game of physician-oriented computer order entry has put the game in a different light, according to results of Modern Healthcare's 14th annual survey of information systems trends.
Executives polled in this year's survey are even less inclined than respondents were a year ago to commit to a physician order-entry initiative. Just like last year, one in four respondents said they were operating or in the process of implementing a system in which physicians enter orders and are alerted to possible adverse consequences of a drug or treatment (Feb. 10, 2003, p. 6). But only 26% of those without such a system had plans to purchase one within the year, compared with 40% in 2003.
And unlike last year, half of the polled executives opting against the project say the money is not there to pay for it. Only 17% in the 2003 survey said lack of money factored into the decision to wait.
Respondents in 2003 mainly blamed physician resistance and the demands of complying with federal privacy and administrative simplification requirements of the Health Insurance Portability and Accountability Act of 1996. Without HIPAA to hang onto as justification for sitting it out, more executives pinned the blame on lack of cash.
"The focus on cost is a result of the fact that many IT leaders and their organizations investigated the path towards (computerized physician order entry), confirmed its complexity and long implementation time," says Michael Kreitzer, president of Michael H. Kreitzer and Associates.
Healthcare's ultimate measure of sophistication for clinical decisionmaking requires a host of prerequisite capabilities to make it successful, from bar-coding systems for medication administration at the bedside to new infrastructure to support wireless communication between data systems and mobile computers carted around by clinicians, says Rich Marreel, principal of R. Marreel and Associates.
The work represented by computerized physician order entry "is kind of like a moon shot for healthcare (IT departments), and a lot of them are still trying to build a launch pad," Marreel says.
Divvying up the dollars
The competition for capital funds to make headway on the IT checklist is getting tougher. More than half of surveyed executives who don't see a physician order-entry project in their near future say other capital spending is higher in priority. Although the survey doesn't ask them what's competing for capital cash, consultants interviewed by Modern Healthcare all say an industry construction boom is laying claim to a big chunk of what's available.
"For the first time, I'm seeing more bricks and mortar than I ever have before," says Stephen Furry, an Indianapolis-based partner with PricewaterhouseCoopers. A surge of hospital-system expansion, from new nursing units to new specialty facilities, is vacuuming up capital dollars needed for IT projects.
Opinions on trends explored in the survey, sponsored and administered by PricewaterhouseCoopers, were those of senior managers of healthcare delivery systems. Questionnaires mailed out in November 2003 were accepted from respondents through mid-January.
The survey drew 185 respondents representing 266 hospitals with a total of 38,000 beds, for an average of 143 beds per hospital.
Of the executives responding, 35% were chief executive officers or administrators, 25% were chief financial officers, and 16% were chief information officers or directors of information services. Chief operating officers accounted for 11% of respondents, and the rest held titles such as chief medical officer or chief nursing officer.
The sample size was smaller than in previous years. As a result, some of the questions-particularly those with many possible answers-were less meaningful than in the past because they split the response into small numbers. But overall, the results in areas such as clinical IT priorities and financial commitment were in line with trends of the past several years and held up against the field experiences of consultants interviewed by Modern Healthcare.
Most notable was the continued slow slippage of spending on IT operations. Surveyed organizations this year planned to spend an average of 2.23% of their total operating budget on information systems, declining only slightly from 2.31% last year but edging further away from the typical weighted-average spending range of 2.5% to 2.6% that had prevailed during the previous five years.
Respondents chose from nearly a dozen spending ranges, from flat budgets to increases of more than 5%. A weighted average was calculated by multiplying the midpoint of each spending range by the percentage of respondents selecting each range.
By comparison, the survey's weighted average of the proportion of capital-budget allotments spent on IT assets was 16%, and one in four surveyed organizations plan to spend more than 20% of capital on IT projects in their current budget year.
"It appears that our industry leaders still cannot adjust to the axiom that the more IT an organization has installed, the more it must invest in support, enhancements and improvements," Kreitzer says.
Though the commitment of capital is crucial to making progress in areas of clinical efficiency and patient safety, the survey's results signal a mismatch between planning new initiatives and managing what's installed or anticipated, he says.
Construction vs. computerization
Hospitals may be more inclined to acquire than fully manage their IT, but the level of projected capital spending still does not bode well for the ambitions of vendors seeking to sell new-era technology to the typical U.S. hospital, Furry says.
There might be a silver lining for IT capital budgeting, however, and it's tucked within the line items of construction projects outwardly competing for available money, he says. Project designers, aware of the importance of clinical computerization at the start, are including the hardware and software to make it happen.
That provision for IT in the context of new construction improves the prospects for technology improvements while under-representing the amount spent on IT assets, Furry says. In that scenario, expenses are an integral part of the construction budget rather than allotted under the capital budget.
Consultant Marreel has grappled with the dual priorities of IT and construction firsthand since last August during a temporary contractual assignment as interim CIO at BryanLGH Medical Center in Lincoln, Neb. The two-campus hospital system, he says, has "a huge building program going on"-adding beds to inpatient facilities, building a new emergency department and constructing a mental health facility.
The medical center also has ambitions of computerizing all clinical operations at its two acute-care sites, a separate campus for ancillary services and the new buildings on the way. Marreel says one of the goals set for increasing efficiency and improving clinical support involves consolidating specialties to avoid duplication at more than one campus and being able to move patients from one site to another without discharging and readmitting them.
That goal can be achieved only by upgrading information networks and integrating dozens of separate computer applications, he says. By assembling the information needed to build an electronic medical record, IT pros will give clinicians what they need to practice anywhere in the healthcare system.
But the need for additional patient-care capacity is just as acute as the need for IT improvement, Marreel says. With a $180 million construction initiative in full swing, BryanLGH financial managers slapped a ceiling on all capital-budget requests when plans for 2005 spending got under way last July. In previous years IT planners "got what they asked for," but the IT capital budget for the coming year had to operate within limits-it ended up at 22% of total capital expenditures, he says.
However, the building program was not included in capital calculations; it's funded and accounted for separately. In addition, the construction funding includes all the investment needed to make the new emergency department ready for an electronic medical record and computerized physician order entry, Marreel says.
A network to support wireless communications, meanwhile, is expected to be completed throughout the BryanLGH system by the end of the summer. "That's a critical component to getting into CPOE," Marreel says, adding, "That's not a minor capital expense for the organization."
Computerizing order entry for physicians is "the ultimate goal, but there are so many things that need to be done first," he says. Just making existing information available generally to all clinicians will require 32 interfaces for installed computer applications.
To complete the picture of electronically displayed data, the IT department will have to plan for and install new information systems to plug holes in the documentation of care necessary for safe and effective decisionmaking, he says. One example is medication administration to patients, a base covered by bar-code techniques to identify patients and drug doses at the bedside and record what drugs are given and when. A system of that type is set to start operating in 2005. Similar project sequences at hospitals nationwide are shoring up IT infrastructure so that when physician order-entry and decision support projects are proposed, the organizations will be ready for the demands represented by such an initiative, Furry says.
The lead time involved in upgrading and preparing for the challenge is likely one factor affecting the sparse count of physician order-entry implementations among hospitals, he says. Much of the activity leading up to a commitment is submerged until a healthcare system actually surfaces to declare itself ready to consider a purchase, Furry says.
Preparatory activities, including projects to capture key elements of the medical record electronically, have continued to be high priorities in the past several surveys-reflected broadly in oft-stated top IT priorities and specifically in classes of IT projects gaining support.
For example, clinical information systems were identified, for the sixth straight year, as respondent organizations' top priority related to developing integrated delivery systems, followed by clinical communications and links to physicians. The only priority to intrude on that 1-2 finish during the past five years was last year's No. 2 ranking for HIPAA requirements on the eve of federal compliance deadlines.
Asked about their top IT project priorities during the next 24 months, respondents again said improved patient-care capabilities were their top priority, followed by improved productivity and improved clinical decision support. Except for HIPAA and Y2K spikes and a flirtation with Internet technology as a cure-all a few years ago, the same three clinical and productivity priorities have prevailed for the past six years.
Filling out the picture
The long track record for the same priorities fuels the conclusion that hospital executives "are attempting to slowly move down the road towards CPOE-executing these priorities will be the first steps," Kreitzer says.
Along the way, some electronic capabilities that once were not well understood in the larger scheme of amassing crucial data have shot up in priority.
Third this year behind the perennial 1-2 integrated-network priorities of clinical IT and physician links was the capability to store, retrieve and transfer diagnostic images across a healthcare system. That priority was fourth last year, the first time it was offered as a selection.
Hospitals are not just talking about it. Electronic transfer of diagnostic images has moved steadily up a list of 11 key projects that respondents have completed or are in the process of implementing in the quest to build a computerized patient record.
The diagnostic-image project was in operation or being installed at 49% of surveyed organizations in this year's survey, ranking it second in product adoption. Last year, the adoption rate ranked fourth; in 2002, fifth; in 2001, eighth; and in 2000, 10th.
Viewed skeptically in the late 1990s for its multimillion-dollar cost and elusive value, the project hasn't gotten any less expensive but gradually has proved to be important to the clinical goal of presenting all the information doctors need to make decisions, Furry says.