Money has nothing to do with it.
At least that's the message put forth by a new report on what types of hospitals have implemented computerized physician order-entry systems, published in the November-December issue of Health Affairs.
Government, teaching and money-losing hospitals are more likely to have invested in CPOE systems, according to the report which was compiled by researchers at Harvard University in Cambridge, Mass., Ben-Gurion University in Israel and the University of Michigan Law School in Ann Arbor.
In a comparison of 751 hospitals in 19 states using self-reported data provided by the Leapfrog Group consortium of 130 large employers from 2002 through April 2003, only 4% had fully implemented CPOE systems and only 17% had made "good progress" toward doing so.
Among the types of facilities studied, teaching hospitals had made the most use of CPOE, with about one-third reporting at least making good progress toward implementation.
The researchers called the low implementation rate the most "troubling" finding in the report and the strong correlation of government ownership with CPOE the most surprising -- particularly because the government sample consisted of community hospitals and did not include federally owned facilities such as Veterans Affairs hospitals, which are well-known for their use of electronic medical-record systems.
The report states that government-owned hospitals are three times as likely to have satisfied Leapfrog's requirements for making a "good early-stage effort" toward CPOE implementation as not-for-profit hospitals and seven times more likely than for-profit hospitals. Also, teaching hospitals were about three times more likely than non-teaching hospitals to have done so.
Looking at the equation from a variety of angles, the researchers concluded that there was no correlation between net income per admission and CPOE implementation. They also concluded that neither net income nor system ownership has a positive association with spending on CPOE.
The cost of implementation can be significant. The report states that CPOE systems can cost from $3 million to $10 million to set up. The report cites a study which estimated that an urban hospital could expect to spend $8 million initially plus $1 million annually on CPOE. This equals a per-bed expense of $32,000 for set up and $4,000 annually for operation.
Although CPOE supporters say these systems lead to savings in transcription, patient charges, personnel time and malpractice costs, exact figures are not easy to calculate. The researchers, however, conclude that money was not the issue and that hospitals that had implemented CPOE were those that had made strong commitments to patient safety and quality improvement.
American Hospital Association Senior Associate Director for Policy Chantal Worzala said the study didn't necessarily correspond with an AHA information technology survey from this spring which saw a correlation between hospital revenue and CPOE use.
"We saw that money matters," Worzala said.
She added, however, that the AHA survey's finding that only 3% of hospitals were "advanced CPOE users" roughly matches the 4% figure given in the Health Affairs report.
Leapfrog Executive Director Suzanne Delbanco said the report's findings correspond with anecdotal but "unquantifiable" information she has received.
'A determined leader'
"Often, it doesn't come down to a financial decision," she said. "Usually, there is a determined leader at a hospital who says 'This is just the right thing to do.' "
Delbanco added that she has also heard of several instances where large employers have gone to a hospital that serves their employees and requested that CPOE be made a priority.
"Once you get over a certain threshold of access to capital, it comes down to a leader deciding to prioritize it," she said.
Worzala somewhat agreed but added that the health IT landscape has shifted since Leapfrog made CPOE a priority when the group was launched in November 2000.
"Implementing CPOE can be disruptive and you need to have physician champions and determined leadership to make it happen," she said. "CPOE was a specific focus of Leapfrog when it started, and a lot of hospitals have realized that CPOE is very important, but it's an end goal. You can't start there."
Worzala said hospitals IT implementation is done in "evolutionary" steps.
"Hospitals are adapting the pieces of IT that make sense for them," she said. "There's a lot of forward movement, but they're not jumping to the end goal right away."
Read the report abstract: http://content.healthaffairs.org/cgi/content/abstract/24/6/1654
What do you think? Write us with your comments at [email protected]