Despite five years of private-sector pressure on U.S. hospitals to install computerized physician order-entry systems, the number using such systems remains a small fraction of nonfederal hospitals, according to the latest counts of two key information-technology market watchers.
While some growth may have occurred in the penetration rates of CPOE systems, there also is a growing realization among information technology boosters that these costly and complex systems are very near the pinnacle of clinical computing, making universal adoption of CPOE far more a vision than a realistic expectation anytime soon. In contrast, the Veterans Affairs Department with 157 hospitals and the Defense Department with 70 hospitals have had electronic medical-records systems with computerized physician order-entry for at least a decade.
CPOE systems enable physicians to electronically order laboratory tests, scans, medications and other elements of patient care. The more advanced systems also incorporate artificial intelligence to alert physicians at the point of care to conflicting medications, potential allergic reactions and guidance on treatment protocols and advice using evidence-based medicine.
Over the past decade, more than a dozen scholarly articles have been published in support of the hypothesis that CPOE systems can reduce medical errors, a belief echoed by the Institute of Medicine in its seminal 1999 report, To Err is Human. Recently, however, several studies have been published suggesting that CPOE is a bullet not of pure silver; it has some potential for causing problems as well as solving them, including the possible introduction of medical errors. Most recently, researchers in Pennsylvania found that infant mortality rates rose after a CPOE system was deployed at the Children's Hospital of Pittsburgh. Those studies were assailed over their methodology and practically deemed outright heretical according to IT orthodoxy.
In 2004, KLAS Enterprises, which tests and rates IT systems, asked CPOE vendors for their customer lists. KLAS researchers followed up with interviews at every hospital the vendors named. Their report, released in February 2005, verified that 233 hospitals, or 4.1% of all acute-care hospitals not run by the Defense and Veterans Affairs departments, had CPOE systems. Only 144 of those hospitals used the systems extensively--processing half or more of all their clinical orders through them.
Further, just 11% of the 233 CPOE hospitals in the KLAS study had "closed loop" medication administration in which the order is tracked and checked from order initiation to patient administration, incorporating additional electronic tools such as bar coding or radio frequency identification tags. Nearly a third of those 233 hospitals, or 31%, had to re-enter medication orders at their pharmacies because their CPOE and pharmacy IT systems were not electronically interfaced, saidJason Hess, director of business development at KLAS.
Final results are expected next month on a follow-up KLAS survey using 2005 data. Vendors identified "more than 300" CPOE customers, Hess said, indicative of only modest CPOE growth.
In an early peek at selected results from the 16th annual Modern Healthcare Survey of Executive Opinions on Key Information Technology Systems, to be published Feb. 13, just 11.5% of 601 respondents indicated their organization had completed an enterprisewide CPOE installation while another 24.1% indicated that a CPOE implementation was under way.
Also using a survey approach, HIMSS Analytics, an arm of the Healthcare Information and Management Systems Society, asked hospitals to self-report their IT use in a number of areas. They came up with a figure that was even lower than the KLAS results regarding CPOE--about 2.5% of hospitals have installed the systems, according to Michael Davis, executive vice president of HIMSS Analytics.
Step by step
HIMSS Analytics has outlined seven stages in a clinical IT adoption "staircase" toward a fully paperless facility in which CPOE is but the fourth stage. Davis said that while few hospitals have stepped up to CPOE, far more are on the climb. Just 17% of hospitals have not reached the first stage toward full IT implementation: having computerized laboratory, pharmacy and radiology systems in place. But 22% of hospitals do have these fundamental systems installed and another 48% have achieved stage two, where these systems feed their information into a central, clinical data repository. Stage three--electronic clinical documentation of vital signs, nursing notes, care plans and medication administration records--has been achieved by about 10% of hospitals.
Beyond CPOE is stage five, a closed-loop medication administration system, which has been reached by "only a handful of hospitals," according to HIMSS Analytics. Stage six--in which physicians use computerized templates to fully document patient encounters--and stage seven--IT nirvana, a completely paperless hospital capable of connecting to other providers in the region through an information interchange--are so rare they didn't produce a reportable percentage.
"You gotta have the baseline systems like lab, radiology and pharmacy," Davis said. "Then a clinical data repository so physicians can get access to it and it becomes valuable." Next comes nursing, then CPOE, according to Davis.
"There may be other paths of implementation other than this model where the outcomes are as good as this one, but most of the presentations we've made to CIOs has been fairly favorable," Davis said.
"Going ... paperless, we're at least 15 years away from that, unless something changes drastically in the funding mechanisms for hospitals or the commitment for that kind of investment in IT," he adds. Also, "The will of the organization is an extremely important thing, even when hospitals have the money. There is nothing that scares IT executives more because you have to involve the physicians. When you have physicians who are community-based and the hospitals don't own the physicians, how do you get them to do this?"
Suzanne Delbanco, chief executive officer of the Leapfrog Group, the business coalition that more than five years ago targeted hospital adoption of CPOE systems as one of its first "leaps" to improve healthcare quality, described the slow pace of CPOE adoption thus far as "dismal," but refused to concede it was a leap too far.
Before Leapfrog got started, the healthcare industry had known for 10 years that CPOE systems were a factor in reducing medical errors, Delbanco said. Leapfrog focuses on 31 regions where its employer members have business interests. Because those employers are so large, the healthcare organizations that their workers use provide care to an estimated 55% of Americans, Delbanco said. About 2% of participating Leapfrog hospitals had CPOE in the beginning of the program and just 7% do now.
"I think there is some discouragement, but in every market where we've concentrated our efforts, there is at least one good story," she said.
"We're somewhat encouraged by the progress some folks have made in adopting other healthcare information technologies," Delbanco said. "We do know there are many other pieces to put in place before you get to CPOE. We knew it would require hospitals to do other things first that are also important."
Mark Crockett, a practicing ER physician at Morris (Ill.) Hospital and Healthcare Centers, doubles as president of the emergency-care division of software maker Picis, based in Wakefield, Mass. The company develops clinical IT systems, including physician order entry, exclusively for high-risk departments such as emergency, intensive-care, operating rooms and post-anesthesia units. The extremely complex and diverse needs of physicians across the healthcare setting remain formidable barriers to IT adoption, according to Crockett. An IT system that works well on a medical ward won't meet the needs of physicians in an emergency room or an outpatient clinic, which puts pressure on vendors, Crockett said.
"The small (IT development) organizations are feeling the pressure that they can't develop the kinds of things they need to develop, and the large organizations are finding it hard to be experts in everything," he said. "We're trying to be the best of a cluster in critical care. We don't have to understand the outpatient market, which is completely different. I think you're going to see more of that, vendors like Philips, whose core competency is in imaging and companies like Epic, whose core competency is in outpatient."
That said, according to Crockett, the adoption of effective CPOE systems across the hospital "is going to be completely dependent on the delivery of standards. If there is some sort of certification process (verifying) that your application can communicate with some sort of standard, then you'll have accelerated adoption." The efforts of the Office of the National Coordinator for Health Information Technology to coordinate IT communications standards development and certify vendors' products "are absolutely on the right track," Crockett said.
Tiny Citizens Memorial Hospital in Bolivar, Mo., is already well on its way. The system won a 2005 Nicholas E. Davies Award for IT excellence from HIMSS for deploying a clinical IT system that includes CPOE. Its 74-bed hospital is owned by a public hospital district; its five nursing homes with 476 beds are scattered across three southwestern Missouri counties and are owned by a not-for-profit corporation. All operate in a service area with only 80,000 people, said Denni McColm, chief information officer.
Planning for a clinical IT system to link the facilities together began in 2000; implementation started in October 2002, with labs and pharmacies going live that December. Physicians and nurses started using the system in the fall of 2003, with order entry beginning that December. Only the ER is still partially using paper.
The goal was not to launch CPOE or any other IT system, McColm said. "We did not say we were going to an electronic medical record or CPOE; we said the patient would have access to all their information across the healthcare system," she said. "We were separate entities. We were trying to bridge that and you can't do that with paper."
But of all the IT components, "The centerpiece really is the EMR that crosses the continuum of care," she said. "Each patient has only one record. When they (patients) come to the emergency department from one of the long-term-care facilities, the doctors can have access to everything about them, and when they go back (to long-term care), the nurses can see what the doctors are doing. It's been a big help."
McColm said the hospital spent $6 million, including hardware, software, staffing, training and travel, for the system by Meditech Information Technology, and the system is maintained by an IT budget that's 2.2% of Citizens' total expenses. At Citizens, McColm said, laughing, expenses and revenue are pretty much the same number. But money wasn't everything, she said.
"The thing that I think has made us successful is we've had visionary leadership here with the board, the CEO (Donald Babb) and the medical staff," she said. "We didn't try to sneak this in. We were very upfront. There was no big secrets, no hidden agendas. We were out soliciting how can we make this better and made an effort to solve problems proactively," an approach McColm advises other hospitals considering CPOE installations to adopt.
"If you run into a problem with physicians, call a meeting," she said. "It will be painful, because they're bargaining from a strong position." But she urged perseverance.
"Our guys and ladies would no way go back," McColm said.
What do you think? Write us with your comments at [email protected].