Computerized physician order entry was a futuristic curiosity when it was first rolled out in the early '70s at El Camino Hospital in Mountain View, Calif.
The first CPOE system in a U.S. hospital was developed as part of a pioneering collaboration between the Silicon Valley hospital and defense contractor Lockheed Corp., which had missile and aerospace facilities in nearby Sunnyvale.
Three decades later, CPOE became a cause celebre when the Business Roundtable, a coalition of large corporations, formed the Leapfrog Group to push for healthcare improvements. Leapfrog soon made hospital adoption of CPOE one of the first three goals, called "leaps," of its public-reporting program.
An early Leapfrog survey in 2001 showed that just 21 of 425 hospitals responding had functioning CPOE systems.
Meanwhile, that summer, the American Medical Associations House of Delegates presented a resolution telling members to exercise "extreme caution with the Leapfrog Group and other business coalitions to avoid implied and unintended concurrence with the recommendations of such groups." An AMA committee said the Leapfrog standards were "unsubstantiated by research (and) implemented without regard to the potential for disrupting clinical practice."
As recently as 2004, physician and hospital executives still viewed CPOE as both costly and risky and "a stretch for most hospitals," according to a report by the Center for Studying Health System Change.
Today, some 34 years after the U.S. debut of CPOE at El Camino, a majority of respondents to Modern Healthcare's annual IT survey still say they are not using CPOE, but it is now the narrowest of majorities.
Asked whether their organization has a CPOE system either in operation or being implemented, not quite 51% of respondents to our 2006 survey said "no," but that was down from 57% who said no in the 2005 survey and from 68% in 2004.
Of those without CPOE in our 2006 survey, 56% indicated they planned to implement a CPOE system within 12 months, up from 38% of readers in the survey the previous year.
In the 2005 survey, not having enough money was the most often cited barrier to CPOE implementation. In 2006, it was other budget priorities, not cost per se, as the most-cited reason their organization hadn't purchased and installed a CPOE system.
"We have some statistics to share with you that are similar in nature but are a little bit less rosy," says Suzanne Delbanco, chief executive officer of the Leapfrog Group, which measures CPOE use.
In comparison with Modern Healthcare's Survey of Executive Opinions on Key Information Technology Issues results, Leapfrogs numbers are a lot less rosy when it comes to the percentage of hospitals adopting CPOE systems, but the upward trend of CPOE penetration rates is similar in both surveys.
Modern Healthcare's survey relies on its readers to self-define CPOE and does not set criteria for the systems as Leapfrog does. In contrast, to be eligible for a Leapfrog listing as CPOE-compliant, a facility must pass 75% of all orders through its CPOE system, the system must alert physicians of possible errors, and require and record physician responses if an alert is overridden. Hence, the nation's first CPOE system as initially installed at El Camino wouldnt pass muster with Leapfrog today.
"It's much more rigorous than saying, 'Do you have CPOE?' " Delbanco says.
At the end of 2006, 6.7% of hospitals (87 of 1,295) that reported to Leapfrog about their CPOE status claimed compliance with the groups standards. Thats up from 5.7% (69 of 1,204) in 2005 and the 3.6% (41 of 1,143) that reported compliance at the end of 2003, according to Leapfrog numbers.
"We have seen steady growth," Delbanco says, adding that another 8% of hospitals reporting this year say they will have attained CPOE compliance with Leapfrog standards by the end of the year.
To further verify compliance, Leapfrog plans to launch a Web-based CPOE evaluation tool to test how effectively a hospital's CPOE system intercepts serious errors, Delbanco says. The tool was developed with initial funding by the federal Agency for Healthcare Research and Quality. "It's as close as you're going to get to an outcomes measurement tool," she says. "They'll be given scenarios and will report back which errors were intercepted and which weren't. The whole thing can be done in a few days."
The tool's Web interface and the test scenarios are done, she said, but so far there's no date set for deployment of the CPOE evaluator, which will be incorporated into the Leapfrog compliance program sometime in the future.
"We're looking for a host and a business model to support it," Delbanco says. "We don't want there to be a barrier to using it on the part of the hospitals."
More than five years ago, Trinity Health, a Catholic healthcare organization based in Novi, Mich., that now owns or manages 46 hospitals across nine states, embarked on a $300 million, groupwide program of clinical IT system adoption.
Today, systems are up and running in nine of 18 districts in the Trinity group, but they represent only about 40% of the capacity of the healthcare system, and installations at many of the larger Trinity hospitals are upcoming, with the last "go live" not scheduled until the end of 2009.
All of the systems running have CPOE, says Trinity President and CEO Joseph Swedish, who started at Trinity in January 2005, and thus inherited the IT program already under way.
"Right out of the gate, we mandated 100% compliance," Swedish says, noting his predecessors "made the commitment to go into the deep end of the pool. Believe me, it's not without its challenges."
But Swedish insists the gutsy call was the right one to make; he says CPOE isn't too far a reach for hospitals but rather an essential component in a healthcare IT system to maximize patient benefits.
The systems have been hooked up to a central data repository that Trinity has been able to use to begin developing its own evidence-based order sets and alerts, Swedish says. "We're tremendously committed to CPOE."
Having a few installations under its belt has helped speed up the process and reduce problems, with preparations beginning a year in advance at hospitalscalled healthcare ministries at Trinitythat are scheduled for an IT upgrade.
"We've developed a prescriptive model that every ministry must adopt pre-go live," Swedish says.
Richard Rydell, president and executive director of the Chicago-based Association of Medical Directors of Information Systems, or AMDIS, was recruited in 1970 by John Gall, the chief information officer at El Camino, to help implement the pioneering Lockheed CPOE system at the hospital.
"We were way ahead of our time back in those days," Rydell says. "We didn't have any computers at the hospital; they were all at Lockheed."
Rydell says the early system was crude by today's standards, noting it purged itself of data every three days.
"It had no permanent record," he says. "After the patient was discharged, it had to go to paper." But nurses loved the system and physicians grew to tolerate it. "There were always a few who had complaints, but the complaints were always valid."
At first, there were other early adopters of clinical systems following in the footsteps of El Camino, Rydell recalls. New York University and the Medical College of Virginia were "not far behind." But, to Rydell's surprise, CPOE simply did not catch fire and gain wide acceptance.
Vendors have been part of the adoption problem, Rydell says. "Companies sell real well, but the reality of what they're selling isn't always what they are delivering. But if you stick with it, you can get what you want and there are happy customers out there."
As much as anyone, though, Rydell blames greed and the lack of courage by the largest hospital consulting firms and hospital leaders for the slow progress of CPOE.
"The guys that control the way things happened in hospitals were the Big 8 or Big 6 accounting firms," Rydell says. "In addition to doing the audits, they were the key people who gave advice to CEOs and CFOs about major systems change. The last thing they (the advisers) wanted to do was lose a client by getting involved in a sticky situation with their medical staff. They just promoted the installations that involved the financial systems. It was a selfish way of doing business that made them rich. You can also blame the CEOs and CFOs because they didnt want to take it on. Now, its become a popular thing."
Rydell attributes the consciousness-raising to a combination of individuals and groups that include physician informatics organizations like AMDIS, the Institute of Medicine and the Leapfrog Group.
"I am not surprised we don't have that many adopters yet," he says. "It's only been recently that it's become mainstream to do this and it's become accepted by the medical community. It just takes a long time."
This story initially appeared in the Feb. 26 edition of Modern Healthcare magazine.
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