Is computerized physician order entry ready for prime time?





Is computerized physician order entry ready for prime time?

Purchasers are pushing hard for hospitals to adopt computerized physician order entry (CPOE). The systems provide an effective, albeit expensive, means of reducing the number of deaths from prescription errors.

CPOE refers to a variety of systems that share the common features of automating the ordering process. Basic CPOE ensures standardized and legible completed orders by accepting only typed orders in a standard and complete format. But, experts say, more effective—and even more expensive—CPOE systems address errors in all four components of the medication-use cycle: prescribing, dispensing, administration, and monitoring.

The issues

CPOE systems eliminate illegibility and sharply reduce ordering errors and contraindicated prescriptions, but they are not without their critics. Some physicians resent the technology, some hospitals are intimidated by the cost, and some experts wonder why currently available systems are not adequate and why the money shouldn't first be spent on unit dose bar-coding, an established technology.

Bar-coding of unit doses of medication improves patient safety at the administration stage of hospital prescribing. The Veterans Health Administration is implementing unit-dose bar-coding in its 172 hospitals, and its system is simple and fairly universal. Patients wear bar-coded wristbands. An attending nurse scans a bar-code on a blisterpack dose of a prescribed drug and scans the patient's wristband. Prescription information has already been entered into a centralized database. If the medication is the wrong drug or dosage, the nurse is immediately notified through a handheld device.

"No one is against CPOE," said Mark Neuenschwander, president of The Neuenschwander Co., a prescription automation consulting firm in Seattle. "But hospitals have limited resources. Bar-coding is less expensive, less complex, and a more mature technology, so we suggest hospitals place their resources in developing those systems first. CPOE is many times more expensive and takes time to implement. Bar-coding is something we can do immediately."

Neuenschwander admits, however, that even bar-coding has its problems. "Too many meds lack standard coding, and I think we're going to need federal regulation before we're down to bar-coding on single doses by manufacturers." He said he believes code standardization and single-dose bar-coding will become virtually universal within the next couple of years, and that, overall, bar-coding still offers "a more mature technology than CPOE, at a lower cost."

"While bar-coding can be implemented right away by a hospital, is less expensive, and the technology is more readily available, CPOE addresses lots of errors that can't be addressed with bar-coding," countered Michael Cohen, president of the Huntington Valley, Pa.-based Institute for Safe Medication Practices. A good CPOE system includes a patient database and laboratory information, so it "doesn't just help prevent the wrong dose. It provides information, about allergies, contraindications, and any other issues that might result in an adverse drug reaction, right back to the doctor at the point of ordering. We need both CPOE and bar-coding."

Studies show that about half of med errors occur at drug ordering, said David Bates, M.D., chief of general medicine at Harvard's Brigham & Women's Hospital in Boston and a leading advocate of CPOE. A mega-analysis of medication errors suggests that integration of CPOE with clinical decision support systems (CDSSs) further reduces medication-related errors. Bates added that effective CPOE/ CDSS integration includes suggestions or default values for drug doses, routes, and frequencies; drug allergy checks; drug-drug interaction checks; drug-laboratory value checks; reminders about corollary orders, such as glucose checks; and drug-use guidelines.

CPOE systems capable of slashing the number of adverse drug events (ADEs)—currently estimated at three deaths per 1,000 patients and occurring in up to 30% of hospital admissions—are already on the market, say proponents. "CPOE solutions for the hospital have evolved considerably," according to a report on CPOE vendors by the Leapfrog Group, a Washington, D.C., coalition of about a 100 employers who are pushing hard for adoption of the systems nationwide.

At the beginning of the year, according to Leapfrog, there were 13 CPOE products being sold or in development. "The number of options is increasing," said Suzanne Delbanco, Leapfrog's executive director, "and the clinical tools available in CPOE systems keep expanding. We anticipate that by 2003, hospital and vendor experience will probably triple."

The case for CPOE

The Leapfrog CPOE initiative has been widely supported by purchasers since it was announced in 2000, and health plans are starting to get on board. In June of this year, Blue Shield of California in Chico, Calif., announced changes to its tiered reimbursement cost-reduction incentive plan, which also evaluates hospitals for quality, based on Leapfrog's three safety measures: the staffing of intensivists (physicians specializing in intensive care), reporting to consumers on the volume of patients treated for certain high-risk conditions and procedures, and CPOE.

In New York, five employers—IBM, PepsiCo, Verizon, Xerox, and Empire Blue Cross & Blue Shield—are paying bonuses to 10 hospitals that have installed or are installing CPOE. The hospitals are paid up to 4% extra when they treat any of the 100,000 employees, retirees, or family members from the sponsoring companies.

CPOE advocates say the systems are cost-effective. Brigham & Women's implemented a computerized prescription program in 1997, at a cost of $1.4 million, with an annual maintenance cost of $500,000. It is credited with catching 400 ADEs or potential ADEs a week out of 13,000 medication orders, said Bates. According to a General Accounting Office study, ADEs cost about $2,000 each, so "the system pays for itself almost weekly," he said.

Leapfrog estimates that if CPOE were used in all the nation's nonrural hospitals, about 522,000 serious medication errors could be averted each year. Researcher John D. Birkmeyer, M.D., an assistant professor of surgery and community medicine at Dartmouth Medical School, said that even a very conservative estimate of CPOE effectiveness results in a 55% medication error reduction rate. "If only 0.1% of medication errors are fatal, over 500 deaths could be avoided every year. If the fatality rate were 1%, over 5,000 deaths would be avoided," said Birkmeyer.

As of now, however, fewer than 15% of the nation's 5,800 hospitals have partially or fully implemented CPOE systems. An ASHP survey of the pharmacy directors of 1,050 acute care hospitals, published in 2000 and entitled "ASHP National Survey Of Pharmacy Practice In Acute Care Settings: Dispensing and Administration," reported that 13% of hospitals had an electronic medication order entry system in place, while an additional 27% were in the process of obtaining such a system.

Today, following public pressure by Leapfrog and other purchaser coalitions, that number is probably higher, said James Stevenson, Pharm.D., director of pharmacy services at the University of Michigan Health System in Ann Arbor and associate dean of the university's college of pharmacy. He said his system is examining CPOE, as "just about everyone is now. CPOE has the potential to solve a lot of problems."

The other side

"CPOE systems can improve many aspects of medication safety, including the timeliness of communications between physicians, pharmacists, and nurses," Stevenson said. "But the systems are not a panacea. Not every [medication safety] problem is solved, and some new problems are created."

For example, he continued, while removing the significant safety issue of prescription illegibility, CPOE can create problems associated with the similarity of medication names. "Physicians have to pick the names of the medications they choose from a list, often in alphabetical order, and the names of many medications look very much alike. So while you've addressed the illegibility issue with CPOE, you still have the possibility of selection errors," he said. Thus, even in hospitals that have CPOE, "pharmacists still have to review prescriptions." The importance of the pharmacist in the medication use cycle is not diminished through CPOE technology, he contended.

Another issue with CPOE, said Stevenson, is its complexity—and physician resistance to systems that require frequent data entry. "Physicians won't tolerate too many decision-support steps," he said. "The people I've spoken to who are implementing the systems say that right now, they have to turn off many decision-support steps and not use much beyond allergy notification. The big issues are cost and complexity, which lead to a wide variety among vendor options. Right now, you can't point to one system and say, 'That's the perfect system.'"

Although many hospitals are looking at CPOE, the pace of implementation is slow, compared with what proponents would like to see happen, and the main reason is that adequate systems are expensive. The cost varies widely, relative to a hospital's size and the complexity of the system. Hardware and software estimates run from $1 million to $5 million, plus millions more for customizing, staff training, and maintenance, said David Classen, M.D., an internist who works for the First Consulting Group of Long Beach, Calif., and helps hospitals choose computerized systems. Total costs for large, fully integrated systems can reach $60 million.

In spite of the costs, some states and the federal government are encouraging hospitals to proceed.

California passed a law in 2000 that calls for all hospitals to implement a formal plan, such as the use of CPOE, to eliminate or substantially reduce medication errors by Jan. 1, 2005. Other states are considering similar legislation.

CPOE proponents would like Congress to offer federal tax credits or other incentives to hospitals that purchase the systems in the name of increasing patient safety. Congress is considering the idea.

The Medication Errors Reduction Act, introduced in the Senate on May 3, 2001, calls for the provision of just under $1 billion over the next decade to help health facilities pay for new technologies to decrease medication errors. It authorizes $97.5 million per year for 10 years for grants to hospitals and skilled nursing facilities to purchase or lease new computerized medication tracking systems or improve existing technology and to provide education and training for staff. Systems funded by the grants would include automated prescribing programs that intercept errors as drugs are initially prescribed; electronic medical records systems; automated pharmacy dispensing systems; and bedside verification programs, including bar-coding.

As of July 2002, the bill was stalled in committee, like much of the nation's healthcare legislative agenda since Sept. 11, 2001. In June 2002, Sen. Edward Kennedy (D, Mass.) introduced a bill calling for $100 million in funding for CPOE systems in federal matching grants. The bill, entitled "Efficiency in Health Care (eHealth) Act of 2002" (S. 2638), was referred to the Committee on Health, Education, Labor, & Pensions, where it remained as of July.

Some employers and health systems, including some Leapfrog members, have shown a willingness to fund CPOE systems. Blue Cross Blue Shield of Alabama is seeking volume discounts on CPOE systems for its member hospitals, and HMO Illinois and Aetna Inc. have agreed to offer hospitals financial incentives to comply with Leapfrog principles.

But, potential funding notwithstanding, several hospital officials have complained publicly that the Leapfrog initiative promoting CPOE is too expensive. "The general feeling among community hospitals is that they should proceed carefully," said Suzanne Corrales, editor of Inside Healthcare Computing, which recently surveyed several community hospitals on the viability of implementing CPOE. "They know the systems can do the job and offer the possibility of saving lives, but they see implementation as a tall mountain to climb."

Some physicians, too, are resistant to CPOE, said Corrales. "No matter how you slice it, sitting down to enter data into a system takes longer than writing a prescription," she said. "The question doctors have is whether the payback is great enough for the extra time involved. Physicians are notorious for being protective of their time."

Community hospital officials and physicians also appear to resent being pressured into adopting CPOE, claimed Corrales. "Many feel they are being pressured by purchasers and health plans to spend money they don't have now, when a few years from now, better technology will be available at a lower cost," she said.

The case for bar-coding

Neuenschwander agreed. "The bar-code technology is here now, and it's not nearly so expensive and does not have nearly the resistance among physicians. In any case, it may soon be a required system for any hospitals receiving federal dollars, which nearly all do," he indicated.

Bar-code scanning technology is advocated for national use in community pharmacies by the National Coordinating Council for Medication Error Reporting & Prevention, in Rockville, Md., a coalition of 20 health-related organizations. In July 2001, the coalition called on the Food & Drug Administration and United States Pharmacopeia to establish uniform bar-code standards to help prevent medication errors. The drug industry lobbying group Pharmaceutical Research & Manufacturers of America, in Washington, D.C., supports the national council's initiative.

Any regulatory requirements for bar-coding would have to be implemented by the FDA. In December 2001, officials of the Department of Health & Human Services said they are considering such regulations. HHS estimates that using bar codes to track and dispense medication could save as much as $11 billion in reduced medical errors. The FDA proposal calls for bar codes to include medication properties and expiration dates, "allowing doctors to more quickly and accurately determine which drug and how much of it is best for the patient," said Assistant U.S. Health Secretary Bobby Jindal. He suggested that the FDA's bar-code requirement could be in place by the end of the year.

"We think this is what will happen," said Neuenschwander, "and it's a very positive step. CPOE is a great idea, but bar-coding technology is here, ready, and affordable. It would be a shame if the strong interest surrounding CPOE kept us from implementing something we can do today for something we want to do tomorrow."

Martin Sipkoff

The author is a healthcare writer in Gettysburg, Pa.


Martin Sipkoff. Is computerized physician order entry ready for prime time?.

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