CPOE adoption sluggish, but guidelines are coming

In the information age, harmful mistakes from illegible prescription orders were to be reduced with the adoption of new electronic ordering systems. Although it was expected to sweep the country, partly because of growing national concern over patient safety and futuristic technology, implementation of computerized provider order entry (CPOE) systems is low, and rising healthcare costs threaten to detour hospitals from making the investment.

Despite studies that demonstrate how the technology reduces medical errors, only 4.2% of hospitals nationwide have implemented CPOE systems, according to an ASHP survey. The hospitals that have taken the plunge say the investment has paid off in delivering safer health care. Published studies have credited the systems with reducing medication errors by as much as 81%. But there are still no research studies documenting how the systems actually reduce adverse drug events and impact patient safety.

CPOE is much more complex to implement than originally anticipated, and the shortfalls, rather than the success stories, have been more widely publicized. Cedars-Sinai Medical Center, Los Angeles, decided in 2003 to suspend its system after physicians protested it was too slow and cumbersome to use, and the hospital has no plans to implement a new one.

The resources required for CPOE have been a barrier to adoption of the technology. The American Hospital Association, along with First Consulting Group, reported in 2003 that for an average 500-bed hospital, a system would cost about $7.9 million. To operate on an annual basis, CPOE systems cost about $1.35 million for upkeep and regular maintenance. Experts estimate that the cost of purchasing the system accounts for only about one-fourth the cost of implementation and utilization because additional personnel are usually required to manage the system.

"There continues to be a lot of interest in implementing CPOE; however, many health systems are probably more realistic about the costs of implementing these systems now than they were four years ago," said Douglas Scheckelhoff, M.S., director, pharmacy practice sections, ASHP. "As hospitals have seen others go through challenging implementation processes, they have realized that it is going to take significant commitment, time, and resources to do it right."

Scheckelhoff added that ASHP is currently developing guidelines on the selection, implementation, and maintenance of CPOE systems that will be completed next year.

Electronic ordering

Introduced about two decades ago, CPOE systems were designed to transform paper-based prescriptions into computerized orders sent directly to the hospital's pharmacy. The systems were heralded as the solution to eliminating handwriting or transcription errors, reducing adverse drug reactions, and ultimately improving patient safety.

CPOE systems have caught on in some small hospitals, but largely at major teaching medical centers. Brigham & Women's Hospital in Boston, for instance, put its own system in place in 1992 and has since rolled it out to several other hospitals in its network.

The technology has evolved from simple order-taking software to become a major component of electronic health records. State-of-the-art CPOE systems offer clinical decision support that can calculate the appropriate drug doses based on a child's age and weight, highlighting possible allergies and drug interactions. The orders are sent to the hospital pharmacy, eliminating the need for pharmacists to track down clinicians to clarify or translate indecipherable orders.

As CPOE systems continue to be implemented and enhanced, Ross Koppel, Ph.D., an adjunct sociology professor at the University of Pennsylvania, advises institutions to consider the errors caused by such systems as much as the errors prevented. Indeed, he and his colleagues suggest, among other things, that IT-assistance programs focus primarily on the organization of work in an institution, rather than on the technology itself. "Computers do some things brilliantly, and people do many things brilliantly, but substitution of technology for people is a misunderstanding of both," he said.

Sluggish adoption

Despite these benefits, along with pressures from the Institute of Medicine and at least one major employer group called Leapfrog, which ask employers to base their healthcare decisions partially on hospitals' adoption of the technology, CPOE is still not widespread.