Hospitals' slow adoption of CPOE impedes Meaningful Use

While many hospitals are expected to attest to Meaningful Use of their electronic health records in 2012, it's doubtful that the majority of facilities will. There are a number of reasons for that, starting with the cost. But, for providers that have the necessary resources, the biggest barrier to Meaningful Use is the requirement that hospitals use computerized physician order entry (CPOE) to order medications for at least 30 percent of patients for whom drugs are prescribed.

Hospitals are accelerating their CPOE efforts in response to the challenge. According to a recent KLAS survey, 21.7 percent of hospitals had CPOE systems in 2010--a big increase from the 15.7 percent that had them in 2009. But that means that nearly four in five hospitals did not yet have CPOE last year. Considering that it can take a few years to implement these systems and get buy-in from physicians, the prospects for most hospitals doing this by the end of 2012 are not bright.

A new HIMSS Analytics study casts additional light on the issue. The research arm of HIMSS uses a seven-stage model to categorize progress in the implementation of hospital clinical information systems. By the second quarter of this year, 12.3 percent of hospitals had reached stage 4, which includes physicians' use of CPOE on at least one inpatient unit. Considering that 10.5 percent of hospitals were in stage 4 at the end of 2010, it's clear that some facilities are ramping up fairly quickly. But two-thirds of the hospitals in the country remain in stages 1 to 3, and 10 percent haven't even reached the starting gate.

And that tells only part of the story. It takes time to win over physicians--especially those who are not employed--and to get them to trust a CPOE system. After a struggle that can last a year or more, a healthcare system is lucky to have 70 to 80 percent of its doctors aboard.

One tactic that some hospitals are employing to gear up for Meaningful Use is to install emergency-department EHRs that include CPOE. The Centers for Medicare and Medicaid Services (CMS) allows hospitals to count either all ED patients, or just those admitted to the hospital or an observation unit in the denominator for calculating CPOE utilization. Since EDs generate 45 percent of admissions, the latter method can be a big boost for a hospital that has an ED CPOE system.

Nevertheless, that alone is not likely to qualify many hospitals for Meaningful Use, and the implementation of inpatient CPOE is very challenging. Beyond the technical complexity of CPOE and getting physician buy-in, CIOs and CMIOs must deal with other issues that touch nearly every aspect of a hospital's clinical operations: the medical staff has to agree on order sets; alert levels have to be set high enough to improve patient safety without slowing physicians down too much; interfaces with pharmacy and lab systems must be written, unless the facility relies on a single vendor for all of these applications; and, crucially, the hospital's workflow must be transformed to accommodate CPOE.

A couple of years ago, Dean Morrison, CIO of Concord (N.H.) Hospital, told me about his facility's tussles with CPOE. One detail sticks in my mind: To prevent medical errors and adverse drug interactions in the paper-based ordering system, hospital nurses, as well as pharmacists, would check the unit secretaries' entries of the doctors' prescriptions. When CPOE was introduced, the orders began going directly from the physicians to the pharmacists, cutting out the nurses. But the nurses were not ready to accept that, partly because they wanted to know which meds had been ordered for their patients. Morrison had to add an extra step in the electronic routing that allowed the nurses to acknowledge the orders before they went to the pharmacy.

Multiplying these kinds of workflow and IT changes--none of them trivial--times the thousands of hospitals that don't yet have CPOE shows why it will take years for most of them to fully adopt these systems. And, until then, hospitals will struggle to achieve even Stage 1 of Meaningful Use. - Ken

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