CPOE remains a challenge for many, surveys show

By Bernie Monegain
02:03 PM
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Indicators show adoption, safety still weak

WASHINGTON – Even as meaningful use moves full steam ahead, a survey on the testing, monitoring and safety of computerized provider order entry, or CPOE, conducted every two years by healthcare watchdog the Leapfrog Group shows only slight progress on the safety front. 

Testing, monitoring and safety of CPOE remains a major challenge for hospitals and technology companies, said Leah Binder, CEO of the Leapfrog Group. Binder unveiled last month the results of the most recent survey.

Two years ago, 214 hospitals used Leapfrog's Web-based simulation tool to test the ability of their CPOE systems to catch common medication errors, including errors that could lead to fatalities. The hospitals found their systems on average missed half of the routine medication orders and a third of the potentially fatal orders. Nearly all of the hospitals improved their performance after adjusting their systems and protocols and running the simulation a second time.

According to Binder, in a similar test conducted over the last nine months of 2011 by 253 hospitals, the missed routine medication orders dropped to slightly more than a third and the fatal orders plummeted to just over one percent.

"This is the kind of improvement that shows what persistent monitoring and adjustment of these systems can achieve, and the hospitals that participate in the Leapfrog Hospital Survey and took the test deserve real credit," said Binder. "But hospitals and technology companies haven't finished the job. When CPOE is implemented the right way and hospitals and vendors follow up to monitor and improve it, the result is what every patient hopes for when their life is at stake – the perfect harmony of caregiver and technology working for them.”

David Bates, MD, chief of research for the division of general and internal medicine and primary care at Brigham and Women’s Hospital; David Classen, MD; Jane Metzger and other researchers developed the CPOE evaluation tool promoted by the Leapfrog Group with funding from the Agency for Healthcare Research and Quality and others.

The hospitals that took the test are voluntary respondents to the Leapfrog Hospital Survey, a national patient safety survey that measures and publicly reports on how well patients fare, resources used to care for patients, and management practices that promote safety. The hospitals that participate in the Leapfrog Hospital Survey are considered among the most advanced in the country in their use of information systems, Binder said.

CPOE has been the topic of discussion at recent meetings of the federal Health IT Policy Committee.
Paul Tang, MD, chief innovation and technology officer at the Palo Alto Medical Foundation and vice chairman of the panel, said at a last month that CPOE was “the single most important objective of the entire EHR incentive program.”

Yet the panel was divided over whether physicians would have to type in the orders themselves – because it was then that clinical decision support alerts kicked in – or whether it would be feasible to have a scribe enter the orders.

Neil Calman, MD, president and CEO of the Institute for Family Health, said it is common practice for physicians to sign off on CPOEs that were typed in by other people.

“As long as the decision support appears at the time of authorization, the person who enters the order isn’t really that important,” he said.

However, in Bates’ view, if physicians are to use decision support, they have to see it when they type in the order. “I’ve looked at a lot of different systems, all of them deliver decision support at the time that you’re actually entering the order.”

The results of a survey released last month by Lexington, Mass.-based technology company Imprivata showed 45 percent of respondents indicated that more than half of their physicians were placing orders using CPOE. Yet, 38 percent reported that still less than 25 percent of their physicians were using CPOE.

Sixty-three percent of respondents reported resistance to workflow changes as the leading obstacle to CPOE adoption.

Senior Editor Diana Manos contributed to this story.

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