CPOE far from the debacle it once was
Ten years ago, the Center for Information Technology Leadership at Partners HealthCare in Boston published a widely heralded report suggesting that nationwide adoption of ambulatory CPOE, tightly coupled with electronic health records and clinical decision support, could prevent 2 million adverse drug events, 130,000 life-threatening medication errors and 190,000 hospital admissions per year – all while saving $44 billion, largely from avoiding duplication.
"Those were the days when electronic medical records were kind of a gleam in some people's eyes," recalled Jan Walker, RN, who served as executive director of the now-defunct CITL at the time the report came out.
Those also were the days when the Leapfrog Group, a Washington-based coalition of large healthcare purchasers, was heavily promoting CPOE adoption as a way to boost patient safety.
Most notably, though, hospitals were treading carefully after Cedars-Sinai Medical Center in Los Angeles turned off its CPOE system in early 2003. Medical staff there rebelled after a house-wide "big bang" rollout, realizing that the poorly planned system increased their workloads and encouraged cutting corners. It took another eight years before Cedars successfully implemented CPOE.
In the past decade, several studies have been published suggesting that CPOE can introduce and even magnify errors without proper safeguards, particularly against physicians suffering from "alert fatigue" turning off notifications.
Today, of course, EHRs are hardly a gleam. CPOE adoption has lagged a bit in the past decade as gun-shy hospitals and physicians sought to avoid earlier mistakes. But growth has accelerated since the advent of meaningful use in 2011, even as some remain wary.
A February 2013 paper in the Journal of the American Medical Informatics Association estimated that nearly a third of U.S. acute care hospitals had fully implemented CPOE by 2008.
Leapfrog used to give hospitals credit if they were merely planning on installing CPOE. Now, the technology not only has to be operational, it has to work properly.
In 2008, when Leapfrog began evaluating CPOE systems, 108 hospitals met the organization's minimum standards. Five years later, 847 reported having functional CPOE and 523 passed the test. That represents about half of all hospitals reporting to the Leapfrog Group, and is up from 292 reporting and 181 passing in 2011.
"It's a completely new ball game," said Binder. She said meaningful use, which began in 2011, is the primary driver, even if the Stage 1 CPOE requirement of at least one medication order for 30 percent of patients was so low.
In Stage 2, the minimum increases to 60 percent of patients for medication orders, 30 percent for lab orders and 30 percent for radiology orders.
Leapfrog's criteria are more stringent. The organization tests to make sure clinical decision support mechanisms are in place. A hospital has to show that more than 75 percent of medication orders are entered electronically in at least one inpatient unit because Leapfrog members want to emphasize prevention of adverse drug events.