CPOE seen as vital to meaningful use
Once considered the leading edge of information technology, computerized physician order entry is now simmering on the back burner of healthcare priorities. While it is not forgotten, attention toward CPOE has been deflected in favor of other concerns, such as meaningful use, interoperability, RAC audits and ICD-10 coding projects.
Yet CPOE's role remains vital as a vessel for clinical decision support, data aggregation and electronic health records - all key elements of meaningful use.
Jonathan Teich, MD, chief medical informatics officer for Elsevier's Health Sciences Division has been working in the CPOE domain since 1990 and has witnessed its growth over the past two decades.
"It has been a time since I first started working on it, but the most noticeable thing is that CPOE is now a normal part of the framework and not a question of 'should we' or 'might we' - it has been accepted that if you're going to be doing EHRs, you'll be doing CPOE," he said. "The growth of CPOE itself and how most people are dealing with it is to make it as workable as possible."
The most common fear with CPOE, Teich says, is the disruption associated with implementation. And while that fear may have some justification, he insists that the disruption is short-lived and that the benefits are well worth the minor inconvenience.
"Everyone is afraid of that first month when you're not used to it and productivity is lost as a result," he said. "But we did a study that shows productivity catches up in six weeks and after that it gets much better.
Once people get used to it, they can improve their speed with everything."
Robert Hitchcock, MD, vice president and chief medical information officer at Dallas-based T-System, acknowledges that there has been "some difficulty" in getting CPOE utilized the way it is supposed to be, by physicians at the point of care instead of having notes transcribed. He also notes there is a disparity between emergency and inpatient physicians in their attitudes toward adoption.
"ED finds adoption easy because CPOE helps so much with throughput time," he said. "On the inpatient side, hospitalists are adopting regularly, but inpatient physicians who are not at the hospital all day don't like to log onto the system. It is harder to get them used to it."
Even so, hospitals are required to focus on CPOE in order to facilitate and comply with meaningful use requirements, says Teresa Luckey, delivery director at CTG Health Solutions in Greenwood, Ind.
"CPOE requires more direct physician interaction with the EHR, necessitating increased training and support for physicians," she said. "It has also directed more accountability toward the physician to ensure that EHR orders are correct and fit the patient's diagnosis."
CPOE has a strong connection to meaningful use because it is included in the guidelines, said Teich, who has served as an adviser to the Office of the National Coordinator (ONC). "If it weren't highly used they wouldn't have put it in meaningful use," he said. "The only things that can be included in meaningful use are those that are already being used."
That said, Teich says meaningful use "has changed things a bit" with regard to CPOE. The first requirement is for reporting quality measures in Stage 1, followed by using clinical decision support in Stage 2 and then demonstrating its impact in Stage 3.
"Even in Stage 1 if I can document that I did a cholesterol test or foot exam on a diabetic, I can use this order set as a way of documenting it," he said.
Luckey adds that there are specific MU metrics addressing the percentage of orders being placed via CPOE.
"It is also expected that as CPOE becomes more embedded in the everyday processes of an institution, there will be measurable increases in better outcomes to patient care, fewer errors in orders for procedures and medications, and better tracking of the total course of care for a patient - all of which are measured in some way by meaningful use reporting,' she said.
Stage 2 raises the requirements of how CPOE must be utilized, as opposed to how often it is used for orders, Hitchcock added.
"It sends the message that it must be used," he said. "It is a mechanism for placing orders for tests and on the other end is the checking for allergies and medication interaction. While the EHR captures so much information about the patient, CPOE can help enhance clinical decision support."
The thrust of MU and CPOE is "usability," Teich says. "There is room for improvement, but it is being addressed."
The government and some of the major trade organizations are pushing for usability, which should bring the healthcare industry to where it needs to be with meaningful use, he said.
"You should be able to do common things very fast and everything somehow," Teich said. "It should be pretty clear what you should be doing next, with screens organized in a clinically oriented fashion."
The goal, Hitchcock says, is to bring CPOE to a point where "it can participate in an environment where it can make an impact. It's sort of like the evolution of the automobile and the highway system."