When I read the Leapfrog Group’s most recent report on the adoption of computerized physician order entry systems, or CPOE, by hospitals, I was both pleased and disappointed. I was pleased that the percentage of surveyed hospitals that met the Leapfrog Group’s CPOE standard has increased. But I was disappointed that the percentage was not higher.
Hospitals can pursue three strategies to accelerate the adoption and correct use of CPOE rather than relying on the escalating CPOE-adoption requirements of the “meaningful use” regulations from HHS to force the technology on their physicians.
Let’s first look at what the Leapfrog Group found. The group’s survey of nearly 1,500 hospitals found that the percentage of hospitals that met the group’s CPOE standard rose to 43% in 2013 from 31% in 2012. To meet the standard, at least 75% of medications used in all inpatient units must be ordered through a CPOE system. The standard requires a hospital to test its CPOE to make sure it notifies physicians of medication errors, both common and serious. The survey also found that the percentage of CPOE test orders that failed to prompt the appropriate medication warnings did not decline as hoped. It remained at 36% in 2013, the same level as in 2012.
Both components of the standard are reasonable but provide important clues on how to push the compliance numbers higher.
The clues – and solutions – can be found by analyzing why certain medications aren’t being ordered through CPOE and why certain physicians aren’t using CPOE to order medications. In other words, nationally, let’s look at that 25% and start breaking it down into buckets of things that we can fix and things that we can’t fix.
1. More sensitive technology needed by physicians
In one bucket you’ll find medication error alerts and clinical-decision support. Doctors are seeing too many alerts, and they are suffering from alert fatigue. In response, many physicians either ignore alerts or turn off the alert function altogether. CPOE systems don’t differentiate between medical students, who may need more alerts to teach them about potential medication contraindications, and attending physicians, who don’t necessarily need those reminders. CPOE systems also don’t differentiate between medical specialties. Better technology can fine-tune medication error alerts and clinical-decision support to the type of physician using them.
2. Show physicians the evidence of effective CPOE
In another bucket, you’ll find lack of physician education over the clinical and financial benefits of CPOE. Some early and much-publicized research suggested that the use of CPOE increased medication errors. What those studies actually revealed was the extent of the problem. Research since then has pointed favorably in the direction of CPOE as a method of reducing medication errors. For example, HHS in August released the results of the study that found that hospitals that implemented the five core “meaningful use” medication management functions, which include CPOE, dramatically reduced the number of adverse drug events at their institutions. Separately, the FDA recently opened up its database on medication errors to the public and to researchers. This gives vendors and clinicians valuable information to fine tune CPOE to target the most problematic areas of medication use. Those results, too, need to be shared with physicians as part of the educational process.
3. Name should reflect the doctor’s role
In the final bucket you’ll find people, and you’ll learn that doctors just don’t like the last word in the name “computerized physician order entry.” It’s the word “entry” that upsets them. They say it makes them feel like clerks whose job is front-line data entry. As a physician, I think it’s a mistake, too. I much prefer “computerized physician order management,” or CPOM. Doctors are managing the medication orders for patients. They are not simply entering them into a system. A number of health care institutions have started using the term CPOM, and their use rate for medication orders by physicians is much higher than the average for all hospitals.
I spend a great deal of time meeting with physicians on staff at hospitals across the country. I’ll ask them: “So tell me, why did your hospital put in a CPOE system?” If they use the words “government” or “meaningful use” in the first two sentences of their response, it generally means they haven’t embraced CPOE as an effective clinical and financial tool. The better approach to accelerating CPOE use by physicians is better technology, better evidence and a better name.