The CPOE Revolution Begins

Thanks in part to the new Medicare Reform Law, computerized physician order entry systems & related technology are--at last--taking the stage in LTC

by Joanne Kaldy

Computerized physician order entry (CPOE) is coming--perhaps sooner than you think. To date, the move to CPOE in long-term care has limped along at best. But it may pick up its pace, thanks in part to the new prescription drug benefit signed into law last December.

What does the prescription drug benefit have to do with CPOE? Buried in the new law is authorization for the Department of Health and Human Services to administer grants to physicians for the purpose of assisting them to implement electronic prescription drug programs. Because the cost of hardware and software is one of the barriers to the use of technology, such as CPOE and electronic medical records (EMRs) use by physicians, this grant program could pave the way for greater use of e-prescribing in long-term care.

It is important to note that CPOE and EMRs often go hand-in-hand. In many ways, CPOE is a component of EMRs and links to this data. But before you embrace or reject any of this technology, consider the pros, cons, truths, and myths about it.

Is the Technology Really Necessary?

Not everyone sees the value of CPOE or EMRs. But those who do tend to be strong advocates. Gary Applebaum, MD, chief medical officer at Erickson Retirement Communities in Maryland, is one such advocate.

"It's sad that the local Pizza Hut has more digital information about you than your physician does," he said, referring to the widespread use of computers in industries such as food service.

He cited the Rand study on quality of health care that found only 57% of seniors were getting appropriate cardiac care. "If only 57% of Pizza Hut customers were getting the right orders, the company would never stay in business," he said.

Dr. Applebaum suggested that one important reason that CPOE and EMRs haven't become more widespread is that there is no incentive for physicians and others to invest the time and money in the equipment and training necessary to make them work. "If we want physicians to use CPOE, we need to incentivize them," he added.

In the Beginning...

In truth, some policymakers, practitioners, and others have been promoting the benefits of CPOE for years.

Back in 2001, the Leapfrog Group, a consortium of business leaders and health experts, endorsed CPOE in hospitals as one change that would improve patient safety nationwide. The group cited several specific benefits of CPOE, including:¹

• Prompts that warn against the possibility of drug interaction, allergy, or overdose;
• Accurate, current information that helps physicians keep up with new drugs as they are introduced into the market;
• Drug-specific information that eliminates confusion among drug names that sound alike;
• Improved communication between physicians and pharmacists; and
• Reduced health-care costs due to improved efficiencies.

The Leapfrog Group acknowledged that that fewer than 2% of U.S. hospitals currently use CPOE and that costs are a major barrier. Implementation of even "off-the-shelf" systems generally requires a significant amount of customization.² The group also cited "cultural obstacles" to CPOE and suggested that many physicians prefer to order prescriptions the way they've always done this task.

Also in 2001, the Agency for Healthcare Research and Quality released a report suggesting that hospitals could save as much as $500,000 a year through the use of CPOE. Of course, the agency also estimated the cost for a start-up computerized prescription system as $1 million to $2 million for a 200-bed facility or as much as $50 million or more for a high-end system.³

A few studies document the effectiveness of CPOE in hospital settings. While some anecdotal information suggests that CPOE can totally eliminate errors, studies suggest a reduction of serious errors of 17% to 55%.^4,5 However, one study did show a 100% improvement in the rate of corollary orders.⁶ Six of 14 studies reported improvements in patient outcomes, and 43 of 65 studies documented improvement in physician performance.⁷

Myth-Busting Technology

Like the urban legend about alligators in the sewers, myths about CPOE and EMRs perpetuate. One is that older physicians will never accept CPOE or technology of any kind. According to Dr. Applebaum, who has implemented EMR technology throughout 10 continuing care retirement communities in seven states, "We trained 36 physicians of all different ages, with 10 years as the average years of practice experience. They all did great.

"Some of the people we were most worried about turned out to be our biggest champions," he added. "I think that most people underestimate the intellect of physicians and their passion to do their jobs better."

Of course, physicians' enthusiasm is not necessarily universal; there is resistance. CEO Charlie Franz's facility in Alaska has already implemented EMRs and is preparing to employ CPOE in a similar fashion.

"Some of our physicians are very supportive and looking forward to it," he said. "Others say 'not in my lifetime.' Most physicians will only implement new technology when it is absolutely necessary. As a rule, they don't like it."

Resistance may be related less to physician age or personality and more to a lack of "good CPOE products that are really easy for long-term care physicians to use," speculated Jim Baker, MS, RPh, national director of professional services for Pyxis Corporation. "If a product or system takes physicians more time and effort to use, it's going to be much harder to gain their buy in."

Dr. Applebaum suggested that the way an organization approaches a conversion to technology can make the difference between enthusiasm and hesitation.

"I presented all the reasons that we were going to do this. Then I gave them a disc to play with on their own," he recalled.

When the time came to implement the system and go live, he ensured that there were enough trainers around and that no one had to wait long for help. He also made sure that physicians could use the system when and where they needed it most and it was most convenient.

"We made sure that physicians were able to use the system from their homes and on weekends," explained Dr. Applebaum. This enabled physicians to see how the system could benefit them personally by saving time and giving them access to patient information without leaving their homes. And once they saw how easy the system was to learn and use, they were hooked.

Dr. Applebaum emphasized the need for adequate support to keep physicians and others from getting frustrated with new technology. "Few organizations are prepared to provide support nights and weekends. But that is often when it is needed the most," he explained. "You need to realize that once you're not counting on paper charts, people become dependent on technology. Two months after implementation, your system momentarily crashes, and everyone is totally lost without it."

Another myth--system compatibility--is not really a myth. "Compatibility and the ability for different systems and hardware to communicate really was a problem for much technology at one time," he said.

This is much less of a concern now, but he suggested compiling a list of all of the systems and organizations with which you expect your system to communicate and sharing this with potential vendors before purchasing or leasing any hardware or software.

Baker cautioned that some vendors may not have the incentive to make their systems compatible with others. "Customers have to drive compatibility," he offered.

Pharmacist David Kazarian, president of InfuServe, St. Petersburg, Fla., agreed that compatibility is still a concern, although less so than it was five or 10 years ago.

"The bridge between computers is still not complete," he said. "There still is a lot of water there. One of the problems is that software designers and manufacturers don't want people to have access to their 'secrets.' They're very proprietary."

Cons of Technology

"There is no downside to more accurate prescribing," said Dr. Applebaum, although he admitted that problems can occur with EMRs, CPOE, or any technology. Technical glitches are always a possibility that needs to be addressed.

Example: Dr. Applebaum's facility put wireless keyboards at all workstations and found that some signals got crossed when the computers were too close together. While problems will happen along the way even with the best of systems, it's important to plan ahead, have appropriate backup arrangements, and ensure that staff members know what to do when there is a problem.

Cost is an issue for most organizations and individuals considering technology upgrades. And CPOE is no different. While this justification is difficult, it's not impossible. As validated studies begin to show the value of CPOE in terms of cost cutting, time savings, and enhanced patient outcomes, it will be easier for physicians and others to rationalize the investment in CPOE.

At the same time, grants from the HHS and other sources may help lighten the financial load. The HHS grants, in particular, will make funds available for purchasing, leasing, and installing computer software and hardware, including:

• Handheld computer technology;
• Upgrades and other improvements to existing computer software and hardware to enable e-prescribing; and
• Education and training for eligible physician staff on the use of technology to implement the electronic transmission of prescription and patient information.

Dr. Applebaum and others insisted that improved patient care and elimination of medication errors that harm patients should be incentive enough for more organizations and individuals to invest in CPOE, EMRs, or other technology. Still, there are other practical and real financial benefits in terms of risk management.

"We know that many lawsuits are related to medication errors," said Dr. Applebaum. "Isn't it worth investing $100,000 for a lawsuit that never happens?"

One downside to CPOE and EMR systems is true of any technology--from a single laptop to the computer system for a big city hospital system: the speed at which technology is updated and becomes obsolete.

"No matter what you do or buy, it will go out of date rapidly," suggested Tim Hutchison, vice president of Delphi Associates, Pittsburgh. "This is a testament to the brain power of the folks in Silicone Valley. But no matter what you buy today, you'll be throwing rocks at it in three years."

Conclusion

Ready or not, technology is upon us and will change long-term care. Educate yourself and your staff about the pros and cons of CPOE and EMRs, partner with knowledgeable technology staff to make technology transitions as stress-free as possible, and keep an open mind about the possibilities of technological change.

Contributing Writer Joanne Kaldy is based in Maryland.

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