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November 11, 2008

On the Right Track in Massachusetts
By Lindsey Getz
For The Record
Vol. 20 No. 23 P. 16

A mandate that tells hospitals they must adopt computerized physician order entry by 2012 has the state advancing at an impressive clip.

Throughout the years, medication errors have been a significant cause of injury and death among hospital patients. In fact, estimates have shown that adverse drug events cause more than 770,000 hospital injuries and deaths nationwide each year and cost each hospital up to $5.6 million. More specifically, a new study conducted by the New England Healthcare Institute and the Massachusetts Technology Collaborative found that one in every 10 patients in a Massachusetts community hospital has suffered a preventable adverse drug event.

It’s a primary reason these organizations are recommending that all state hospitals adopt computerized physician order entry (CPOE). Though these systems have been around for some time, this recent study, along with a growing demand for improved technology in the healthcare industry, has pushed them to the forefront.
The errors examined by the study focused on patients who had a serious and preventable medication error, such as a bad reaction to a drug, an inappropriately prescribed drug, a renal dosing error, or a redundant laboratory test. “We didn’t count something like a simple rash,” explains Nick King, vice president of communications at the New England Healthcare Institute. “We counted really serious events that increased the patient’s average hospital stay by an additional four to five days. They were also all preventable cases. For instance, someone at the hospital should’ve known that Patient X was allergic to penicillin.”

The study, “Saving Lives, Saving Money,” focused on six community hospitals that voluntarily allowed their records to be put under the microscope. This first-of-its-kind study, conducted by David Bates, MD, of Brigham and Women’s Hospital, with financial analysis by PricewaterhouseCoopers, was based on a review of 4,200 medical charts. It found that a CPOE system could reduce preventable drug errors by as much as 80%.

“There is a very small window of errors that could slip through,” admits King, “but nonetheless, if you take the fact that in Massachusetts alone, CPOE could reduce or eliminate 55,000 of these types of errors each year and extrapolate that into a national figure, you’re talking about eliminating an enormous number of medication errors.”

The findings have prompted the Massachusetts legislature to pass legislation requiring hospitals to implement CPOE by 2012 as a condition of licensure. In addition, Blue Cross Blue Shield of Massachusetts changed its policy to require hospitals to use this technology after 2012 in order to participate in its quality and incentive programs.

“We believe the findings, along with the positive results seen in hospitals that have already implemented CPOE, demonstrated that this technology will improve the quality, safety, and affordability of healthcare,” says Steve Fox, vice president of provider network management at Blue Cross Blue Shield of Massachusetts. “Requiring hospitals to implement and utilize CPOE as the threshold to participate in our quality and incentive programs ties into our efforts to improve the quality of healthcare.”

The process of statewide implementation has already been steady. As of early October, 13 hospitals had implemented CPOE, and several more were underway with their plans. “The reaction from hospitals that have already adopted the technology has been extremely positive,” notes Fox. “But one major concern has been the cost and return on investment [ROI]. It is a substantial investment. When a facility has to choose between a cost-savings effort like CPOE and new, technologically advanced equipment that generates revenue, the decision tends to go to the choice that has that immediate ROI. As a result, the CPOE investment can get bumped lower on the priority list. We wanted to make a strong statement about how important we think it is—creating an economic situation that provides a financial incentive for implementation is priority.”

Overcoming Barriers
As Fox mentions, cost is one hurdle that hospitals need to clear on the road to implementation. However, reimbursement incentives, such as those being offered by Blue Cross Blue Shield, help ease some of that burden. And in the long run, studies have demonstrated how CPOE can save hospitals money.

For example, by preventing adverse drug events and errors and renal dosing, healthcare organizations can bank a few more dollars in their coffers. According to “Saving Lives, Saving Money,” the decrease in extended hospital stays resulting from a reduction in medication errors could add up to annual savings of approximately $2.7 million per hospital. The one-time average total cost of adopting a CPOE system is $2.1 million with annual expenses in operating costs somewhere in the neighborhood of $435,000.

“Not only can you increase the value and quality of your healthcare, but you can save money while doing it,” says King. “The fact that one in every 10 patients is affected by a drug error should be shocking enough to prompt hospitals to want CPOE, but on top of that, hospitals can get a return on their investment within 26 months of implementation. That really eliminates any financial excuse.”

While the price tag may give hospitals second thoughts about adopting CPOE, the learning curve involved can be the largest barrier to overcome. “Implementing CPOE requires a doctor to completely revamp the way he or she does business or interacts with patients in the hospital,” says Bethany Gilboard, director of health technologies with the Massachusetts Technology Collaborative. “Depending on the software or vendor, some systems are easier to use than others. But regardless of which system you have, the workflow redesign and process reengineering can still be a huge barrier. It does require the hospital to make a lot of changes to the way things are run, and that concept alone can be daunting.”
“It does entail a lot more than simply buying the technology and then pushing a button,” agrees King. “There is a huge learning curve, and that is a challenge for many hospitals. These are very real technological barriers, and it’s one reason why the state legislature is giving hospitals until 2012 to fully implement the technology. They want hospitals to confront these challenges and implement the system properly—not rush through the necessary steps.”

In an effort to speed CPOE adoption, the Massachusetts Technology Collaborative and the New England Healthcare Institute, in partnership with the Massachusetts Hospital Association, organized the Massachusetts Hospital CPOE Initiative. To address the problems associated with a steep learning curve, the initiative has recently announced the opening of the CPOE University, an educational program designed specifically for physician training. “This training and facilitation series will give physicians a place to go and learn how other hospitals have already implemented the technology,” says Gilboard. “The university began in October and includes courses and seminars based on topics that physicians want or need to learn about. It’s also been an opportunity to pair hospitals that may be ahead of the learning curve with those struggling to adopt. They can talk about what has and has not worked for their hospital.”

“It’s an opportunity for hospitals under the gun for adopting CPOE to learn from hospitals that have already done so,” adds King. “Hospitals working to adopt are no longer alone. The university provides an opportunity for hospitals with successful implementation to serve as mentors.”
The program is free for physicians, and there are plans to make materials and the curriculum available online for the public to use. Dan Morgenstern, MD, MBA, consulting physician director for the northeastern United States at Computer Science Corporation, facilitates the series. “He was really the brainchild behind the university,” Gilboard says. “He had originally run some focus groups for us to determine what physicians needed for implementation, what their frustrations had been so far. Out of that came the concept to run some very focused seminars and courses that would allow physicians to be more effective leaders and drive their adoption rates forward. We are not asking people to become technology experts. We’re just trying to give them the tools to be more effective and to better understand some of the jargon.”

Of course, the weight of the problem is not on physicians alone; the lack of trained hospital staff is also a barrier to CPOE adoption. But it’s physicians who can spearhead change. Currently, the training exists only for “physician leaders,” who are then expected to share their knowledge with other hospital staff who would be using the system. “CPOE adoption is really a clinical IT initiative that needs to be driven by physicians,” says Gilboard. “They need to be at the head of the curve as opposed to an afterthought. First semester is an opportunity to provide physician leaders with the tools and skills that they will need to work effectively with their colleagues, hospital IT departments, and other clinical departments. Without physicians on board, the CPOE project would come to a grinding halt.”

If the first semester of the CPOE University is successful, future courses and seminars will be held to train additional staff. “Depending on our success, we will continue with the program and eventually also enroll nurses and the pharmacy, too—not just the physician,” continues Gilboard. “Our intent is to engage the other clinical providers throughout the hospital and develop programs targeted specifically to them.”

Is National Adoption Next?
The drive to adopt CPOE statewide in Massachusetts may influence other states to do the same. And it may be the consumer who pushes for change in some areas. “Today’s consumers are very smart about where they go for their healthcare,” says Gilboard. “They are more in touch than ever with the issues, and there will be a point where they only want to go to a hospital that has CPOE in place.”

While it may seem that hospitals being told to do something would have a negative effect, most have been positive about getting on board with adoption and are making efforts to get the ball rolling. In fact, a technology adoption survey conducted by Blue Cross Blue Shield of Massachusetts found that only 30% of the state’s hospitals had not yet begun to budget or plan for CPOE implementation. The rest are already in the process.

For those who haven’t been as enthusiastic, the state regulations may feel like a demand, but there is often no better way to initiate change. “Given the fact that the healthcare system can sometimes be slow to make changes, the fact that the legislature has put a mandate in place will help get people’s attention,” says Gilboard. “Sometimes it takes that extra push or else there are constantly going to be excuses why it’s not being implemented. And from the study we did, the investment is relatively small considering the opportunity for improvement and the ultimate payback.”

The bottom line is that CPOE is just one of many new technologies hospitals are expected to adopt. Like any other industry being revolutionized by this electronic age, it’s crucial that something as important as our nation’s healthcare keeps up with the times. “Hospitals are always under pressure to adopt new technologies,” says King. “This is just one more advance that will ultimately improve the quality of their care. And it’s a win-win situation because it will pay off for them financially as well.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.