How CPOE Will Make Healthcare Smarter

Computerized physician order entry is a key requirement of meaningful use stage 1. Now that CPOE has reached a tipping point, healthcare IT leaders are at the beginning of a journey that takes the accumulated wisdom of a healthcare provider and codes it into decision-support systems.

This article appears in the November 2013 issue of HealthLeaders magazine.

A key requirement in stage 1 of meaningful use was that providers employ computerized physician order entry for at least 30% of medication orders entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines.

Now that more than 80% of eligible hospitals have received reimbursement for adopting electronic medical record technology, CPOE has gone mainstream. It is also in some ways just the beginning of a journey that takes the accumulated wisdom of a healthcare provider and codes it into decision-support systems that, over time, make CPOE smarter.

"We've got much higher CPOE adoption than we had three or four years ago," says Bill Spooner, senior vice president and chief information officer of Sharp HealthCare, a not-for-profit regional healthcare system based in San Diego with 1,735 licensed beds at four acute care hospitals.

Providers such as Spooner observe that some of the productivity-enhancing technology that fuels CPOE is the same technology that gets criticized as potentially illegal shortcuts for providers.

In September 2012, U.S. Attorney General Eric Holder Jr. and Health and Human Services Secretary Kathleen Sebelius sent a letter to the American Hospital Association and other industry groups, stating that "false documentation of care is not just bad patient care, it's illegal … a patient's care information must be verified individually to ensure accuracy; it cannot be cut and pasted from a different record of the patient."

Spooner acknowledges cut-and-paste probably does get used in some situations. "If that's all that's happening, that's totally wrong; but if in fact the patient's condition hasn't changed in 24 hours, then do you want to write all this stuff, or do you want to use cut-and-paste?" Spooner says.

Templates are smart productivity-enhancing tools, Spooner says. And while he says the Holder-Sebelius letter "was kind of overreaching," he adds, "At the same time, there's no excuse for somebody using it to cheat the documentation in any way."

Meanwhile, rural hospitals such as 100-staffed-bed St. Claire Regional Medical Center in eastern Kentucky still struggle just to get CPOE and electronic medical record systems adopted by doctors.

Six months after implementing CPOE, "we have some physicians … who just can't get past that point of using a computer to take care of a patient," said Randy McCleese, CIO of St. Claire Regional Medical Center, speaking at a July 2013 hearing of HHS' HIT Standards Committee. "We have had huge issues with some of those physicians being able to use a computer to take care of that data rather than writing it down."

And yet, if EMRs have achieved anything so far beyond producing incentive checks, it is probably the banishment of illegible physician notes, which have been the scourge of healthcare since its inception.

"I think the biggest benefit of CPOE as it stands is that the orders are legible and clear, and it's menu-driven," says William Park, MD, senior general surgeon and former chief medical officer at North Hawaii Community Hospital, a 33-bed rural hospital in Waimea.

"Truly the biggest challenge with CPOE is it's not terribly intelligent," Park says. "It's not a time-saver, nor necessarily in my opinion a quality improver. It's become more of a clerical issue in legibility and efficiency of the systemswide approach to clinical orders, but I don't truly think that it's delivered the benefit to the extent that everybody thought it would. There's a lot of room for improvement."

Park says the way forward is for providers to campaign for better-designed, more intuitive, straightforward, simple CPOE.

For example, when a physician is preparing an order for IV fluids, "If you're writing something that's inappropriate for the patient's admission chemistry, the system ought to tell you immediately: 'Do you really want to do that?' " Park says. "If a patient's potassium is 3.7, do you really want to give this patient no potassium supplements in their intravenous fluids? It's not smart enough to do that, and it should be."

On the cut-and-paste issue, Park says the challenges of avoiding inappropriate shortcuts while retaining potential productivity enhancements affect his physicians as well.

"EHRs can be as dumb as the template and force you to check boxes, which makes it a chore," Park says. At the same time, if there is no box to check, physicians must still dictate or type clinical notes into the system. "It's a mish-mash that doesn't work well," Park says. At some point, Park believes that EHRs will acquire a kind of organizational intelligence with more intuitive design.

One provider's CIO says he picked an EHR, from Medhost, with just such a design. "It is a picture: You look at it, you can figure it out," says Lee Powe, CIO of Hugh Chatham Memorial Hospital, which has 81 acute care beds in Elkin, N.C. Clinicians in the emergency department have lots of visual cues. "You see a test tube with blood in it, and it means something. Graphics and pictures are good for clinical people. They see it. They get it."

Other hospitals have been up to speed with CPOE for a number of years and took the meaningful use requirements more in stride.

At Albany (N.Y.) Medical Center, two electronic medical records have been live since 2005, with the early elements of CPOE beginning in 2007, says George Hickman, executive vice president and CIO of the 714-licensed-bed teaching hospital. CPOE "is not one of those the things that's a concern for us going forward in terms of the high level of physician adoption." Incoming medical residents "expect walking in the door to have all these capabilities in there waiting, so that's the way our new doctors are," he says.

Hickman, who also serves as the current chair of the College of Healthcare Information Management Executives, acknowledges that achieving CPOE compliance in meaningful use does not necessarily achieve the greater goal of leaving paper behind.

"What really starts taking away from paper is when all of the supporting clinical documentation becomes paperless and is available only in an online form," Hickman says. "We have something in the range of 50–60 of our documentation forms automated and CPOE online. We have not yet fully implemented all standardized and structured physician documentation."

Albany Medical Center still uses dictation as a form of getting documentation into the record, Hickman says. "It can be done in a very structured way or it can be done in a very unstructured way. We provide it both ways, especially with the physician clinic supporting the EHR," he says.

At Chatham Memorial, Powe employs printer control to tame the paper monster. Working with printer supplier Ricoh, Powe removed many printers from the hospital, and put technology in place to figure out what is still being printed and by whom.

"I have no idea what some of these documents are, but I got the person working for me who does, so I'll say, 'Hey, go find out where this is coming from and why is it coming out of the system instead of staying in the system,' " Powe says.

Despite best efforts, CIOs might feel a little like they're playing whack-a-mole as paper notes continue to pop up. But eventually, physicians will be in the habit of doing it electronically.

"Now in your beginning stages, no matter what software product you implement, everybody will whine, moan, and groan," Powe says. "Three months later, you turn it off for a software patch or something. Everybody will whine, moan, and groan, 'What do we do now? The system's never down.' "

But while that presents its own challenges, the fact that physicians now can't live without the EHR was exactly the point of meaningful use in the first place.

Reprint HLR1113-6

This article appears in the November issue of HealthLeaders magazine.