Computerized order entry brings practice protocol off the shelf

April 1, 2005

CPOE is a necessary intermediate step in creating an EMR.

ASK BRIAN JACOBS, MD, director of technology and patient safety at Cincinnati Children's Hospital to outline the benefits of the hospital's new computerized provider order entry (CPOE) system, and be prepared for a lengthy conversation. It's not that Dr. Jacobs is verbose. Rather, the benefits are far-flung and, two years after the system was implemented, are still being uncovered.

Medication errors are down 35%. That's partly because illegible handwritten orders have been replaced by electronic orders that are automatically sent to the pharmacy, radiology and lab. It's also because of the fact that the system red flags or blocks dosages outside the typical range preventing accidental overdoses.

Orders are filled faster and more efficiently. Before the CPOE system was installed, it took an average of 112 minutes for a prescription to arrive at a patient's bedside; now it takes 53 minutes. X-ray orders, which used to take 22 minutes to fill, now take only eight minutes.

Patients are being discharged faster. Before Cincinnati Children's implemented CPOE, 58% of patients were discharged after 3 p.m. Because orders, including discharge orders, have been expedited, that share has dropped to 35%.

Then there are all the less-obvious benefits Children's is only beginning to uncover. "The fun really begins after you've implemented the system because you can start to understand how you provide care in a way you never have before, Dr. Jacobs says.

Because the system provides prompts and decision support, physicians are in a better position to comply with regulations, hospital policies and practice guidelines because relevant policies are displayed on screen and "aren't sitting in some three-ring binder up on a shelf somewhere," says Dr. Jacobs.

Such on-screen displays have helped the hospital reduce its unsigned verbal orders from nearly 10% of total orders to about 1%.

Integrated decision support has enabled the hospital to reap savings by altering prescribing behavior. Thanks to an alert notifying physicians of a national solumedrol shortage, prescriptions for the drug dropped 55%. That has saved the hospital more than $36,500 annually.

The list could go on, but occasionally Dr. Jacobs needs to take a breath.

"It's nice to know that you can do something like this that will have a striking advantage to your patients," he says. "There are very few things-maybe developing a new antibiotic or life-saving procedure-that can have such a tremendous impact on safety and quality of care."

Dr. Jacobs isn't alone in singing CPOE's praises. It's one of three cornerstone initiatives for the Leapfrog Group, a growing consortium of healthcare purchasers dedicated to improving the safety and quality of hospital care.

"When Leapfrog decided to promote CPOE as one of our 'leaps' we did it because it is a gold standard for safety and because it would require hospitals to put in underlying clinical information systems that, in the long run, will lead to quality improvements," says Leapfrog CEO Suzannne Delbanco.

Nearly five years after Leapfrog began promoting that "gold standard," however, only about 6% of U.S. hospitals have adopted it. Despite the system's obvious promise, the testimonials of its advocates and the endorsement of Fortune 500 employers, the move toward CPOE has been-and continues to be-slow, arduous and extremely expensive.

While CPOE may be the best thing since the proverbial sliced bread, it requires a mighty pricey knife. Leapfrog estimates the typical hospital system runs somewhere between $500,000 and $15 million to implement. Cincinnati Children's spent $5.5 million on its system and invests another $1.5 million to $2 million annually to maintain it. Other larger hospitals with multiple campuses and outpatient clinics reportedly have spent far in excess of $30 million on their systems.