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Power steering: A push toward technology

Corporate giants like the Big Three automakers are using their muscle to get physicians to use computer technology in their practice.

By Tyler Chin, amednews staff. March 26, 2001.

Efforts to push physicians into using technology aren't new. What is new these days is who is doing the pushing: large employers.

For example, a consortium of Fortune 500 companies known as the Leapfrog Group is offering incentives to encourage hospitals and physicians to use computer systems to reduce medical errors.

Making the grade
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And in a separate but complementary initiative, General Motors Corp. will give handheld devices to thousands of physicians as part of an electronic prescription project it will undertake with Medscape Inc., an Internet health and electronic medical records company.

Although doctors and industry observers say the two initiatives are good ideas, they note that they and their colleagues already use technology and don't have to be pushed into it.

"I don't think physicians are afraid of technology," said Alan Tonnesen, MD, anesthesiologist, intensivist and physician liaison to information systems at Memorial Hermann Hospital, Houston, which plans to test a computerized physician order entry system this year. "Physicians are for any technology that makes them efficient."

But a key hurdle to implementing CPOE systems is that it can take physicians up to three times longer to enter orders on them than writing orders on paper, Dr. Tonnesen said.

Computerized physician order entry systems can cost more than $1 million. Less than 2% of hospitals have them.

"Physicians are all for patient safety, but they don't see themselves ordering medications that patients are allergic to or the wrong dosage," he said. "Yes, errors occur, but they don't occur very often to any one physician, and most of the time the [potential] consequence is caught before it reaches patients. We're saying [to our physicians], 'Yes, it takes more time to put the order in the computer, but downstream you will save more time for other reasons.' "

Still, doctors say the big-employer initiatives will help speed up adoption of technology because of the sheer size and economic clout wielded by the corporations involved. "It will augment what is already going on in the physician community," said Joseph J. Weiss, MD, a rheumatologist in Livonia, Mich. For example, many doctors already use handheld devices to check dosage and drug interaction and to write prescriptions.

Members of the Leapfrog Group, which consists of Fortune 500 companies and large public- and private-sector purchasers of health care services, represent more than 20 million employees. They and their employees spend more than $40 billion on health care annually. Many of the consortium members are self-insured, but many also have typical contracting arrangements with managed care companies.

These employers, including General Motors in Detroit, Boeing Co. in Seattle and Delta Air Lines Inc. in Atlanta, want hospitals and physicians to adopt technology and other patient safety measures at a faster pace because they believe those measures will save the lives of and improve care for employees.

It takes a village

A 1999 report from the Institute of Medicine influenced the Business Roundtable, an association of Fortune 500 CEOs, to create the Leapfrog Group. The report, which estimated that up to 98,000 Americans die annually from medication errors, called on private purchasers to make patient safety a priority in contracting decisions.

It also called on hospitals and other health care organizations to independently implement established medication safety practices and other methods known to reduce errors, including CPOE systems.

"We can't do it alone," said Arnold Milstein, MD, national health care thought leader at the San Francisco office of William M. Mercer and a member of Leapfrog's steering committee. "This needs to be a partnership. If the response from providers, regulators and health plans to the IOM report is to rely totally on the purchasers of health care to respond to what the report pointed to, we're in trouble."

One problem is that few hospitals have implemented CPOE systems because they are expensive and difficult to implement. Less than 2% of the country's hospitals have CPOE systems, which cost more than $1 million, the Leapfrog Group said.

Aware that hospitals and physicians have been reluctant to invest in technologies that in theory improve care and reduce costs, employers say they are trying to create "a business case" for hospitals and physicians to make the investment.

Thus, the Leapfrog Group said its members would favor hospitals and physicians who use CPOE systems, said Suzanne Delbanco, PhD, MPH, the consortium's executive director.

Consortium members also will favor hospitals that perform a high volume of certain high-risk medical procedures because studies have shown that those hospitals offer patients better odds of survival. They also will favor hospitals that staff intensive care units with specialists trained in critical care medicine.

Reward or punishment?

The Leapfrog Group said its members would educate employees about medication errors and their causes, and would recommend that employees select hospitals that had adopted its patient safety standards criteria, Dr. Delbanco said. Employers also may reward those physicians and hospitals by paying them higher reimbursement rates and publicly recognizing and promoting them.

But the consortium will not punish hospitals and doctors who fall short of its standards by kicking them out of the network, Dr. Delbanco said. The group wants to encourage, recognize and reward hospitals and physicians for adopting technology rather than punish them for not using it, she emphasized.

But Dr. Weiss, who also is treasurer of the Wayne County Medical Society, which includes Detroit, said he and colleagues at the medical society were skeptical of those assurances. Detroit's Big Three auto companies -- General Motors, Ford Motor Co. and DaimlerChrysler Corp. -- are all members of the Leapfrog Group.

Local media coverage of the consortium's initiative last year gave doctors the impression that employers were indeed trying to force them to use computers, Dr. Weiss said. Also, when one party is rewarded over another, that means by definition that somebody is being punished, he said.

Semantics aside, employers could force doctors to use technology in Michigan and regions where they are the dominant employers if they are willing to do whatever it takes, Dr. Weiss said. But the move ultimately wouldn't work for several reasons.

First, Dr. Weiss estimates that only three hospitals in Michigan have CPOE. If the auto companies tried to steer all their employees to those facilities, patients would have to wait days or weeks for treatment.

Second, employees would be up in arms about having to travel great distances to receive care. And third, doctors don't have admitting privileges at every hospital. They would have to be credentialed, which takes time. Meanwhile, seriously ill patients could die before they could even be admitted, Dr. Weiss said.

Some consultants are skeptical that the Leapfrog Group initiative will succeed based on previous efforts to get groups of different health care stakeholders to build networks known as community health information networks, or community health management information systems.

"I'm skeptical that there will be cooperation on the provider side or that there are good enough incentives for providers to provide this information," said John Osberg, president of Informed Partners LLC, a health care information technology consultancy in Marietta, Ga.

Osberg said that in the 1990s he was involved in the John A. Hartford Foundation's effort to get physicians, hospitals, insurers and others to build technology infrastructures to improve clinical outcomes and quality of care.

"I think what is being attempted here is interestingly similar to some of the characteristics of those CHMIS organizations that were created and dissolved because of a lack of progress and consensus on what should or could be measured, and how the information would be used," Osberg said.

In any event, large employers are taking some early steps to reach their objectives.

In January, General Motors announced that it and Hillsboro, Ore.-based Medscape will fund the cost of a three-year project involving 5,000 physicians electronically writing prescriptions on handheld devices.

In March, large employers in California, Georgia, Michigan, Minnesota, Missouri, Tennessee and Washington began working to get other employers, physicians, hospitals and other parties in their region to work with them in achieving the Leapfrog Group's goals on a regional level.

In April, Leapfrog Group employers will invite hospitals to complete a survey asking whether they meet or plan to adopt the consortium's patient safety standards.

We get it

But some hospitals already have a head start in implementing the very systems that the IOM and the Leapfrog Group are calling on them to deploy.

After a few years of planning, for example, the Los Angeles-based Cedars-Sinai Medical Center will test a CPOE system in December that it is co-developing with a software company, said M. Michael Shabot, MD, the hospital's director of surgical intensive care and medical director of enterprise information services.

"This is more than Leapfrog. This is California law," Dr. Shabot said, referring to legislation that requires hospitals to implement technology such as computerized physician order entry to reduce errors as a condition to licensure.

The law, which was passed last year, requires all hospitals except small and rural hospitals to adopt and implement a formal plan, including using technologies shown to be effective in reducing medical errors, by Jan. 1, 2005.

"We didn't know the law was going to happen, but it's going to be very important in helping the medical staff understand that not just our hospital, but all hospitals, will have to do this," Dr. Shabot said.

The hospital decided to invest millions of dollars in a CPOE system because it is a key building block of an electronic medical record and many quality initiatives it has rolled out, he said.

"We just came to a point where we have these finely honed quality processes at the hospital and we needed to provide a CPOE to really make progress in a number of areas," Dr. Shabot said. "For example, if we have guidelines on the use of antibiotics and want to make it absolutely impossible not to order a drug the patient is allergic to, how could we do it without a CPOE?

"We just wanted to go to the next level. It may turn out to be a competitive advantage, but that's not why we did it. It's simply the next level of care. And it's the right thing to do."

ADDITIONAL INFORMATION:

Making the grade

The Leapfrog Group, a consortium of large purchasers of health care services, will favor physicians and hospitals that:

Use computerized physician order entry systems.
Perform a high volume of procedures on patients with certain high-risk conditions, because studies have shown that such hospitals offer better outcomes.
Staff their intensive care units with physician intensivists trained in critical care medicine.

Leapfrog employers will publicly recognize, promote and reward physicians and hospitals that meet its patient safety standards by, among other things, offering them higher reimbursement rates.

Weblink

The Leapfrog Group, a consortium of businesses working to drive patient safety (http://leapfroggroup.org/)

California's SB 1875, which requires hospitals to implement technology to reduce errors as a condition of licensure (http://info.sen.ca.gov/pub/99-00/bill/sen/sb_1851-1900/sb_1875_bill_20000928_chaptered.html)