Working hard for the data (Toward an Electronic Patient Record meeting)

Proponents of computerized physician order entry point to the efficiencies of electronic medical records. Opponents say these systems just pile more work on physicians, and the payoff isn't there yet.

By Tyler Chin, amednews staff. June 13, 2005.

Reports from conferences important to physicians

Is adoption of computerized physician order entry ready for takeoff? Judging by year-to-year growth in CPOE adoption, and from interviews of physicians attending the 21st annual Toward an Electronic Patient Record conference May 16-18 in Salt Lake City, the answer is yes. But 20 years of history says -- not so much.

Physicians are entering orders electronically in about 4% of the country's hospitals, up from 3.2% in 2004, said Jason Hess, director of business development of KLAS Enterprises LLC, an Orem, Utah-based health technology market research firm.

E-evangelism
Typing away
The right EMR fit for your practice
E-prescribing's hope: Pay-for-performance
See related content
Topic: Electronic medical records

A major reason for the rise is 163% growth in nonteaching facilities using CPOE, compared with 60% growth in teaching facilities, which overall make up the majority of hospitals using CPOE, Hess told conference attendees. "I think what this represents is privileged non-employed physicians are embracing CPOE and are starting to do a lot more with this compared to where we were in years past," he said.

But while the increase in the rate of adoption is encouraging for CPOE proponents, the reality is that CPOE is one of the least adopted technologies in health care, despite being around for more than two decades. "It's still very much in its infancy," said Adam Gale, vice president of operations at KLAS Enterprises.

There are several reasons that few hospitals and doctors use CPOE, which calls on physicians to enter hospital orders themselves into a computer system. These include cost; a culture in which physicians are used to writing and handing orders to nurses and clerks; and the fact that vendors sell systems that are poorly designed for physician use. Doctors also haven't adopted CPOE because it takes time and doesn't make their job easier or better, critics say.

"There are many advantages of CPOE, and we'd like to do it," said Keith Conover, MD, an emergency physician at Mercy Hospital, Pittsburgh. The hospital is interested in buying CPOE, but not until at least 2009, because "we've seen so many people fail so miserably at it," he said. Also, "the systems available now are so -- in a word -- clunky. They slow people down and they induce other errors. The trouble is that the people who are designing them don't understand much about user interaction design," or usability.

For example, when he enters orders on paper, Dr. Conover doesn't have to check off whether a patient is pregnant or needs a wheelchair for an x-ray. But "most CPOE systems insist that the physician [answer] those questions," said Dr. Conover, a first-time TEPR conference attendee. "It doesn't make sense to pay someone $150 an hour to do data entry."

Another reason few hospitals use CPOE is that most of them don't have the technology infrastructure to support the application, including having a clinical data repository and ancillary information systems in place, said John Quinn, chief technology officer at CapGemini, a New York health care technology consultancy.

Dennis Regan, MD, an internist and medical director of information systems at Deaconess Billings (Mont.) Clinic, echoed Quinn's comment.

Citing research done by Deaconess Billings, a health system currently rolling out CPOE, Dr. Regan said infrastructure differentiates hospitals that successfully implemented CPOE versus those that failed. The successful institutions had transcription, laboratory orders and results, microbiology, radiology, pathology, medication administration records, physician documentation, master patient index or admission discharge transfer, scheduling and prescriptions online, Dr. Regan said.

"CPOE's not one of those things where you just go, 'OK, here's CPOE and now quality's [suddenly] improved,' " he said.

For example, it's common for a physician to order 2 mg to 6 mg of morphine to be delivered intravenously to alleviate a patient's pain. Good nurses will know what dosage to give within that range, but "the computer just chokes on that," because it doesn't understand that the physician did not order a specific dose, Dr. Regan said. "This is a process that is very hard to replicate in some reasonable way in the computer, and it is just one [example] of, like, a zillion."

Still, Dr. Regan believes CPOE "is poised to take off because we have been through the first bleeding-edge implementations where people didn't understand all this stuff and just blamed the doctors saying, 'Oh, they don't want to use it. They are just a bunch of reactionary jerks,' " he said. "Then they realized that the doctors are making sense and have really legitimate problems with this."

Some say physicians eventually will have to enter orders electronically whether they like it or not. But unless they are residents or hospital-employed, doctors at this time don't have to worry about CPOE being rammed down their throats because so few hospitals are using it, said KLAS Enterprises' Gale.

"In the community hospitals, a lot of doctors have said, 'Look, if you make me do this, I'll go practice somewhere else,' " Gale said. "But when CPOE is more fully deployed, and any hospital they go to is going to be doing CPOE, they won't be able to use that threat anymore."

ADDITIONAL INFORMATION:

E-evangelism

Since his 2004 appointment as the country's first national coordinator for health information technology, David Brailer, MD, has crisscrossed the country to speak and promote electronic medical records health care information technology at various industry conferences. He was scheduled to speak at TEPR May 17 but had to cancel at the last minute because of business in Washington. Among the stops on his EMR tour this year:

Conference	City	Date
Healthcare Information and Management Systems Society	Dallas	Feb. 17
The American Health Quality Assn.	San Francisco	Feb. 25
American Medical Informatics Assn.	Boston	April 11
Milken Global Institute Global Conference	Los Angeles	April 18
American Hospital Assn.	Washington, D.C.	May 2
National Healthcare Information Technology Summit	Nashville, Tenn.	May 5
Toward an Electronic Patient Record	Salt Lake City	May 17 (Cancelled)
Workgroup for Electronic Data Interchange	Baltimore	May 24
Governing magazine / Managing Technology Conference	Chicago	June 2
HIMSS: Public/Private Partnership	New York	June 7
4th Annual Telehealth Leadership Conference	Washington, D.C.	June 8

Source: Office of the National Coordinator for Health Information Technology

Typing away

The percentage of the country's 5,764 hospitals using computerized physician order entry systems is going up, according to KLAS Enterprises LLC.

	Percentage of hospitals	Estimated physician users
2003	2.8%	45,000
2004	3.2%	69,000
2005	4.0%	113,000

Source: KLAS Enterprises LLC

The right EMR fit for your practice

As physicians increasingly hit the market for electronic medical records software, they may find that their inclination to buy products from large, established vendors could backfire on them, warned Arthur Gasch, CEO of Medical Strategic Planning Inc., a Lincroft, N.J.-based EMR market research company.

Because physicians are sensitive to making a substantial investment in an EMR that could put them out of business if it fails, doctors tend to go with "larger vendors that are perceived as being more stable," Gasch said at the Toward an Electronic Patient Record conference held May 16-18 in Salt Lake City. But the problem is that large vendors are more likely to lack "workflow management engines" in their products than smaller vendors, he said.

"One of the things that is important about workflow and workflow engines being embedded in [EMR] products is that it gives the vendor the ability to custom-tailor the capabilities of the system to the needs of a specific practice," Gasch said. "Many vendors sell flexible kinds of products but generally, I think, the smaller vendors with the newer products are selling more flexible products."

Before physicians even attend a health information technology conference such as TEPR to check out EMRs -- or ask vendors to visit their practices -- they should analyze their workflow, Gasch suggested. For example, what is the workflow required for a newborn visit? After you know your own workflow, the next step is to ask vendors "to show you how that specific workflow in your practice can be implemented and not necessarily ... the workflow they generated for the specific show you're going to," he said.

When shopping for an EMR, doctors should keep in mind that a vendor's product may be an excellent fit for one specialty but not travel well for another. "One size fits all doesn't work," Gasch said.

E-prescribing's hope: Pay-for-performance

Pay-for-performance initiatives will boost physician adoption of electronic prescribing, predicted Anthony Schueth, managing partner of Point-of-Care Partners LLC, a Margate, Fla.-based health care consulting company.

A big reason why is that those initiatives are starting to give physicians financial rewards for using technology or meeting certain outcomes -- rather than just simply having an e-prescribing system, Schueth said at the Toward an Electronic Patient Record conference May 16-18 in Salt Lake City. Current estimates put the percentage of doctors adopting e-prescribing in the low single digits.

"Too many doctors get this system, install it in their offices and then they use it and come upon a glitch and sit it down," he said. "So, pay-for-performance [as it evolves] is going to improve utilization for e-prescribing. It may not be a boom but it certainly will have a very positive impact."

Another reason Schueth believes pay-for-performance initiatives will drive e-prescribing is that he expects the insurers and employers sponsoring those plans to offer a 5% to 10% differential above current reimbursement levels. Many observers believe that's the payment threshold that needs to be crossed in order to get physicians to participate in pay-for-performance. Right now, few plans are offering more than a 5% differential.