Marriage Peril
CPOE: Treating Healthcare's Reign of Error

Computerized physician order systems offer prescription for patient safety.

by Douglas Page 2003

Soon after the Institute of Medicine issued its 1999 report "To err is human", charging that as many as 98,000 people die in any given year from medical errors that occur in hospitals, more than 100 organizations joined hands under the banner of the Leap Frog Group for Patient Safety to help find industry-wide solutions to avoidable medical errors.

Computerized Physician Order Entry (CPOE) quickly emerged as a key component of such solutions.

"Today, the number of people who interact with any clinical process, when coupled with the number of steps involved, creates a prescription for problems," said Stephanie L. Reel, CIO and Vice Provost for Information Technologies, Johns Hopkins University.

An effective CPOE solution, as a component of a strategic portfolio that is tightly integrated in the care process can be instrumental in reducing the opportunity for error, Reel said. CPOE systems feature two principal attractions. They encourage physicians to order electronically rather than through handwritten or oral instructions, and they provide a high level of information about patients by integrating clinical information from a variety of sources, most notably pharmacy, laboratory, and radiology.

Handle with Care

The impact on radiology may at first seem transparent, that physicians will order imaging exams whether or not they can do it with the computer. One of the virtues of computerization, however, is that it introduces a measure of discipline.

"Radiologists complain that ordering physicians frequently omit the reason they are ordering the exam, denying to radiologists clinical clues that might change their a priori probabilities for certain findings," said Philip Drew, Ph.D., president, Concord Consulting Group.

As a result, radiologist accuracy, either for finding

diseases present or for ruling out diseases absent, suffers. A computerized order entry system can force the ordering physician to fill out all fields, including the reason for exam, before it will accept the order, thus, perhaps, improving the practice of medicine, Drew said.

Improving patient safety is the real intent of CPOE, and radiology has a role in this.

CPOE can reduce or eliminate order errors created when clerks transcribe imaging orders from written charts, said Deniese Chaney, an SAIC Healthcare consultant.

In a manual system, clerks transcribe chart orders to radiology requisitions, which are sent to radiology for processing. With CPOE, physicians enter orders directly, eliminating clerical intervention along with transcription errors.

At Montefiore Medical Center in New York City, the multiple handoffs associated with getting these orders to the radiology

department and the numerous clarifying phone calls and conversations are virtually eliminated by deploying CPOE functionality.

"While the extent of any improvement depends on the system, we’ve measured between .5 and 1 FTE saving in radiology from eliminating re-keying of orders from physicians," said Rick Taylor, IDX Systems, Seattle.

CPOE could also help determine the efficacy of certain imaging studies. Dr. Steven Horii, clinical director of Medical Informatics, University of Pennsylvania Medical Center, said that while he believes it is the radiologist's responsibility to determine if contrast is, or is not, indicated or is contraindicated, "if referring physicians are allowed to order CT studies with contrast, CPOE could screen for out-of-range renal function studies, use of glucophage, etc., that could be used to provide a warning back to ordering physicians."

Likewise, CPOE software could screen for appropriateness or contraindicated examinations, such as abdominal CT immediately following a barium enema or upper GI. Or, CPOE could feed questions back to the ordering physician based, say, on the patient's age - e.g., 'Is, or could, this patient be pregnant?' CPOE software could also direct the requesting physician to call radiology based on certain rules, such as if the patient had a previous examination of the same type within 24 hours, Horii said.

"CPOE is the logical place for radiology to provide point of presence decision support," said Dr. Paul Chang, Director, Radiology Informatics, University of Pittsburgh School of

Medicine. "We will be able to educate and guide our clinical colleagues with respect to appropriate test selection. We will be also be able to get access to more accurate clinical history and indications using CPOE. This is not only good medicine but increases the likelihood of accurate ICD9 coding."

CPOE will be critical to anyone trying to get a handle on over-utilization of radiology services. The challenge will be making the CPOE interface efficient and friendly-enough to

be acceptable to clinicians, he said.

"CPOE is a huge win for radiology," said Paul Nagy, Ph.D., assistant professor of radiology, Medical College of Wisconsin.

Radiology is an ancillary service driven by orders from the primary care physicians and clinicians.

"We spend so much time triple checking the accuracy of an order," he said. "Patients come to the department all the time without the correct order information and we have to end up tracking down the ordering physician, which is time consuming to say the least.

CPOE provides an awesome front end that can save radiology alot of time in checking accuracy of orders."

Radiology can also use CPOE as a feedback mechanism to correct poor ordering practices of certain physicians who keep asking for exams that are not in keeping with current

industry best practices. It improves billing by forcing accurate ICD-9 codes (or symptoms) that justify certain procedure codes (CPT).

"CPOE can be a challenge for clinician acceptance, but it is all gravy for radiology," Nagy said.

Patient Safety

"There is probably nothing that will challenge us as an industry as much as patient safety, and yet there is probably no greater way to make an impact in the macro-economic future of healthcare than by addressing patient safety," Reel said.

Technology is not the complete answer. Fundamental

attention to the details, and low-tech solutions are often equally important, and are sometimes the differentiating factor between success and failure, she said.

Two recent studies help formalize the impact of CPOE on radiology, care delivery, and patient safety.

One paper (J Am Med Inform Assoc 2002 Sep-Oct;9(5):529-39) suggests hospitals implementing CPOE can significantly cut the time it takes to complete radiological studies, obtain lab tests, and deliver medications to patients by having doctors fill out orders via computer rather than by hand.

Aside from the obvious benefit of eliminating prescription drug errors associated with handwritten prescriptions, the study found that CPOE cut turn-around times for x-rays and other radiology procedures by 43% (from just over seven-and-a-half hours to four hours and 21 minutes), cut medication turn-around times by 64% (from nearly five-and-a-half hours to just under two hours), and reduced turn-around times for lab tests by 25% (from 31 minutes to 23 minutes).

Another study, presented at the January 2003 meeting of the Society for Critical Care Medicine, showed that an order entry system implemented at Cincinnati Children's Hospital Medical Center significantly reduced the time it takes to obtain radiology film on patients in the pediatric intensive care unit and to receive oral reports from the radiologist.

CPOE reduced the time of arrival to take the x-ray from 18 to eight minutes (56% improvement) and the time the x-ray was available for viewing from 33 to 24 minutes (27%).

All patient orders, including radiology studies, medications, special diets, laboratory studies, tests, and consultations are included in the system. Stat radiology orders, for example, are electronically routed to a pager carried by a radiology technician.

The system also resulted in fewer phone calls between clinicians and radiologists to either clarify or augment information. User satisfaction surveys indicated that physicians, radiologists, and radiology technicians are pleased with the new system.

One Surprise Fits All

Those contemplating CPOE can expect to be surprised, said Dr. Richard Dykstra, assistant professor of medical informatics, School of Medicine, Oregon Health & Science University.

"Every location we studied and almost all in the literature faced serious challenges, among them communication problems," Dykstra said.

Healthcare has developed communication channels over the past century from pneumatic tubes to fax, beepers, and email. CPOE promises to replace much of this with 'instant' communication, threatening to replace face-to-face communication in the process.

"It is in the face-to-face that the CPOE effect is felt the most," Dykstra said. "Without communication, care teams loose coordination and may cease to be teams."

This effect, though serious, is temporary, he said. Healthcare workers are remarkably resilient and always discover new ways to communicate.

Reel advises enterprises to leverage their strengths, encourage and celebrate the small victories, build on examples of success, listen carefully, and include clinicians in the process.

"Clinicians long to contribute to the solution, and failing to give them an opportunity to do so is wasteful," Reel said. "And be absolutely certain that you have created a reliable, robust technological and support environment that can support the people who must interact with the system."

Reel offers a final caveat. Top-down "big bang" approaches are almost always destined for failure.

To succeed in the challenging environment ahead, radiology departments must evaluate business and technology strategies against their ability to create a more efficient healthcare service delivery model, said Jim Bloedau, president, Information Advantage Group, San Francisco.

"Improving efficiency and safety means getting the right information to the right person at the right time, the Holy Grail of realtime computing," he said.

At the heart of this computing model will be the RIS and the integration of enterprise CPOE into it.

"The RIS is the brains of the radiology departmental operation, in the very near future it will look quite a bit different than it does in most places today," Bloedau said.


Comments? Questions? Corrections? Purchase Orders? douglaspage@earthlink.net
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