Montefiore Medical Center
When Montefiore Medical Center executives explored purchasing a new clinical information system in 1994, they were committed to bringing information to physicians where and when it was needed. The Bronx, N.Y.-based organization's blueprint included computerized physician order entry for patient medication. However, four years would pass before the organization, which has 1,250 beds in two hospitals in Westchester County, began implementing a CPOE system for medication management. And it was another three years until the process drew to a close.
According to the hospital's leadership, CPOE always was part of Montefiore's strategy. When the hospital looked for a clinical information system in '94, physicians made up more than half of the search group. The mandate for clinicians' hands-on approach came from Montefiore's president, who championed the value of getting information to the people making decisions to improve quality and reduce the cost of care.
Montefiore's goals always were clear, but the combination of installing a CPOE system while moving to a paperless environment contributed to the lengthy implementation period. This illustrates some of the challenges CPOE presents to hospitals seeking to reduce errors and improve operating efficiency.
CPOE technology can be applied to any or all orders a physician makes at a provider organization. These include, among others, prescriptions, tests and therapies. To date, though, the technology is used primarily for automating the process of writing prescriptions.
CPOE systems help clinicians make decisions about ordering medication by reviewing data, including drug-drug interactions, patient allergies, and other patient information such as weight and current medications. Further, many systems available today include a decision support component.
However, taking advantage of multiple electronic information resources means CPOE systems typically must draw data from other sources, such as pharmacy information systems.
Add to that the cultural challenges inherent in changing the way physicians are accustomed to conveying medication orders - on paper - along with the substantial costs of CPOE, and implementing the technology becomes a monumental undertaking.
Montefiore and a few other pioneering hospitals started down the CPOE road years ago - in some cases more than a decade ago. Most hospitals now implementing CPOE technology, however, began the process only recently, industry observers say. CPOE's market penetration is underwhelming: Industry estimates of hospitals using or installing the technology range from 2% to 6%.
But those numbers won't be dormant for long, many experts say, as the impetus for reducing medical errors - of which medication errors are a major subset - gains momentum. A variety of factors will help awaken hospitals. They include the oft-cited Institute of Medicine report on medical errors and pressure from the Leapfrog Group and other similar employer-led organizations.
Further, even some states are beginning to apply CPOE pressure. For example, under legislation enacted in 2000, hospitals and surgical clinics in California must implement by 2005 a plan to substantially reduce medication-related errors. The law exempts small and rural hospitals.
Reaffirmed with clarifying legislation enacted this spring, the law does not mandate use of computerized physician order entry systems, but it comes close. It references CPOE as a technology shown as effective in reducing medication-related errors. Providers do not have to implement CPOE, but must justify the effectiveness of technology they do implement. While CPOE technology can be used for test or procedure orders, most hospitals begin CPOE efforts with a sharp focus on improving communication of medication orders.
For Montefiore Medical Center, the idea was to replace 11 homegrown information systems with one umbrella system, with a goal of having only one patient identifier number. To replace the 11 disparate systems, the organization purchased an enterprisewide clinical information system in 1995 from IDX Systems Corp., Burlington, Vt.
Montefiore brought up pharmacy, some medical records, lab and radiology in the first phase. In 1998 it began phase two, which included CPOE, online medical charting and charting of other key clinical data, including patient vital signs gathered by nursing staff and other ancillaries. The first nursing unit went live in March 1999.
About 6,000 people were trained to use the physician order entry and online charting applications, including 1,250 full-time and affiliated physicians, 1,800 residents, and 2,000 nurses. The rest are ancillary staff trained in receiving online orders and accessing chart data.
Physicians can order medication, procedures and tests and can enter nurse instructions electronically via personal computers throughout the medical center. Doctors get immediate feedback on drug interactions, patient allergies and any duplicate orders, and can adjust their decisions accordingly.
Physicians also can remotely access the CPOE system from their homes or offices via a secure portal on Montefiore's Website, which passes through its firewall, then connects to the IDX system.
Errors cut 70%
Since the CPOE system was implemented, Montefiore is seeing the rewards of removing the often-redundant steps following a physician's medication order in the old paper-based system. Medication error studies consistently show an error reduction rate of more than 70 percent.
Working with clinicians
Medical school residents do most or all of the electronic ordering at Montefiore and other academic institutions, but they typically are active learners eager to make use of technology. A continuing challenge for the I.T. department is that the residents turn over 500 at a time, which means each new "crop" must be cultivated.
Physician order entry results in a better product, and doctors realize that. Doctors are scientists at heart, and this is just another stage of scientific development.