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

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.

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."