Computer Physician Order Entry: Benefits, Costs, and Issues

In 1998, the Institute of Medicine's (IOM's) National Roundtable on Health Care Quality noted that the quality of health care in the United States has substantial problems and that the problems will be addressed only through profound changes to the current health care system (1). The recent IOM report (2), Crossing the Quality Chasm, contained an unsettling list of studies documenting the prevalence of poor-quality care in the United States. Another IOM report (3), To Err Is Human, focused specifically on the current state of patient safety and ways to improve it. All three of these reports recognized the potential for information technology to be an important agent for change. Computer physician order entry (CPOE) allows physicians to enter orders directly into a computer rather than handwriting them (46). Because CPOE introduces supportive technology into orderingone of the key processes in medicineit has the potential to address many quality problems. Computer physician order entry affords a health care organization opportunities to standardize practice; incorporate clinical decision support into daily practice; improve interdepartmental communication; facilitate patient transfers; and capture data for management, research, and quality monitoring. It provides physicians and other clinicians with an environment that is more appropriate than a paper-based setting to the complexities of today's medicine. Patients also can have the comfort of knowing that sophisticated technologies are being applied to help ensure their safety. Because implementing CPOE is an expensive and complex project that touches almost all aspects of the health care operation (4), only a few health care organizations in the United States have implemented it (4, 7, 8). However, such stakeholders as business, government (9), and payers (10) are creating pressures and incentives for organizations to adopt CPOE. In particular, the Leapfrog Group (11), a coalition of the country's largest employers who are eager to acknowledge and reward health-related quality improvement efforts, has identified CPOE as one of three important leaps that organizations can take to substantially improve patient safety. Many health care organizations are moving forward with CPOE efforts. In 2002, 67% of respondents to a survey conducted at the Health Information Management and Systems Society (HIMSS) Annual Conference said that their organizations were planning to implement CPOE; 21% said that they were currently implementing it, and 29% said that they were actively discussing it (12). As health care organizations decide whether and when to tackle the hurdles of implementing CPOE, they should keep in the forefront of their minds the ways in which this technology can be used to improve health care quality and efficiency. We examine the potential benefits, costs, and other important issues associated with CPOE. Benefits of CPOE The National Roundtable on Health Care Quality (1) recognized that problems in health care quality fall into three categories: the underuse, overuse, and misuse of health care services. The Roundtable noted that reducing the overuse and misuse of health services leads to an increase in health care quality while decreasing costs. Reducing underuse increases quality but may increase costs. Computerized physician order entry may affect all three categories of health care quality problems, as well as inefficiencies in the health care system. Table 1 lists studies that have evaluated the effect of CPOE on various aspects of health care. Table 1. Studies Showing the Effect of Computer Physician Order Entry on Health Care Variables Several studies have shown that CPOE can reduce underuse. Dexter and colleagues (13) found that, for eligible patients, reminders in CPOE systems increased ordering rates for prophylactic aspirin for coronary artery disease, pneumococcal vaccine, influenza vaccine, and prophylactic subcutaneous heparin. Teich and colleagues (14) also found an increase in the use of prophylactic subcutaneous heparin with CPOE. Overhage and colleagues (15) demonstrated that compliance with the monitoring of drug levels doubled when automated ordering reminders were implemented. The effect of CPOE on care may depend greatly on the subtle details of the application design. In one evaluation, a decision support feature did not increase compliance with guidelines (16); however, success was realized after the design of the feature was enhanced (13). Inappropriate admissions accounted for much of the overuse documented by the IOM report (2); CPOE applications may not be able to affect this problem. However, overuse of diagnostic procedures (31, 32) and antibiotics (33) has been well documented and can be addressed by CPOE. As part of the interaction with the user, CPOE can present cost data (17, 18), previous results (19, 20), and information about the likelihood of finding an abnormal result (21, 34), all of which have been shown to reduce the overuse of diagnostic tests. In one trial, the Centers for Disease Control and Prevention's guidelines for vancomycin use were embedded in a CPOE application; 28% (P < 0.02) fewer patients were prescribed vancomycin or had their vancomycin order renewed as compared with CPOE without the automated guidelines (26). Of two CPOE-based interventions designed to reduce the use of radiology examinations, one was successful (22), while another had minimal impact (23). In summary, more study is needed to understand which quality problems are best suited to remedy by computerized intervention and which system designs are most successful in achieving behavioral change. Misuse of medications is an important concern that leads to various safety problems, including serious medication errors and preventable adverse drug events, as highlighted in the IOM's recent report (3). Two studies that examined the root cause of serious medication errors (35, 36) showed that about half were ordering errors such as an incorrect choice of medication for the patient's condition, an incorrect dose of the medication given the patient's physiologic state (for example, renal insufficiency or advanced age), and prescribing a medication to which the patient was known to be allergic. Computer physician order entry systems have the potential to address these problems, and studies have shown that CPOE systems can reduce medication errors (24, 25) and associated costs and injuries (27). The features of CPOE that promote the safe use of medications include patient-specific dosing suggestions (14, 28, 37), reminders to monitor drug levels (15), reminders to choose an appropriate drug (14, 15, 26, 27), checking for drugallergy and drugdrug interactions, standardized order sets (that is, departmentally sanctioned predefined collections of orders that promote safety and efficiency, especially in complex situations), increased legibility, automated communication to ancillary departments, and easy access to patient data and reference information while ordering (37). A CPOE application with an integrated antibiotic advisor has been shown to reduce the rates of excessive drug dosages and antibiotic-susceptibility mismatches (27). Additional medication-related benefits can be realized if CPOE is well integrated with other components of the medication process. The benefits of interfacing CPOE to a pharmacy application have been described (38), and interfacing a CPOE application and an electronic medical administration record at one institution eliminated transcription errors (29). Although the IOM report (3) focused on the misuse of medications in the inpatient setting, new data suggest that the magnitude of the problem is similar in the outpatient setting (3941). Emerging technologies that automate prescribing and electronically link the ordering provider, the pharmacy, and the patient may address many medication-related problems in the ambulatory environment. Of note, CPOE applications are complex and are intended for use in complex health care environments. Although CPOE has the potential to reduce many sources of error, organizations must take care as CPOE is implemented so that new kinds of errors will not be introduced (25, 42). Most evaluations of CPOE have examined its effect on specific components of the care process, such as the use of diagnostic testing or medication error rates. A few studies have examined the effect of CPOE on overall hospital costs and length of stay. Evans and colleagues (27) demonstrated reduced costs ($26 325 vs. $35 283; P < 0.005) and length of stay (10.0 days vs. 12.9 days; P < 0.003) in patients in an intensive care unit when the suggestions of a computerized antibiotic advisor incorporated into the ordering process were followed. A randomized, controlled trial at one hospital (30) indicated that inpatient costs were 12.7% lower (P < 0.02) and the length of stay was 0.89 day shorter (P = 0.11) for patients on general medicine wards that used CPOE with decision support. In a time-series design, Mekhjian and colleagues (29) documented a decreased length of stay at one of two study hospitals from 3.91 days to 3.71 days (P = 0.02); the length of stay at the other hospital in the study did not change, and overall costs at the two study hospitals did not change. Researchers are studying ways that CPOE can help physicians plan a therapeutic regimen (43, 44). Such planning systems hold special promise for improving quality and safety; however, they involve complex modeling of diagnosis and therapeutics (45). To be successful, planning programs must be integrated tightly into the workflow of the application and must not require excessive additional data entry by the physician. To date, attempts at integrating complex clinical guidelines into CPOE have met with limited success (46, 47), largely because published guidelines, although suitable in printed form for use by practicing clinicians, have been difficult to translate into