Safer, Cheaper, Smarter.

Computerized physician order entry promises to streamline and improve healthcare delivery.

Computerized physician order entry (POE) will be come part of standard medical practice in the next 10 years. The last decade witnessed the implementation of sophisticated POE systems at institutions such as the Brigham and Women's Hospital in Boston and the Royal Victoria Hospital in Montreal, among others. Currently, however, the vast majority of hospitals and outpatient facilities have either no order entry or limited voluntary systems with low physician participation.

That will change. Medical mistakes and economic realities are mandating the widespread use of POE to make healthcare safer, cheaper, and smarter.

Safer

A conservative calculation of deaths attributable to medical error makes it the eighth most common cause of death in the United States. The high incidence of iatrogenic illness caused by adverse drug reactions and other medical errors has been known for many years.

However, the publication of "To Err is Human" by the Institute of Medicine (IOM) in 2000 has galvanized public awareness and detailed many measures which could improve healthcare safety. Citing studies in which POE decreased the incidence of adverse drug events, the report recommends a switch to computerized order entry to reduce medication errors and adverse drug interactions. Direct order entry has also been supported by the National Patient Safety Partnership of which the American Medical Association, the American Hospital Association and the FDA are members.

In the wake of the IOM report, the business community has become proactive in healthcare safety. Because American industries pay the lion's share of healthcare insurance costs, they have a vested interest in preventing medical errors.

A number of Fortune 500 companies have formed the Leapfrog Group (www.leapfroggroup.org), dedicated to the discretionary purchase of healthcare services based on the established safety record of the healthcare provider. The use of computerized POE is one of the three initial criteria purchasers will use to evaluate safe practice. This policy, which could affect more than 20 million people, is a powerful incentive for POE adoption.

Also, the California legislature has enacted a law requiring healthcare facilities to adopt technology that has been shown to substantially reduce medication errors. Passed in late 2000, this bill requires most hospitals and clinics to have a plan approved by the State Health Department by the end of 2002 and a system in place by the end of 2004.

Cheaper

The cost of a POE system is substantial. Hardware, software and implementation costs, including personnel training, may run into millions. Nevertheless, these costs may be more than offset by the savings generated by an order entry system.

Bates et al reported in the Journal of the American Medical Association in 1997 (277:307-11) that preventable adverse drug events at Brigham and Women's Hospital in Boston (700 beds) cost an estimated $2.8 million annually. Subsequent work by Bates and others has shown that a POE system can reduce the incidence of serious medication errors by as much as 88 percent.

A POE system incorporating expert content and decision support installed at the Royal Victoria Hospital in Montreal reduced prescription costs by 30 percent when compared to traditional paper-based orders according to a hospital audit. Because good POE systems are integrated with laboratory results, digital imaging records and nursing data as well as the medication administration record (MAR), resulting increased operational efficiency portends even greater savings.

Smarter

In supporting clinical decision making, POE systems:

1 Integrate many pieces of data on single screens, providing the physician with easier, timelier access.

2 Raise clinical alerts based on abnormal laboratory data or combinations of information that the clinician may have overlooked.

3 Provide costs and indications for tests as a guide to physician practice.

4 Indicate when a test is redundant.

5 Provide links to academic resources appropriate to a current clinical situation.

Because all data is coded, the electronic order entry record and database provide fertile ground for the measurement of practice patterns and clinical outcomes. This has immense implications for quality assurance studies, research protocols, and cost analyses. Did all patients with renal failure have a urinalysis? Did all patients with congestive heart failure have their left ventricular function measured?

Shopping for the Best

Understanding the rationale of physician order entry and finding a system that respects the needs of the clinician are two different things. Early medical informatics systems met with resistance because they were developed by IT personnel after little or no consultation with healthcare workers. Here are criteria an institution should consider when evaluating POE software:

* The system was designed with major input from physicians and other healthcare personnel.

* At the installation site users participate in customizing the software to meet their requirements. The system should be modifiable in plain English so that a user-administrator can alter it to reflect local medical practice.

* The system contains expert content and decision support, both modifiable to conform to local practice standards. Good POE software is more than a clerical tool.

* The system uses biometric security technology such as fingerprint scanning to accelerate access, leaving the miseries of passwords to a backup role.

* Customizable order sets are available for standardized treatments such as hip replacement or anticoagulant therapy.

* Order entry is integrated with pharmacy, laboratory, imaging, and nursing activities, including the MAR. This implies an open architecture supporting links with existing systems.

* Navigation through the system is intuitive with many crosslinks to avoid "backing up" through several screens to perform new tasks. Response time must be sub-second for most screens.

* The training cycle for all users is short. Doctors should be able to use the system without formal training if necessary.

* The software comes with a packaged set of clinical alerts and algorithms that review clinical decisions or suggest additional orders. These should be modifiable to suit local conditions.

* The system handles as much entered data as possible in a coded format. This information is used to generate discharge documents or case summaries and provides a database for quality assurance studies and clinical research.

* The program allows for various qualities of users including medical students and residents. Signing rights and areas of access are assignable in accordance with local policy. The system should discriminate among various clinical specialty rights and respect practice limitations (such as restricted drugs) specific to the user institution.

* The electronic format is HIPAA compliant.

* The system accepts the wireless input of data. Locally-transmitting radio frequency devices can further increase workplace efficiency because clinical information can be provided in real time through wireless blood pressure cuffs, glucometers and other instruments.

Learning to Love POE

Despite the endorsement of POE by business and government groups, computerized order entry succeeds only as much as it satisfies its clinical users. The nurse must perceive that order entry saves time and improves his or her communication with the physician. The physician must feel that the program facilitates rather than dictates medical practice. Healthcare workers in general must report that the effort invested in the computerized health record pays dividends in efficiency, quality improvement or both. Our experience with the VisualMED Clinical System indicates that the medical community will soon find this tool as essential as a new MRI. The transition from paper to the electronic healthcare record is upon us. Safer, cheaper, smarter. Gutenberg would be impressed.

Todd McConnell, M.D. is chief of medicine at St. Mary's Hospital, Toronto. He is also director of academic content for VisualMED Systems, Deerfield Park, FL. Contact him at [e-mail].