While the focal point of computerized physician order entry (CPOE) and decision support tools has been reducing medication errors, end-to-end CPOE is integrated with clinical systems in radiology, cardiology and the clinical laboratory. Utilizing CPOE to order imaging exams, clinicians are provided with alerts and reminders to determine which imaging exam is appropriate for the patient. Technologists never question where the order is; they access it from an electronic worklist. And radiologists are provided with more information about the area of concern and indications as to why the exam was ordered.

Computerized physician order entry (CPOE) refers to a variety of computer-based systems that automate and standardize the process for ordering medications and exams. These electronic ordering systems are equipped with intelligent clinical decision support (CDS) tools, a.k.a. alerts, which provide guidance and incorporate knowledge to assist physicians in entering complete, accurate and appropriate patient care orders.

In the past, providers did not rely on informatics in this realm of patient care. But in the 21st century, both workflow and workload are quite different from years past - physicians are confronted with mass amounts of patient data and medical evidence. CPOE systems with CDS mitigate the pressures associated with information overload.

Despite its benefits, the number of U.S. facilities adopting CPOE is still low (and a little uncertain). According to the LeapFrog Group, a consortium of large employees advocating for the implementation of patient safety technology and practices, fewer that 2 percent of U.S. hospitals have CPOE completely or partially available and require its use by physicians. The First Consulting Group of Long Beach, Calif., puts the numbers a little higher, at 5 percent.


WHAT'S THE HOLD UP?

One of the hindering factors is cost - CPOE systems are very expensive, ranging from $1.5 million to $10 million. The cost of developing and implementing CPOE at Brigham and Women's Hospital in Boston, which is maximizing CPOE for radiology ordering and decision support among other applications, was approximately $1.9 million, with $500,000 maintenance costs per year, according to LeapFrog. Installation of even off-the-shelf CPOE packages requires a significant amount of customization for each hospital and can be very expensive, LeapFrog says.

Time is another hampering factor. Rolling out an order-entry system calls for sophisticated levels of integration, especially if it is enterprise-wide. "The platform is provided by the vendor but the problem is that every hospital's catalog of things that are ordered is a lot different," says Donald Rucker, MD, chief medical officer at Siemens Medical Solutions. "There are a lot [of system features] that [vendors] ship, but there are things that institutions have to do themselves and that means that [CPOE] installs run for 18 months to two years."

And a third stumbling block, cultural change, is a component of time. Analysts suggest that CPOE implementation is 30 percent technology-focused, 70 percent organizational. In addition to increasing competition, staffing shortages, rising costs and HIPAA challenges, physicians must learn how to use the system and accept that orders are made via a computer system versus written by hand. "You need to prove the system's clinical relevance by showing how it is going to clinically improve the lives of the physicians, not just get the bill out the door faster," explains Mike Sommers, CIO of Cook County Bureau of Health Services in Chicago, which implemented CPOE in 2002.


THE BRIGHTER SIDE

Early installations of CPOE at university settings have paved the way for their inclusion in mid-size hospitals and smaller clinics. Industry observers estimate CPOE utilization will increase over the next couple of years.

In the 2004 Leadership Survey conducted by the Healthcare Information and Management Systems Society (HIMSS), healthcare CEOs and other senior executive said patient safety concerns remain top priority. Respondents ranked clinical applications, such as electronic medical records (EMR) and CPOE, 60 percent and 55 percent respectively, as the most important applications to be implemented in the next two years.

In 2003, Sheldon I. Dorenfest & Associates Ltd. of Chicago released a report based on data from more than 1,000 healthcare delivery systems, indicating that 15 percent of U.S. hospitals are in the process of implementing a CPOE system in the next three years.


CPOE & RADIOLOGY

Historically, CPOE and decision support has been pushed on medication ordering. But order entry is not a standalone application, but rather a key component of an integrated clinical information system. An end-to-end CPOE can and should be integrated with clinical systems throughout the hospital, such as in radiology, cardiology, laboratory and others. Reducing errors and improving efficiency in these departments, CPOE also decreases ordering delays, improves legibility of orders and helps with the elimination of redundant paper process-oriented tasks.

CPOE also provides an indication for the study, facilitating reimbursement. Sarasota Memorial Health Care System in Florida is at 100 percent order entry throughout the hospital with Eclipsys Corp.'s Sunrise Clinical Manager CPOE. About 50 percent of the hospital's clinicians use electronic order entry, but the provider will soon mandate that all physicians use the system. According to Teresa DaCosta, RN, clinical systems analyst, the hospital has developed a number of mandatory fields specific to radiology in the order form that must to be filled in by the clinician to indicate the reason for the study.

"We actually got together with the radiologists to come up with primary reasons why specific tests would be ordered," says DaCosta. "Because of the list of choices, it is a lot easier for the radiology department to figure out why the test is being ordered. Before the order entry system, we were told to put in [general reasons] such as 'diagnostic' or 'rule out' something. Those are the two main reasons why the tests get rejected from Medicare. Having a list of choices makes it less likely that the physicians are going to put in a reason that will get rejected."

At Sarasota, a study was performed at the very beginning of CPOE implementation to determine reimbursement improvement. "The hospital did a small study in the ER on rejection from portable chest x-rays," says DaCosta. "Having the reason in there resulted in approximately $3,000 more per month of reimbursement that used to get lost."


EARLY ADOPTERS

The Ohio State University Health System (OSUHS) implemented Siemens' Invision CPOE at its James Cancer Hospital in April 2000 and its Medical Center in May 2000. Many implementations at that time were home-grown systems, says Andrew Thomas, MD, assistant medical director at OSU Medical Center.

Order entry is used by physicians for radiology, nursing, medication, laboratory, pharmacy, ancillary consults and physical therapy. "One of our goals in implementation was to minimize the transition phase, so that we did not have some people on paper and some people on electronic on the same unit," he says.

OSUHS showed significant workflow improvements and cycle time reductions in numerous aspects of clinical care by using CPOE, including radiology turnaround time - which experienced a 43 percent reduction. "The data that we published was from the time the test was ordered to the time the test was complete," says Thomas. "We looked at chest x-rays and ultrasound over a two-week period of time, pre-implementation and post-implementation. The ease and timeliness of getting things scheduled in radiology improved with CPOE."

Prior to the system's integration with IDX Systems Corp.'s ImagecastRIS (radiology information system), orders were printed out in radiology and someone had to manually schedule them. Once the two systems were integrated, the orders went directly from the CPOE into an order cue in the RIS.

The system has eliminated the paper trail, but it has not entirely replaced human-to-human communication needed for particular cases. "In the paper world, it might have taken hours where with this it takes less, but it still takes time," explains Thomas. "For example STAT procedures, if somebody has a focal neurological deficit that changed from an hour ago and needs a CT done in the next 20 minutes. You still need to get on the phone and call people in radiology to notify them the test was ordered."

Kathy Tunstall, director of PACS and RIS at OSUHS, was a technologist when CPOE was installed. On the tech end, the biggest benefits include the ability to look at patient history, the limited number of phone calls made to clinicians and overall improved workflow. "You don't have to figure out where the piece of paper is to do the exam, it's all very easy to find it online right on the system," says Tunstall.


GREAT EXPECTATIONS

Cook County offers a unique CPOE implementation because the healthcare provider was able to transition its services in December 2002 to Stroger Hospital, a 1.2 million-square-foot, $623 million filmless facility. Cerner Corp. converted the systems already in place at Cook County, such as registration, scheduling, EMPI, PowerChart, RadNet and CPOE - and install new SurgiNet and FirstNet systems in surgery and the emergency department.

When Stroger's doors opened, the facility was live with CPOE. Physicians use order entry for radiology, laboratory, cardiology, dietary consult and ancillary equipment (medication will be added later this summer). In addition to its tight integration with the RIS, CPOE is integrated with GE Healthcare's Pathspeed PACS (picture archiving and communication systems) and voice recognition.

Ubiquitous access is critical to the system's success so that no one has an excuse not to use it, says Sommers. Cook dispersed a number of terminals throughout the facility, including 2,200 thin-clients, 140 slim-clients (high-end workstations) and 150 COWS (computer on wheels). Some clinicians use wireless PDA (personal digital assistants) and tablet PCs, although Sommer says the latter have not been really been embraced by many clinicians.

Robert Dunne, acting chair, Department of Radiology at Stroger, worked closely with both vendors for the first three months after opening to go over their "problem list" and refine how orders flow to each modality. "In the beginning, we made some errors," says Dunne. "For instance, with fluoroscopy guided biopsy procedures, we originally said fluoro procedures should route to the six machines. But the biopsy procedures are actually done in interventional radiology. When they went to look for the orders online on their systems, they were not there because they had been routed to a different room and a different modality."

As is true in many IT implementations, sites learn over time what works and what doesn't. At the same time, Sommers explains that it is imperative to know what your expectations are before you begin. "Dunne insisted when we did the respective contracts with the two vendors to be very specific in what our expectations were," adds Sommers. "It was a key thing that we did."


ON THE ORDERING END

While technologists and radiologists benefit from the legibility and accessibility of online ordering, the inclusion of pertinent patient information and indications for why the exam is being ordered, clinicians benefit from decision support tools designed specifically for radiology studies.

For imaging exams at OSHUS, Thomas says decision support exists for a couple of reasons, such as preps that must be done prior to tests. "With an abdominal CT, a patient may need to drink barium ahead of time, so this information flashes up to alert the physician that this needs to be [communicated to the patient]," explains Thomas.

In addition, if the physician orders an exam with contrast, there are certain reminders that come up regarding a patient's creatinine level. Similar alerts exist at Sarasota Memorial, where a combination of generic alerts provided with the system and in-house-created alerts are used.

"If the exam has contrast and the patient has an allergy to iodine, dye or shellfish, an alert will pop up as the order is being placed," explains DaCosta. "We are working on one right now that will alert the clinician as he or she is placing the order if the patient has an abnormal creatinine level and then have ordered something with dye or if there is no creatinine level on the chart at all."

DaCosta says an alert exists as a message that pops up to inform clinicians that certain items are out of stock, such as a particular isotope used for nuclear medicine examinations.

Dunne highlights how decision support in turn impacts radiologists. "For radiologists, we don't have to make a million phone calls to doctors, nurses and laboratories to find out what the kidney function is, for example," explains Dunne. "We have it and can determine whether or not the patient can get contrast. For invasive procedures, we know if the patient has abnormal or normal coagulation studies. With the BHCG [test], we know if the patient is pregnant or not. This is important to know [when working] with radiation-producing devices."

Berkshire Health System of Pittsfield, Mass., which consists of a 305-bed medical facility and 25-bed clinic, utilizes Meditech Inc.'s Healthcare Information System (HCIS) with Meditech's Physician Care Manager (CPOE application) and EMR application. Alerts are an important component to the system, says Chuck Podesta, Berkshire's CIO.

In radiology, alerts are used for duplicate testing within a 24-hour period. If the same test is ordered for the patient, the system will alert the physician. "Another alert exists when a physician is going to order a particular type of imaging study and there is a protocol that certain types of lab tests should be viewed before the test is ordered," he says.


REAPING THE BENEFITS

Berkshire installed its EMR first and then introduced CPOE into ancillary departments such as radiology, cardiology, laboratory and pharmacy. Physicians adapted quickly to the order entry piece because they were already accustomed to accessing the EMR and getting test results online. "By having the integrated CPOE, physicians are able to take care of all the orders without going back and forth between multiple systems," says Podesta.

With the automation, Podesta notes that radiology has streamlined workflow and organized their schedule better to avoid wasted time. While no specific numbers have been generated that relate directly to a reduction in patient turnaround time, Podesta notes that the time it takes to get an appointment on the outpatient side is down from what it used to be. "We can do CTs and MRIs within 24 to 48 hours, when in the past it was one to two weeks," details Podesta.

CPOE also organizes the documentation process so that hospitals can get reimbursed more efficiently for the services they perform. At Berkshire, the charge is automatically sent to billing when the tech obtains the image. "We can do more tests in a day due to the streamlined process, which correlates into more charges," says Podesta. "Also, the physician order is e-signed upon entry which allows the bill to be sent to the payer faster since a co-signature is not needed."


CONCLUSION

Fueled by public pressure for improved patient safety, more intense competition among providers, the need for improved workflow and efficiency to reduce costs, the number of U.S. hospitals utilizing CPOE over the next couple of years will grow. Taking into account all of these reasons, the Center for Information Technology Leadership for the California HealthCare Foundation in April estimated that advanced CPOEs (incorporating medication, radiology and lab orders) could save California $4.3 billion annually before costs, or $29,000 per provider in a physician practice setting through lower events-related costs. National savings were estimated at $44 billion a year for advanced CPOEs.

Of CPOE adopters, most will integrate the application's electronic ordering capabilities with other clinical information systems, including radiology. While attending physicians are primarily interested in CPOE, radiologists will remain active participants in the integration since CPOE provides a mechanism whereby a reason for the examination is generated when the exam is ordered. This improves overall patient care and streamlines reimbursement processes. In the future, expect vendors to soup up their CPOE applications and provide more capabilities for building a robust enterprise information and image management system.