Qual-IT - June 2006 | Archived

Comparing national health care expenditures—including investment in and use of HIT—a recent article in Health Affairs found U.S. per capita health spending to be about two-and-a-half times that of other leading industrialized nations (Anderson 2006).  In 2003, data from the Organization for Economic Cooperation and Development (OECD) show, health care spending accounted for 15 percent of the U.S. gross domestic product, compared to a median of 8.4 percent for the other OECD countries.

Despite higher per capita spending, however, the U.S. lags in its efforts to promote widespread adoption and use of HIT.  Several other countries, including the United Kingdom and Canada, are well on the way to implementing national electronic health information systems, while the U.S. has only recently launched initiatives to design prototypes for a national health information network.  Current federal HIT initiatives account for $0.43 spending per capita, compared to $192 per capita in the United Kingdom, $31.85 in Canada, and $21.20 in Germany.  Legislation pending in Congress would only modestly increase government funds for HIT implementation.

The Health Affairs authors assert that public subsidies for HIT are needed to overcome the lack of economic incentives for providers to invest more in these systems.  Previous research has estimated that it would take more than $150 billion for the capital and operating costs of a broad HIT network in the U.S., so both the public—as in other OECD countries—and private sectors will need to make major financial commitments to HIT if this vision is to be realized.

Research points to—but does not conclusively prove—the quality and safety benefits associated with computerized physician order entry (CPOE) systems, particularly in the hospital settings where they are most commonly used.  While CPOE has a variety of potentially beneficial uses, its primary value for patient safety seems to lie in its ability to reduce medication errors and adverse drug events, common problems resulting in both significant harm to patients and increased costs.

One literature review of patient safety practices, commissioned by the Agency for Health Care Research and Quality (AHRQ) and published in July 2001, found that almost 800,000 people are injured or die in hospitals annually as a result of adverse drug events (Kaushal 2001).  The majority of these events, the review suggests, result from errors in ordering, the point at which CPOE could have the greatest effect.  Research on CPOE, especially when used in tandem with clinical decision support systems (CDSS), is limited, however.  Both the 2001 study and a more recent AHRQ study on HIT costs and benefits (Shekelle 2006) found the overall number of studies available for review, and their scope, too small to draw definitive conclusions about CPOE/CDSS and the prevention of adverse drug events.

Nevertheless, there is encouraging evidence that CPOE and CDSS together reduce medication errors.  One study cited in the 2001 report demonstrated a 55 percent decrease in serious medication errors, and a 17 percent decrease in preventable adverse drug events, and the 2006 report found that CPOE and CDSS reduced medication errors in pediatric inpatient settings.  Despite the small numbers, the results were promising enough that both reports recommend additional research on these systems.

With a lack of standards often cited as a major barrier to widespread HIT adoption and use, it is hardly surprising that specifications and protocols for CPOE vary widely.  Inpatient CPOE was one of three safety practices evaluated in a hospital survey by the Leapfrog Group, the national health care-purchaser initiative.  Given a limited number of studies on which to draw, Leapfrog commissioned the development of a CPOE evaluation methodology to establish criteria for functions improving the safety, quality, and efficiency of care, and to assess hospitals' implementation of computerized order entry systems based on those criteria.  While the authors note that there is no “gold standard” against which to compare their methodology and the evaluation results, application of this tool did reveal significant differences in the range of CPOE functional capabilities, and performance of those functions covered, across systems (Kilbridge 2006).  The development of standards and HIT product certification would help providers and purchasers as they work together to improve health care delivery and outcomes, the study concludes.

But completing the value equation for CPOE requires similar studies of the costs associated with acquiring, building, and implementing these systems.  Just such a detailed assessment of a hospital's CPOE system was conducted recently by members of the Brigham and Women's Hospital CPOE Working Group, who, individually and collectively, conducted much of the research on medication errors and adverse drug events discussed earlier.  While it took five years for Brigham and Women's to begin accruing net benefits, and longer to achieve actual operating budget savings—most costs are incurred in the initial years of implementation—the hospital ultimately realized significant net cost savings, the researchers found (Kaushal 2006).  And when 100 percent of the hospital's physicians began using the system, and CPOE was effectively interfaced with a variety of other HIT functions—both conditions necessary to obtain the full benefits of CPOE—additional benefit accrued in the form of improved patient safety.  Despite the length of time from initial implementation, and the need for upfront capital financing, there is a strong return on investment in CPOE, both financially and in terms of quality, the authors conclude.

Hospitals will also evaluate the costs and benefits of HIT, including CPOE, in the context of both regulatory and market considerations.  Leapfrog has provided the initial impetus on the market side, and now the new Joint Commission on Accreditation of Healthcare Organizations requirements for documentation and tracking of patients' medication histories and inpatient and post-discharge medication orders will give hospitals one more reason to make CPOE implementation a priority.  In addition, quality improvement organizations under contract with the Centers for Medicare & Medicaid Services are providing hospitals with technical assistance on CPOE and other HIT implementation efforts.  This combination of forces may help push the nation's hospitals to achieve widespread adoption and use of CPOE and CDSS.

More and more HIT leaders are advising that it is time to accept the benefits of HIT as currently documented and move on with widespread implementation efforts.  As John Halamka, MD, a pioneer in Boston-area HIT collaborations notes, the U.S. so desperately needs the quality and value gains that HIT offers that there is a new sense of urgency and willingness to bet on electronic health records despite the limited scope of existing evidence.  “Several applications seem so likely to improve the quality and effectiveness of care that we should use them now,” he advises (Halamka 2006).

Adds Mark Frisse, MD, a leader in national and Tennessee HIT collaborations, “A growing body of hard data on the benefits of CPOE presents a compelling case for all who make CPOE decisions to move forward.  They should accept, once and for all, that substantial benefits will accrue to hospitals and patients following the successful implementation of effective CPOE systems.  The challenge is not to fine-tune the financial benefit models, but instead to determine how to identify and successfully install an effective system” (Frisse 2006).

One of the leading researchers on CPOE and patient safety, and the lead author for the Brigham and Women's Hospital study, Rainu Kaushal, MD, MPH, works with a number of New York HIT initiatives to develop their research and evaluation plans.  Now on the faculty of Cornell Weill Medical School and director of quality and patient safety at the Komansky Center of NewYork-Presbyterian Hospital, Dr. Kaushal is principal investigator on the United Hospital Fund grant-supported NewYork-Presbyterian project “Determination of Physicians' Expectations of and Satisfaction with an Electronic Medical Record (EHR).”  Dr. Kaushal, who is board certified in both internal medicine and pediatrics, received her medical degree from Harvard Medical School and her MPH from the Harvard School of Public Health.

On May 24, Governor Pataki announced the award of 26 grants for community initiatives, across New York State, through the first phase of HIT funding under the Health Care Efficiency and Affordability Law for New Yorkers (HEAL-NY) program.  These projects are designed to improve health care quality, safety, and efficiency through clinical data exchange, electronic prescribing, electronic health records, and other elements of HIT implementation.  Additional information about the grants and the HIT component of HEAL-NY can be obtained through the New York State Department of Health website.

Anderson GF, BK Frogner, RA Johns, UE Reinhardt. 2006. Health care spending and use of information technologies in OECD countries.  Health Affairs 25(3): 819-831.

Frisse ME. 2006. Editorial: Comments on “Return on Investment” as it applies to clinical systems. Journal of the American Medical Informatics Association 13(3): 365-367. Available online at www.jamia.org (subscription or fee for copy required).

Halamka JD. 2006. Editorial: Health information technology: Shall we wait for the evidence? Annals of Internal Medicine 144(10): 775-776. Available online at www.annals.org (subscription or fee for copy required).

Kaushal R and DW Bates. 2001. Computerized physician order entry with clinical decision support systems. In Making health care safer: A critical analysis of patient safety practices. Evidence Report/Technology Assessment No. 43. Rockville, MD: Agency for Healthcare Research and Quality. Available online at www.ahrq.gov/clinic/ptsafety/

Kaushal R, AK Jha, C Franz, et al. 2006. Return on investment for a computerized physician order entry system. Journal of the American Medical Informatics Association 13(3): 261-266. Available online at www.jamia.org (subscription or fee for copy required).

Kilbridge PM, EM Welebob, DC Classen. 2006. Development of the Leapfrog methodology for evaluating hospital implemented inpatient computerized physician order entry systems. Quality and Safety in Health Care 15(April): 81-84. Available online at http://qhc.bmjjournals.com

New York State Department of Health. Information on the HEAL-NY HIT awards is available online at www.health.state.ny.us/technology