New Report
on Computerized
Physician Order Entry
 |
MTC Executive Director Mitchell Adams with Governor Romney, Lt. Gov. Healey and Peter Slavin, MD, President of the Massachusetts General Hospital at the press event on December 6, 2004 in the historic Ether Dome at MGH. This report was released December 6, 2004 in conjunction with Governor Romney's announcement of the Massachusetts eHealth Collaborative (MaeHC). Read the Executive Summary below or the full report in pdf. |
Executive Summary
Treatment Plan: High Tech Transfusion
Case Statement for Implementation of CPOE in all Massachusetts Hospitals
"There are advanced technologies which can dramatically lower health care costs and improve quality. The technologies are proven. The associated benefits are known. But there are barriers in the system which impede their implementation. We can change that."
From: "Advanced Technologies to Lower Health Care Costs and Improve Quality"
Computerized Physician Order Entry (CPOE)
is a computer application used by physicians to order clinical services for patients. CPOE improves the accuracy of orders and provides clinical decision support so that the most common medical errors are avoided. Implementation of these systems has demonstrated substantial cost savings and significant improvement in patient safety and overall quality of care.
What if we could both improve the quality of medical care and decrease its costs by bringing 21st century technology to health care?
If CPOE systems were operating in all acute care hospitals in Massachusetts, patient safety and the quality of patient care could be greatly improved, and costs could be substantially reduced. Yet now, in 2004, 70 percent of all Massachusetts hospitals — 46 institutions — do not have this essential technology.
The Massachusetts Technology Collaborative (MTC) and the New England Healthcare Institute (NEHI), in conjunction with First Consulting Group (FCG) and a Working Group broadly representing the state's health care system, concluded that fully implementing CPOE programs in all of the state's acute care hospitals has the potential to reap $275 million in net cost savings annually to the state's health care system. Full installation of CPOE systems could be completed for a capital expenditure of $210 million.
So if a $210 million investment can generate on-going savings of $275 million, not to mention significantly improve patient safety and care, what's keeping that investment from happening? This Case Statement first explains the barriers that currently impede the implementation of CPOE systems, and then proposes a solution to these problems. We identify a framework and pathway for universal adoption of CPOE systems in all Massachusetts hospitals.
THE STATE OF THE ART CPOE Adoption Rates in Massachusetts' Acute Care Hospitals are Very Low
Today, just 10 percent of Massachusetts' acute care hospitals have CPOE systems installed and operational. Another 20 percent are currently in the process of implementing systems. Most often these are the large tertiary care hospitals. The remaining 70 percent of the state's acute care hospitals, typically those with fewer than 500 beds, do not have CPOE systems.
But Why? Barriers to Adoption of CPOE
This is no easy task. There are three significant barriers that hinder the adoption and implementation of CPOE:
- A CPOE system is a major IT installation. Costs can be substantial and may present a significant, and in many cases, overwhelming challenge. Up to this point, it has been difficult to quantify the anticipated savings from implementing such systems, and equally hard to determine to whom the savings accrue (payers vs. providers).
- Resistance to CPOE systems among clinical and administrative staff remains a significant barrier to adoption. Implementation of a CPOE system results in major changes in the work processes of a hospital. Not only is it disruptive, it also requires a reconfiguration of hospital operations and a willingness on the part of the staff to accept change.
- Up to this point, there have been no clear specifications and standards regarding the capabilities and performance of CPOE systems, or guidelines regarding best practices for installation and implementation.
Costs and Savings for Statewide Implementation
If standardized CPOE systems were installed in each of the 46 Massachusetts hospitals currently not using this technology, total one-time installation costs would be approximately $210 million. Conservative estimates and accepted studies show total net savings to the health care system in Massachusetts to be at least $275 million annually. Of this amount, $175 million would accrue to the hospitals, and the balance of $100 million to payers and patients.
CLEARING THE PATH AHEAD: Removing the Barriers
- Standards: The Case Statement presents a full set of minimum application and performance
standards for Massachusetts hospital CPOE systems. Best practices to insure successful
implementation are also outlined. - Funding and Incentive Model – A “Straw Man”: Meeting the substantial and in many cases overwhelming capital requirement is critical. And a program of incentives could greatly speed implementation of standard, interoperable systems. As a "straw man" the Case Statement proposes that all payers (health plans, employers, Medicare, and Medicaid) agree to a collaborative approach in which half of all project costs would be provided by payers. This support would be made available in two parts: half as a grant paid over project implementation, and half contingent, to be paid depending on the achievement of performance metrics.
Governance, Organization and Resources
In addition to the hospital CPOE project, there are a number of parallel and closely related projects underway. Blue Cross Blue Shield of Massachusetts (BCBSMA) is leading an effort to implement a comprehensive system of standardized Electronic Medical Records (EMRs) across all provider settings in the state, and the American College of Physicians (Massachusetts Chapter) has developed a roadmap and collaborative initiative for the universal installation of EMRs in all of the state's ambulatory settings.
Substantial resources have been committed in support of these efforts. In addition to its planning and organizational resources, Blue Cross has pledged $50 million toward these combined initiatives. In addition, approximately $1 million has been committed to the hospital CPOE project by the Massachusetts Legislature and MTC.
A centralized, statewide governing entity, representative of all stakeholders, has been formed and will manage these combined initiatives in a project called the Massachusetts e-Health Collaborative. Planning for the “pilot” phase of this effort is already underway.
Next Steps
This Case Statement presents a compelling case for a broad-based collaborative effort to install CPOE in all the Massachusetts hospitals that do not now have these systems. But it is only an initial framework and pathway. As part of the Massachusetts e-Health Collaborative, the CPOE initiative should undertake detailed planning and analysis to include refinement of specifications and standards, negotiation with key vendors, agreement among stakeholders on specifics of a funding and incentive program, and a project timetable. Planning and implementation should be integrated with the “pilot” phase of the e-Health Collaborative as appropriate, and thereafter carefully sequenced with other elements of the comprehensive effort to maximize the effectiveness of a state-of-the-art, interoperable, state-wide system.
Hospital CPOE Working Group
The Massachusetts Technology Collaborative, the New England Healthcare Institute, and First Consulting Group would like to acknowledge the contributions of the members of a special working group who have served as advisors in the preparation of this report over an eight-month period. Their time, expertise and insight have been invaluable.
Mitchell Adams , Executive Director, Massachusetts Technology Collaborative
Christopher R. Anderson, President, Massachusetts High Technology Council
Gary Austin, MD, Vice President, MEDecision
Charles R. Buck, Jr. ScD, Consultant
Marylou Buyse, MD, President, Massachusetts Association of Health Plans
Rich Castaldo, Senior Vice President, H&W, Fidelity
Benson T. Caswell, Executive Director, Massachusetts Health and Educational Facilities Authority
David Cochran, MD, Senior Vice President, Strategic Development, Harvard Pilgrim Health
Wendy Everett, President, New England Healthcare Institute
John Glaser, CIO, Partners HealthCare Systems Inc.
Paula Griswold, Executive Director, Massachusetts Coalition for the Prevention of Medical Errors
Louis Gutierrez, CIO, Massachusetts Executive Office of Health and Human Services
John Halamka, MD, CIO, CareGroup Healthcare System
Annette Hanson, MD, Former Medical Director, Massachusetts Division of Medical Assistance
Roberta Herman, MD, Senior Vice President and Chief Medical Officer, Harvard Pilgrim Health Care; President, Alliance for Healthcare Improvement
Ron Hollander, President, Massachusetts Hospital Association
Peter J. Koutoujian, Chair, Health Care Committee, Massachusetts House of Representatives
Rick Lord, President and CEO, Associated Industries of Massachusetts
Alan Macdonald, Executive Director, Massachusetts Business Roundtable
Allen Maltz, CFO, Blue Cross and Blue Shield of Massachusetts
Robert Mandel, Vice President E-Health, Blue Cross and Blue Shield of Massachusetts
Jack Mollen, Senior Vice President, Human Resources, EMC
Dolores Mitchell, Executive Director, Group Insurance Commission
Richard Moore, Chair, Health Care Committee, Massachusetts Senate
Tom Pyle, Consultant
Barbara Rabson, Executive Director, Massachusetts Health Quality Partners
Jim Roosevelt, Senior Vice President and General Counsel, Tufts Health Plan
Tom Sommer, President, Mass MEDIC
Elizabeth Bell Stengel, Executive Director, Conference of Boston Teaching Hospitals; Director, Govt. Relations, Boston University School of Medicine
Elliot Stone , Executive Director and CEO, Massachusetts Health Data Consortium
Thomas Sullivan, MD, Immediate Past President, Massachusetts Medical Society
Donald J. Thieme, Executive Director, Massachusetts Council of Community Hospitals
Gordon Vineyard, MD, President and Chairman of the Board, Massachusetts Health Data Consortium
Gene Wallace, Executive Vice President of Administration and CFO, Harvard Vanguard Medical Associates
Charlie Welch, MD, Past President, Massachusetts Medical Society
Mike Widmer, President, Massachusetts Taxpayers Foundation