Category Archives: cpoe

I Will Gladly Pay You Tuesday For A Hamburger Today

It will be three weeks ago tomorrow since CMS and ONC unveiled the Holy Grail of HCIT – the Meaningful Use Final Rule. Why have I waited so long to write about it? Hey, one must savor 864 pages of government-speak every now and again (not counting the comparatively wimpish 228 pages of Standards and Certification Final Rule). True it takes time to go through these with a fine-tooth comb, but one can fairly readily identify the most talked-about pieces of the Final Rule – namely those that tell hospitals and eligible providers what they must do to earn the money. But there have been countless blogs and articles describing the Final Rule – they’ve largely done a fine job with that, and you don’t need yet another one here. I’d rather write about what I think the Final Rule means for HCIT adoption. At least two things stand out to me:

First, there STILL remains a fair amount of important detail left to the imagination, particularly about CPOE, that makes it difficult to predict exactly what it means for HCIT adoption. The Fed clearly lowered the bar across the board by including the Emergency Department and decreasing thresholds for many objectives. But for some objectives (again, CPOE) it’s not exactly clear what the impact will be. CPOE has been made easier (for hospitals AND vendors IMO) by limiting it to medication orders, including the ED and decreasing the threshold to 30% of patients with a medication order. But ONC has created confusion over the issue of who must enter these orders (I mean really enter them). Ironically (perhaps only to me), the Proposed Rule listed RNs by name as being able to potentially enter orders, yet it’s the “by any licensed healthcare professional” in the Final Rule that has everyone scrambling to define whether and which non-physicians must enter orders. Furthermore, by only requiring that ONE medication be entered electronically, has ONC potentially introduced more workflows for providers to navigate – a “compliant workflow” for electronic meds and a “non-compliant” one for paper med orders? That’s not an improvement for efficiency and will only stall physician adoption of CPOE.

Secondly, by introducing the concept of Core and Menu Set Objectives (expected) AND changing so many of the thresholds (expected for some) AND limiting CPOE to medication orders (curve ball) AND bringing the Emergency Department into play (never doubt the power of a good lobby), it’s hard to get a read on what all this really means. And that brings me to this blog post’s mascot – Wimpy. No, I’m not calling the Fed a bunch of wimps – or providers or hospitals for that matter. I will not discount the fact that they still face a daunting challenge to implement, integrate and most importantly use technology that has largely done a poor job at all three.

No, I chose Wimpy because of his famous saying “I will gladly pay you Tuesday for a hamburger today“. Am I saying that the government has created requirements for hospitals and providers for which they will not pay incentives in the future? Some fear just that, but it’s not my point in citing the wise Wimpy. In fact, I’m kind of saying the opposite – we’ll have to wait and see if by giving hospitals and providers a hamburger today whether they will pay us all back (it is the taxpayer’s money after all) with use of systems that will achieve the 5 broad Health Outcome Policy Priorities (remember those?) defined by the Fed way back in February of 2009 when the HITECH Act was created.

So what do I really think? I think the government has provided short-term relief for a long-term challenge. If the lowering of the bar in Stage 1 causes hospitals and providers to just go after Stage 1 incentives and then stop then HITECH will have been a failure. If lowering the bar causes hospitals and providers to lose focus on the longer-term challenge of Stage 2 and beyond, then HITECH will have been a failure. Will it have created jobs in the vendor market? Will it have created a lot of investment and interest in HCIT? Yes to both. But neither of these will satisfy the Health Outcome Policy Priorities of:

  1. Improve quality, safety, efficiency, and reduce health disparities
  2. Engage patients and families
  3. Improve care coordination
  4. Improve population and public health
  5. Ensure adequate privacy and security protections for personal health information

Wimpy, pay up!

You Say Physicians Don’t Like Technology?

Many in the healthcare IT industry generally believe that physicians don’t like technology. They cite years of research that shows physicians do not adopt the technology that is ostensibly purchased for them. The research, it turns out, is true – fewer than 10% of hospitals have achieved significant physician adoption of Computerized Physician Order Entry (CPOE), and fewer than 5% have achieved adoption of electronic documentation. Most of the”successful” adoption comes from Academic Medical Centers who employ physicians and residents, and therefore, can control system use to a greater extent. But 90% of US hospitals are community hospitals with largely voluntary staff comprised of independent practitioners – physicians who can and do practice elsewhere including multiple offices and even other hospitals. I would argue these community hospitals are the true test bed for physician adoption of IT.

The notion that physicians don’t use technology simply because they don’t like it is incorrect. Healthcare is replete with examples of physicians incorporating ground-breaking technologies of all kinds into their practice of medicine. From medical devices like implantable defibrillators to the most sophisticated imaging technology, physicians have shown a willingness, indeed a penchant toward adopting technology. These examples are not limited to technologies that involve direct patient care – witness their adoption of smartphones. The number of physicians using smartphones surged to 64% in 2009, and this number is projected to grow to 81% by the year 2012. This adoption rate out-paces that of consumers, among whom 65% are expected to own a smartphone by 2012.

“Usability” is often cited as the main culprit behind meager physician technology adoption statistics. Calls for improved user interfaces and screen layouts often lead to attempts at trying to weave these constructs into EHR certification criteria, for example. Indeed, the talk in the industry of late is around trying to impart usability as a requirement of Meaningful Use certification. As with prior attempts to legislate usability, however, these efforts are largely doomed to fail as the color, size and location of a button or a screen is not the primary culprit behind historically poor physician adoption.

The primary reasons for poor adoption have more to do with utility than usability. Simply put, if the technology is of no real benefit (or worse a detriment) to the physician and their practice of medicine, they will not use it. CPOE is the poster child for this challenge. Since before the Institute of Medicine’s landmark 1999 study “To Err is Human,” the industry has tapped technology, namely CPOE, as the keystone for reducing medical errors. Despite broad agreement on this as a chief benefit of CPOE, physicians have shown no real inclination to use these systems. Do physicians not believe in reducing or avoiding medical errors? Of course not. Instead, physicians struggle with systems that do not support their logical workflow and require them to provide information and respond to alerts that are better suited to other clinicians such as nurses, pharmacologists, radiologists, etc. These systems consume additional time on their busy schedules – time they cannot spare (a 10% reduction in physician productivity results in a 20% reduction in revenue).

Ask yourself, would you use something that provided no direct benefit to your daily work, or worse, provided no benefit AND took more of your time? What if that “something” wasn’t even designed for your use, would you use it then? That’s essentially what we are asking physicians to do – use technology that wasn’t designed for their benefit, but we feel is worthwhile nonetheless.

You say physicians don’t like technology? I say they don’t like technology that does not benefit their practice of medicine.

%d bloggers like this: