CPOE and the Doc Dilemma
January, 2010

Recent industry surveys find that a very small percentage of physicians are using CPOE at the
bedside. ARRA’s proposed meaningful use criteria state at least ten percent of orders must be
input via CPOE or your hospital will get dinged, which brings up the decade old question as to
why many MD Luddites refuse to use this great technology.

This article will attempt to answer why, how’d we get here, and what can be done to increase
physician usage. In order to fully understand the core issue we should start by to looking at the
situation from the eyes of a typical community doctor.

Before CPOE:
Mr(s). Doc stands at Ms. Patient’s bedside flips through the paper chart, scribbles a couple of
orders (while conversing with the patient) then pats the patient on the shoulder and says ‘your
doing fine, this new medication should help, see you tomorrow’. Takes all of about one minute.

His order(s) is then reviewed by a unit clerk or nurse and entered into a computer system
(hopefully). Mr. Doc sees about 10 or 15 more patients at Memorial hospital then gets in his car
and drives to his office.

While in his car he gets a call from the nurse looking over his order and the nurse explains to
him that Ms. Patient had some trouble swallowing last night so, can we change the med route
from oral to injection. He says fine.  

In his office an hour latter after seeing four patients and while waiting for the next, he quickly
reads his emails. One from the hospital pharmacist says ‘the med you ordered for Ms. Patient is
no longer available as an injectable, can we substitute another brand?’ The pharmacists lists out
three alternatives with revised doses. He responds OK, go with number two.

At this point the order is now ‘done’. How long did it take? A industrial engineer would say all the
time for the doc, nurse, pharmacist, and unit clerk, all added together, with phone tag and
conversation, probably about fifteen minutes. But if you ask the doc he would say ‘less than a
minute’, basically the time he was in the patient room. In his mind the time in his car does not
count (it’s downtime anyway) and responding to email is part of his usual office routine.

It gets even more onerous if the patient has complications, or there are medication / diagnostic
conflicts, or if multiple overlapping orders are involved. In each situation they get chased down,
sorted out and preliminarily resolved by hospital staff, who then communicate with the physician
if needed to reach final order approval. But in the end it only requires a minute of physician time.

After CPOE:
At Ms. Patient’s bedside he picks up his notebook, or Ipod, or Blackberry…whatever, and enters
the same med order. Not as fast as scribbling on paper, but not too bad.

Assuming response times are instantaneous (could be a big assumption) the system comes
back and displays some new assessment information about the swallowing problem, and then
the system suggests he change the med route (this is a really advanced system!). He is not sure
about this, so he scrolls back into the EMR and sees where the late shift nurse made a note
about swallowing difficulty, so he cancels /changes the original order and requests an injection.

Red flags go up again. Now he gets a message from the Rx system that this med is no longer
available (or recommended) as an injectable. The system then shows him a list of three
alternatives (after a slight delay of course). He picks one, changes the dosage, re-enters the
order, then signs off and now he’s done. Except for patting the patient on the shoulder and
saying see you tomorrow. Total time five or six minutes.

As stated earlier, if the situation involves a more complex case or multiple orders even more of
his time gets eaten up.

How much time did it take nursing and pharmacy to complete this order request? Zero, or near
zero, as all the checks and balances and communication were done by the system.

If he sees 15 patients and each one takes 4 minutes more, to him that’s 60 minutes extra effort.
But the hospital ‘saves’ the hour. I think we all agree it is better patient care, but who’s paying for
it? One hour of his time is equal to four or five patients in his office, maybe $300 to $500 in
billings. If this happens two or three times a week…it quickly becomes real money and nobody is
paying him a salary to hang around the hospital.

So, from where Mr. Doc sits…CPOE is great for the hospital and hopefully delivers better patient
care, but he’s carrying the lion’s share of the time cost, and to an independent practitioner –
time is money.

Where CPOE Works and Why
If you look under the covers at why CPOE has worked in the Mayo, Kaisers and Cleveland Clinic,
it’s because the attending docs are part ‘owners’ in the hospital. They get paid a salary and
bonus on
both the performance of their practice and the performance of the hospital and all
other facilities. Physicians readily accept that less support staff will save the hospital money but
in turn it will be a monetary benefit for them, while improving patient care, which can lead to more
patient referrals and even more revenues.

In military facilities it’s even simpler. The Colonel says ‘do it’ and the MD captain says ‘yes sir!”.
In regard to the VA system, a recent Wall Street Journal report dated October 27, 3009 entitled
“The Digital Pioneer” by Jane Zhang, stated:

To be sure, the VA’s health care system isn’t a perfect roadmap for the industry – since the
agency is in a unique position. The VA…employs the doctors…which makes it easier to mandate
performance standards. The VA has an incentive to keep patients healthier because it takes
care of veterans for life and sicker patients eat up the VA’s budget faster.

How’d we get here?
Today, and for the past half century, we have operated in an environment where the person
most responsible for ‘product definition’ and most responsible for bringing in the business are
not employees of the hospital. It goes back to the establishment of the AMA and the AHA in the
early 20th century. Both of these groups were focused on increasing utilization of hospital and
medical services and even at that time, just as today, medical care was relatively expensive.  So
to drum up business they both came up with the idea to sell an insurance policy. Rather than
work together, the AMA founded Blue Shield and the AHA started Blue Cross. Each with its own
similar, yet different objectives. Keep in mind that almost all doctors in the early part of the
twentieth century were independent practitioners and hospitals were places to be avoided. In
1972 as the insurance industry matured the FTC was getting very concerned, so AMA spun off
Blue Shield, and AHA split with Blue Cross. Latter as the Blues finally saw themselves more as
insurance companies than part of the medical establishment many of the Blues merged and
eventually morphed into today’s United Health, Wellpoint, etc.

Meanwhile in 1966 along came Medicare. If you go back and study the legislation of the day you
will find that physicians fought Medicare with a vengeance and wanted no part of the
government or the institutional side of the package. Of course today if you tried to take Medicare
away you’d have a rebellion – and not just from seniors. So, Medicare in 1966 solidified the arms
length relationship of doctors and hospitals by creating Medicare Part A (hospital) and part B
(physician) payment systems.

The structure we have today, that of full physician independence, has been around a very long
time and is fortified through separate provider and piece work based payment systems. Again, to
the doc time is money. Some challenge this mercenary view by pointing out that true
professional responsibility should come first. If we really want that outcome then we’ll need to
overhaul the organizational structure and payment systems we put in place decades ago.

How do we fix it?
How can we get more of those independent physicians to use CPOE? From my point of view
there are five possible ways to address this issue. None of which are perfect, most of which are
fraught with more challenges. They are:

1) Require all physicians to be hospital employees a la the military and  Mayo model:
Ok, maybe it’s the real solution but not at all feasible and not realistic, and how can you change
one hundred years of precedent in only a year, impossible. Well not completely
impossible, this actually has been happening very, very slowly over the last decade.

As more and more medical school graduates are either female and /or foreign students the
desire to be a ‘lone ranger’ doc is less and less appealing. Female and particularly foreign
docs are more accepting of working as a team in large organizations. Being on call 24x7,
dealing with constantly changing payment rules, and all the hassles of malpractice are not
their cup of tea. They’d rather spend more time with patients and have a predictable
schedule. So, if we can wait long enough, way beyond the ARRA meaningful use target
dates, we just might just get there. For more on changing physician employment patterns see:  
Why Physicians are Seeking Employment.  

2) Expand Hospitalists Programs:
Hospitalist programs got their start about ten years ago. Hospitalist programs are similar to
physician residency programs in that the physician is in the hospital assigned to specific
patients 24x7. The big difference between a residency program and hospitalist is that a
resident has three roles, medical education, clinical research and patient care. Sometimes
these are very conflicted goals. Meanwhile the hospitalist is only focused on inpatient care.
Expanding hospitalists programs is really a derivative of number one. Hospitalists are usually
employees of the hospital, or a contractor to the hospital. Use of CPOE tools by hospitalists
is very high and their operational objectives are almost 100% in line with the institution.

Since hospitalists tend to be newer graduates and frequently foreign doctors, they readily
accept information technologies and understand the downstream benefits of source data
capturing. They are on the patient floor eight or ten hours a day and routinely see the
benefits of an EMR and CPOE. Unfortunately mandating a hospitalist program has its political
hurdles. Attendings may not accept them for fear of losing a patient and the bigger hurdle is
who will pay for them, 24 x 7 physician coverage is not cheap.

The Institute of Medicine and other organizations such as The Leapfrog Group have made
strong positive statements about hospitalist programs, particularly in ICU settings, but alas,
they haven’t been willing to foot the bill.

Here’s a wild idea. When a Cerner or Epic or Eclipsys sells an EMR-CPOE system, usually for
$20 million or more, why not include a hospitalist program with it? Maybe team up with one of
the growing hospitalist supplier companies. Then the system vendor can guarantee 100%
CPOE utilization!

3) Pay attending physicians for their time:
If it takes a doc an extra five minutes to basically do the data entry, why not pay him /her for
it? I have heard several physicians suggest this. Again it’s a cost issue, and Medicare and the
insurance companies would not cover it. Secondly the hourly rate for some physicians such
as surgeons, and other specialties could be quite steep.

4)  Better use of physician assistants and other clinical staff.
Some have suggested that to reduce physician time we allow physician assistants,
pharmacists and selected nurses to initiate, change, modify, or cancel orders when conflicts
and other issues arise. This has been done on a limited scale and usually after the fact, but
again as our CPOE and EMR systems get more and more sophisticated and can bring up
more and more real time issues it becomes hard to see how physician time will decrease.
Actually ‘dumbing down’ the systems might work better, but in the end that would be very
short sighted and foolish. If we introduce greater support staff involvement we will
also have to re-engineer many work flow processes and apply tools to monitor and verify all
the clinical hand-offs.

5) Improve the CPOE systems.    
Faster, faster and faster, get to sub-nanosecond response times, that’s the ticket. Faster
response times are always better, but the reality is the faster our systems get, the more
we find for the system to do. We are a long way from building a system that incorporates all
the algorithms, judgments and expertise for even one moderately complex medical order, so
the faster we can handle the order and its component parts the more we’ll build into the
editing, checking, and auditing for quality goals. Ultimately bringing more and more
information to the physician’s screen, all of which would have previously happened after the
fact, means more physician time at the hospital. Faster systems will improve care quality, but
I don’t think it will get more physicians to use CPOE.

More important than faster systems is building in more work flow flexibility and re-engineering  
core processes such as hand-offs, and better case management and care coordination. All
of these have more to do with work flow and process re-engineering than technology.

The conclusion I have come to is we have to stop trying to kid, cajole, arm twist, embarrass, and
penalize community physicians into using CPOE. As things are structured today it just is not in
their self interest. What with the government threatening every day to cut physician payments
most physicians are scrambling for any way to increase their volume by eliminating or off-loading
tasks, not doing more for organizations that don’t pay them.

To my mind, the best approach is a combination of 1, 2, 4, and the workflow of 5. All of which will
take more time than ARRA and Meaningful Use will probably allow.

As testimony to complexity of this issue ONCHIT in it's promulgation of Stage 1 Meaningful Use
criteria allowed physicians to use 'scribes' to enter orders as opposed to requiring direct
physician input.

Frank Poggio
The Kelzon Group
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