Study Finds Weaknesses in the Performance Of CPOE System in Daily Care Settings

Many experts believe that wider use of computerized physician order entry (CPOE) systems can contribute to the better utilization of clinical pathology laboratory tests. CPOE is considered one method for helping the physician order the right medical laboratory test for the patient at the right time—then use the clinical lab test results to implement the most appropriate therapy.

CPOE is an important decision-support tool for physicians at the point-of-care (POC). Regular use of a CPOE is also something that the federal government specifically identified as necessary to accomplish “meaningful use” link under the ARRA/HITECH Act legislation.

A CPOE system’s care algorithms and protocols should help physicians utilize clinical laboratory tests more appropriately. But many CPOE systems in use today fail to deliver all the potential benefits. That fact was confirmed in a recent study of CPOE adoption and use by Washington, D.C.-based Leapfrog Group.

CPOE Accuracy Not 100%

In fact, CPOE performance is about half of what it should be. According to Leapfrog Group’s report, “Between June 2008 and January 2010, 214 hospitals from across the U.S. completed Leapfrog’s CPOE evaluation tool. The 214 hospitals include urban, rural, and pediatric hospitals. Each adult hospital was given a scenario of 10 test patients and 50 medication orders; pediatric hospitals received 10 test patients and 51 medication orders. Each of the orders in the test scenario would result in an adverse drug event, and some of the test orders would result in a potentially fatal medication error.

Of the 214 CPOE systems tested, 187 adult hospitals processed 8,716 medication orders, and of those, 52% did not receive an appropriate warning. Further, out of 311 orders processed that were potentially fatal, 32.8% did not receive appropriate warnings.

The pediatric hospitals’ CPOE systems didn’t do much better. Out of 1,731 orders processed, 42.1% did not receive appropriate warnings, and of the 62 that were potentially fatal, 33.9% did not receive appropriate warnings.

How A CPOE Can Improve Medical Laboratory Test Utilization

According to Leapfrog, out of the nation’s 4,800 hospitals, only 12% use CPOE. In those hospitals, the CPOE system’s care algorithms and protocols should be helping physicians utilize clinical laboratory tests more appropriately. That happened at Vanderbilt University Medical Center in Nashville, Tennessee, when a combined CPOE and clinical decision support system was implemented.

In an issue of The Dark Report published on April 1, 2002, Vanderbilt’s Associate Vice Chancellor for Health Affairs described the performance of the system, called “Wizorder” (and marketed commercially since 2001 as “Horizon Expert Orders” by McKesson Corporation). Stead and his colleague from the clinical laboratory, Martha Miers, currently the Vice Chair of Finance and Administrator for Pathology at Vanderbilt, described how WizOrders had contributed to a 30% reduction in the volume of routine chemistry testing in each hospital department where WizOrder had been fully deployed. This was attributed to better physician utilization of clinical lab testing.

Logically, increased use of CPOE should result in improved utilization of clinical laboratory tests. And yet, findings of the Leapfrog Group study suggest that many CPOE systems in actual use fall short of desired performance.

How Can Clinical Pathology Laboratories Help

The study, which is titled “Leapfrog Group Report on CPOE Evaluation Tool Results, June 2008 to January 2010,” and which is available on Leapfrog Group’s website, stated that “Nearly all of the hospitals improved their performance after adjusting their systems and protocols, and running the simulation a second time.” This indicates that CPOE systems need “fine-tuning” to provide the maximum accuracy. And that is the purpose of Leapfrog Group’s CPOE evaluation tool.

“CPOE systems are not plug-and-play,” said Leah Binder, Leapfrog’s CEO, during a telephone press conference reported in Healthcare Informatics. “And that’s true of any technology implementation in any industry. There’s a complexity to the adoption process that has to be honored, and then systems have to be tested and monitored regularly over time.

“The good news,” said Dr. Barbara Rudolph, Leapfrog’s senior science director, also reported in Healthcare Informatics, “is that 102 hospitals have taken the test twice—we require at least a six-month interval between tests—and those hospitals clearly worked on their systems between tests, because 94% improved their systems’ performance during that interval. And that tells us that this test is useful. And we are glad that this tool can help them do so. But ultimately, the findings are disturbing.”

Because hospital and health system adoption and use of CPOE will be a daily fact of life for pathologists and clinical laboratory managers, the findings of the Leapfrog Group’s study reveal an opportunity for laboratory testing professionals. The effectiveness of a CPOE rests as much on the thoroughness of care algorithms built into the system as it does on physician adherence to the CPOE. That opens the door for pathologists and clinical laboratory professionals to help hospitals develop algorithms and care protocols that optimize use of clinical laboratory and pathology tests.
Related Information:

Leapfrog Group Report on CPOE Evaluation Tool Results June 2008 to January 2010

Leapfrog Group Releases New CPOE Study

Clinical Decision Support System Improves Medical Laboratory Test Ordering; The Dark Report, Volume IX, Number 3, Monday, April 1, 2002