Leapfrog: Quality assurance required with CPOE systems

Wide variance in degree of adoptions, outcomes

In its first-ever evaluation of computerized physician order entry (CPOE) systems in hospitals across the country, The Leapfrog Group found reason for concern when it came to proper implementation of these systems. In fact, the organization noted "a broad variance in both the degree of adoption and in the quality of outcomes."

The evaluation, which is now part of Leapfrog's annual survey of hospitals (more than 1,200 participated), was made possible through a tool developed by First Consulting Group (now Computer Sciences Corporation/CSC) and the Institute for Safe Medication Practices. The tool provides hospitals with an assessment of the adequacy of their CPOE system alerts for common, serious prescribing errors.

"For a long time, Leapfrog has been a proponent of CPOE in hospitals," says CEO Leah Binder, MA, MGA. "We believe it is one of the most important measures hospitals can take to improve safety. But they have asked us a legitimate question — is it the adoption we should measure, or should we be measuring the quality of that adoption?"

The development of the tool, she continues, involved years of research by experts in medication management and medication errors. "Since it is now part of our overall survey, the hospitals will now be required to not only have the system but to evaluate its implementation," says Binder. For this first year, however, all they had to do was test their systems. "Next year, we will be reporting their scores publicly," Binder notes. In order to fully meet Leapfrog's CPOE standard, hospitals must:

  • Assure that prescribers enter at least 75% of medication orders via a computer system that includes prescription-error prevention software;
  • Demonstrate their inpatient system can alert prescribers to at least 50% of common, serious prescribing errors

Learning from the report

Hospital quality managers who read their facilities' individual report will be able to home in on problem areas, Binder explains. "For example, [the report will show] if providers are able to order medications that would produce an allergic interaction, or not alert them that certain other meds the patient is taking would interfere with what the doctor wants to order," she says. "There are a variety of mistakes that can be made, and we can measure if the system alerts you to them."

In addition, she says, it also measures whether providers are alerted too often. "One of the potential problems is that providers can get alert fatigue; they start ignoring all alerts if they think they are frivolous," says Binder. "The tool really examines whether the system is performing as an effective aide for decision support."

Degree of adoption is another important measurable, Binder says. "Some hospitals have CPOE systems just in the ED, or just in other departments, but not in the entire facility," she explains. "The evidence suggests you can reduce errors from 50% to 85% with CPOE. If you do not have all your medication orders handled by CPOE, you expose yourself to more errors than others might." Binder says the report also found variance in the evaluations of how well the systems were performing.

CPOE is not plug and play

One of the common technological challenges with CPOE, Binder says, is that users fail to realize these are not off-the-shelf products that can simply be plugged in; they require customization. "You've got to determine, for example, where the alerts will go and how they should be responded to," she explains. "Every organization is different in terms of how it manages medications."

One of the most positive aspects of this evaluation says Binder is that it forces hospitals that adopt CPOE to go through their own internal system for medication administration. "That alone can show you steps along the way that could potentially create errors," she says. "This requires you to look at your cultures, your systems, your workflow, and then address them."

So, for example, in terms of workflow, in some hospitals the alert may not go to the ordering physician, but only to the pharmacist. "We believe that may not be best," says Binder. "Hospitals need to examine if that is the safest way to handle the administration of medications. Those are the types of questions the organization should raise."

To help hospitals come up with solutions, Leapfrog is forming a CPOE consortium to identify best practices for implementing and addressing the errors found by the evaluation tool. "We hope to have it up and running by January 2009," says Binder. "This will be an important development that helps hospitals implement CPOE without having to 'reinvent the wheel,' and learn from best practices found by CPOE pioneers. We feel those who have implemented CPOE are way ahead of their time, because they are rare. We want to acknowledge them for being out front and learn from them."

[For additional information, contact:

Leah Binder, MA, MGA, CEO, The Leapfrog Group, c/o Academy Health, 1150 17th Street NW, Suite 600, Washington, DC 20036. Phone: (202) 292-6713. Fax: (202) 292-6813. E-mail: lbinder@leapfroggroup.org.]