Computer Consult

By Ken Terry

The move to put office orders online

• ACPOE could prevent 2 million medication mistakes per year.

• ACPOE may increase physician revenue by reducing rejected insurance claims.

• You can do basic ACPOE without an EMR.

Until last year, when Cleveland internist David L. Bronson saw a patient who had just come back from a specialist, he often was in the dark about what medications the patient was taking.

"He was on five when I referred him to the consultant, but he might be on three different ones when he came back," says Bronson, chairman of regional medical practice at The Cleveland Clinic. Now, thanks to an ambulatory computerized physician order entry (ACPOE) system, Bronson is kept up to date, completely and immediately.

At its most advanced, ACPOE computerizes all outpatient orders, including prescriptions, lab and imaging tests, referrals, nursing interventions, and patient education. It also enables clinicians to track lab orders and results online. And like its inpatient counterpart, ACPOE features alerts and decision support tools to reduce medical errors.

Bronson places outpatient orders through a new electronic medical records system gradually being rolled out to The Cleveland Clinic's 1,100 physicians. He believes ACPOE can substantially reduce the medical error rate in the group.

Partners HealthCare, a large integrated delivery network in Boston, has had both inpatient and outpatient CPOE for several years, and medication errors at its Brigham and Women's Hospital have dropped by 55 percent. The rate of outpatient prescribing errors has also decreased, says internist Blackford Middleton, a clinical informatics director for Partners.

The Center for Information Technology Leadership (CITL) at Partners recently issued the results of a study estimating that there are 38 adverse drug events (ADEs) every year per ambulatory health care provider in the US. In theory, ACPOE could prevent about 14 of those mishaps, says the report. Nationwide adoption of ACPOE could eliminate more than 2 million drug errors annually—more than 130,000 of them life-threatening, the report says.

Cost savings from implementing ACPOE systems could be just as huge, according to the report. The reduction in ADEs alone would eliminate hospital admissions and visits that cost $2 billion a year. Much greater savings would come from reduced outlays for prescription drugs, lab tests, and imaging studies. The report suggests that improved decision support and better access to patient data mean that doctors will write more prescriptions for cheaper drugs as well as order fewer redundant or unnecessary tests.

The main flaw in this promising scenario is that physicians would bear the cost of implementing ACPOE, notes Jane Metzger, vice president of First Consulting Group in Lexington, MA. But the CITL report claims that by reducing the number of rejected insurance claims with better documentation and coding, an ACPOE system can raise revenues by an average $10 per visit. Middleton asserts that ambulatory EMRs with built-in ACPOE can pay for themselves within two years.

In any case, he predicts, pressure from employers and the government will motivate physicians to install these systems. For instance, The Leapfrog Group, a consortium of private and public purchasers of health care, plans to announce criteria for reducing outpatient medical errors. The criteria probably will include electronic prescribing, online review of lab results, and computerized reminders for screening tests, says Leapfrog Executive Director Suzanne Delbanco.

A roadmap to the future in a Delaware network

A 17-doctor cardiology group has shown how smaller practices can implement ACPOE. Delaware Cardiovascular Associates in Wilmington recently acquired an EMR to link its nine offices. But the state's biggest hospital and reference labs turned down the group's request to write software interfaces connecting their computer system to the cardiologists' EMR. They said there wouldn't be enough users to make it financially worthwhile.

Undeterred, the cardiologists formed the Blue Ox Medical Network, consisting largely of referring primary care physicians. All 50 practices in Blue Ox—most of them one-to-three doctor groups—agreed to use the same EMR, says cardiologist Anthony D. Alfieri. They're all leasing the software from an application service provider—which cuts the up-front cost—and accessing it over secure, high-speed lines.

Blue Ox is about to go online with LabCorp; additionally, Quest Laboratories, the hospital, and an imaging center are finally developing interfaces, says Alfieri. The doctors are also prescribing electronically, but the local pharmacies aren't ready to accept online scripts yet.

Even without this connectivity, the Blue Ox physicians benefit from being online with each other. "I can e-mail a referring doctor about changing a medication," says Alfieri. "When he opens the chart, he automatically sees the change."

How important are EMRs to ambulatory CPOE?

The Blue Ox experience highlights one of the major questions about ACPOE: Do you need an EMR to do it?

Internist Eric M. Liederman, medical director of clinical information systems at the University of California Davis, says Yes. UC Davis is preparing to roll out an ambulatory EMR with ACPOE to the 105 doctors in its primary care clinics. From the beginning, its EMR will include both inpatient and outpatient data, and will be accessible in its hospital and all of its clinics. Within several years, all 1,300 of its physicians will be entering orders and documenting online.

Liederman defines an EMR as a combination of data lookup, online order entry, documentation, and messaging. He acknowledges that some hospitals enable physicians to place orders and get results online from their offices. But without an EMR that integrates the pertinent clinical data, he says, "You can't find the patient in there. All you see is orders and results."

Middleton agrees that advanced ACPOE requires an EMR, but he maintains that you can have a useful system without it. In a basic ACPOE system, a doctor writes a prescription or lab order electronically, then prints it out and faxes it. He'd at least be able to look up info in an electronic drug reference or lab manual. An intermediate system might allow computer faxing or e-mailing of orders, as well as provide drug interaction alerts and order sets for labs. An advanced system, in Middleton's view, should integrate clinical data, offer secure clinical messaging, and incorporate evidence-based guidelines that trigger reminders and alerts.

How much will all of this cost physicians? First-year costs range from under $4,500 per provider for a basic system that allows electronic prescribing to more than $29,000 per provider for advanced ACPOE incorporated in an EMR, says the CITL report. But many other factors will affect costs, such as whether you already have a computer system, how sophisticated an EMR you buy, how you finance that purchase, and whether labs and hospitals will pay for interfaces to your system.

The author is Medical Economics' Technology Editor. Computer Consult is edited by Senior Editor Robert Lowes.

 

Ken Terry. Computer Consult: The move to put office orders online. Medical Economics Aug. 8, 2003;80:23.