Healthcare CPOE Could Go Awry with ARRA
In a recent interview with Healthcare Informatics Editor in Chief Anthony Guerra, Jeff Cash, CIO of Mercy Medical Center in Iowa, presented an interesting conundrum vis-à-vis the American Recovery and Reinvestment Act of 2009 (ARRA) and its push to drive American hospitals towards Computer Physician Order Entry (CPOE) systems. The conundrum is particularly interesting because it illustrates, yet again, how the Federal government’s favorite go-to solution—throwing cash at a problem—often leads to unintended consequences.
In a nutshell, the Federal government wants to encourage hospitals to use CPOE systems because let’s face it: digitization is the wave of the future, and in the long run, it’s probably best if we all get used to it sooner rather than later. To encourage hospitals to adopt CPOE, the Feds made available dump truck loads of ARRA cash (i.e., American taxpayer money) to those hospitals that mandate CPOE. To punish hospitals that didn’t mandate CPOE, the Feds degraded the Medicare payments that hospital would receive. In other words, go CPOE and we’ll give you stimulus money; forego CPOE and we’ll slash your Medicare payments.
Mandating CPOE, therefore, seems like a no-brainer. As always, however, when things seem the simplest, therein lies the rub. CPOE, as it turns out, is extremely difficult to implement for a host of different reasons, many of which are familiar bug-a-boos in the IT world: costly hardware, scalability and infrastructure issues, cumbersome interaction models, proprietary systems that limit interoperability, and unintuitive user interfaces. Let’s not forget well-meaning but hand-cuffing regulatory pressure as well, for example a regulation that an actual physician, and no one else, be the one to enter data into the front end of a CPOE and “click the button” to make it official. The regulation seems well-intentioned, of course: you wouldn’t want an order enacted that wasn’t checked, double-checked, blessed, and Amened by a physician, for if it were otherwise, the whole system would be ripe for all sorts of exploitation, nefarious and otherwise. But couldn’t a qualified and certified medical assistant do 99% of the legwork, and then just have it approved by the physician?
Precisely at this juncture is where Cash has the gall to mention the 800 pound gorilla sitting directly in the middle of the room, and it goes something like this. A certain demographic of physician, particular the senior set, is never going to be comfortable with CPOE. Neither is the demographic that simply won’t adapt to CPOE because the systems themselves are too much of a hassle. What are the anti-CPOE physicians going to do? They’re going to affiliate themselves with hospitals that don’t mandate CPOE. And that means that the hospitals to which they were formerly affiliated lose the revenue those physicians used to bring to the table.
For a hospital, therefore, it becomes a matter of ROI. Do you accept the Federal government’s 40 acres and a mule, agree to abide by their current standards and requirements, and watch a chunk of your physicians walk leave to practice elsewhere? Or do you tell the government thanks but no thanks, lose out on the ARRA infusion and suffer under devalued Medicare reimbursements, but maintain that chunk of physicians whose walk-out would have otherwise affected the bottom line? Arriving at that equilibrium point—where you’re not shooting yourself in the foot fiscally—is really an exercise in accommodation, where you settle on a solution not by striving for what’s best for physicians, hospitals, and patients alike, but by settling for the lowest common denominator.
An environment that fosters lowest common denominator solutions is deadly to innovation. The Federal government and the health care industry need to level set the playing field so that financial rewards—and financial penalties—aren’t tied to things that could inhibit innovation; things like regulations that require behaviors or workflows that simply make no real-world sense. Or things like regulations that require CPOE systems to be certified, even though certification is possible only via tools or components with known usability or interoperability issues. Federal regulations should set standards and provide the basic rules for the marketplace, not limit solution alternatives to a specific subset of applications or interfaces. If there’s a better way to build the mousetrap, let private industry build it, and let the chips fall where they may.
By Robert Pothier
