Dissemination and Adoption of Comparative Effectiveness Research Findings When Findings Challenge Current Practices. Key Enablers of Clinical-Practice Change


Financial Incentives That Improve the Business Case for Implementation

If financial incentives are better aligned to produce an ROI, hospitals are more likely to adopt CPOE. In general, experts believe that the financial incentives available through the Health Information Technology for Economic and Clinical Health Act (HITECH) to adopt and become meaningful users of EHRs, combined with imminent financial penalties for failing to do so, have had a positive effect on adoption. While success is difficult to gauge at this point, well-designed mandates and financial incentives seem to be somewhat effective. Many experts believe that the HITECH incentives are persuading some hospitals to adopt, because, for a very large medical center, millions of dollars may be at stake. Efforts to develop a framework for sharing the financial benefits of CPOE (as well as the cost) between providers and payers could help speed adoption.

Some experts are skeptical, however, noting that some hospitals, even if penalized for not having CPOE, will still be reluctant to adopt it in the near future. There is ongoing concern among hospital executives, CPOE system vendors, and physicians that mandates and incentives should be introduced on a timeline that allows providers to deploy resources most effectively. Meaningful-use requirements may have the paradoxical effect of slowing progress, in the view of some experts. For example, meaningful use has led some CPOE vendors to put everything on hold for 18 months to await the release of the new requirements instead of continuing to work with hospitals to improve existing systems.

The importance of financial incentives in accelerating CPOE adoption is illustrated by two cases that demonstrate how adoption can occur when such incentives are well aligned with an organization’s interests: The Kaiser-Permanente system and the VA health system are integrated health delivery systems, so both the costs and the cost savings from implementing CPOE accrue to them. Other incentives to adopt CPOE, aside from those incorporated in HITECH, may also be increasing in settings that have been traditionally organized around the fee-for-service payment system, as these organizations adapt preemptively to payment reform efforts such as expected-value-based purchasing and ACOs. Whether these new payment models will accelerate adoption of CPOE in nonintegrated health systems remains uncertain.

The Importance of Mission and Commitment of Local-Organization Leadership

The results of CER studies on CPOE may help strengthen local organizational leaders’ commitment to adopt CPOE and integrate it into their organizations’ missions. Published literature suggests that when hospitals make adoption a priority, implementation is almost always successful (Ash, Stavri, et al., 2003). For example, when a hospital’s mission is to make patient safety a top priority and CPOE is stated as being a crucial part of fulfilling that mission, CPOE adoption and successful implementation appear likely. However, few hospitals may be able (or may want) to formulate or articulate such a mission. Successful CPOE adoption has been found to be strongly associated with—and nearly always requires—strong leadership, a long-term commitment of resources, involvement of physicians (including engagement of physician champions), leveraging of relevant staff (e.g., young physicians), and assuring responsiveness of the information technology (IT) department to address problems and complaints quickly.

Publicity May Motivate Change

The impact of publicity about the problem of medication errors on adoption of CPOE is uncertain, but the IOM report To Err is Human clearly fostered urgency about the need to reduce medical errors more than a decade ago. Advocacy by CPOE vendors, employers, and employer coalitions such as the Leapfrog Group appears to be increasing. Policymakers have also advocated for change. An op-ed in the Washington Post in response to the IOM report cited CPOE as the way to save “tens of thousands of lives every year,” as well as “huge amounts of money” (Gingrich, 2000); the piece called for Congress to consider passing a bill “requiring that within three years every doctor’s prescription and every patient’s record be computerized.” The impact of any specific dissemination activity or publicity effort on technology adoption is difficult to estimate, but collectively, mass-media publicity efforts are thought to motivate change in a positive, although perhaps incremental, fashion (Lasalandra, 1998; Burling, 2001; Johnson, 2001; Finley, 2009).

Learning from CPOE-Champion Hospitals and Failed Implementations

One early CPOE adopter used its experience with an implementation effort that initially failed to develop a simple tool that other hospitals could use to estimate the benefits of adoption based on their own specific data. These efforts may help to address the generalizability problem raised in the peer-reviewed literature and may provide a more unbiased estimate of the potential ROI than that provided by vendors. Stakeholders mentioned that large, champion hospitals often work with vendors to improve CPOE content and the quality of off-the-shelf systems. Such efforts may be very beneficial to small hospitals if they result in better vendor products that require substantially less configuration and modification. The magnitude of the efforts is hard to quantify, but it is believed that they are positive. Failed CPOE implementations may also provide lessons learned for hospital or physician leaders considering adoption.

Identifying Options for Making Quality Improvement Interventions More Affordable

The high cost of CPOE adoption was consistently cited as a barrier. Financial incentives like those created by HITECH may help to offset the costs of acquiring CPOE systems, but they may paradoxically undercut price competition among vendors. Payers might find it beneficial to bear some of the providers’ CPOE acquisition costs. Alternatively, they might share some of the gains that could accrue from more efficient care. Malpractice-insurance discounts for hospitals with CPOE were cited by one expert as a potential way to offset the costs of adoption.

Developing Standard Interventions and Implementation Strategies

Early negative experiences with CPOE implementation (such as overly sensitive drug-drug interaction alerts) might have been averted if a national database or set of guidelines had been developed. Instead, hospitals have been allowed to customize quality improvement applications, particularly alerts. In theory, this can be dangerous, because patients receive treatment in multiple settings in which the CPOE systems may be using different clinical logic or alerts. Standards for interoperability might be beneficial, particularly given some of the disincentives for information sharing. More information on vendors’ track records and their commitment to the CPOE market, along with evidence of successful long-term relationships with hospitals could reduce hospitals’ uncertainty about investment risk. Development of system standards is a core focus area of the Office of the National Coordinator for Health IT, and standards for CPOE may be an area for further development in the future.

Simplification of Quality Improvement Interventions

One stakeholder told us that CPOE systems were so complicated that vendors often did not know their true capabilities—sometimes forgetting that their own systems contained certain functionalities. While certification processes have helped ensure product quality, it appears that hospital decisionmakers still face considerable uncertainty when trying to compare and select CPOE vendors and systems. Reducing the complexity of these systems to reduce the time needed to learn to use them and to enable adequate piloting of systems prior to making an investment could encourage their adoption.

Disseminating Information on Implementation in Addition to CER Results

The general consensus among experts is that CER results on the benefits of CPOE are persuasive. Documenting those benefits in terms of reduced medication errors, dollars saved, or improvements in staff workflows would be beneficial and could incrementally encourage adoption. It is less clear whether sufficient evidence exists regarding successful implementation strategies in different settings. Producing more evidence about implementation may overcome providers’ ambivalence about the risks associated with it.

Improving Dissemination of Implementation Examples Through Channels Other Than Peer-Reviewed Publications

Some of the greatest CPOE success stories remain unpublished. Furthermore, one expert doubted whether academic publications even reach the relevant decisionmakers. While the effect of dissemination through the peer-reviewed literature is unclear, efforts to encourage champion hospitals to publish data and lead in promoting change are clearly important. Vendors may also have a role in describing CPOE successes and failures, although such a role raises concerns regarding vendors’ conflicts of interest.

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