A Mandate in Mass

Dec. 27, 2011
CIOs don't like state governments telling them what to do. Or do they? Gerald Greeley A new state law in Massachusetts mandating that hospitals

CIOs don't like state governments telling them what to do. Or do they?

Gerald Greeley

A new state law in Massachusetts mandating that hospitals adopt computerized physician order-entry by 2012 “is the best thing that's happened for us CIOs,” says Gerald Greeley, CIO of 229-bed Winchester Hospital. “It lends some real meat to the discussion. It sends a signal to the physicians that this is important,” he says. “And any reason for a board of directors not to give their CIO money to proceed has been eliminated.”

The law requires hospitals and community health centers to adopt CPOE systems by 2012 and electronic health record systems by 2015. It even requires demonstrating a level of competency in the use of CPOE as a standard of eligibility for physician licensure.

Is the new law's deadline of 2012 too ambitious? A 2007 KLAS (Orem, Utah) study put the nationwide number of hospitals doing some CPOE at only 6.8 percent. But in Massachusetts, folks at the academic hospitals have been working on their own homegrown CPOE systems for years, and several community hospitals have made progress working with the clinical information system vendor Meditech (Westwood, Mass.). (About 70 percent of community hospitals in the Bay State use Meditech software.)

The legislation, which passed with bipartisan support, was the result of a multi-year collaborative process, says Bethany Gilboard, the director of health technologies for the Massachusetts Technology Collaborative (MassTech, Westborough), a state economic development agency. From its beginning, the Massachusetts Hospital CPOE Initiative had a broad group of stakeholders, including the Massachusetts Hospital Association and the Massachusetts Council of Community Hospitals (MCCH). “It was never done in a vacuum,” says Gilboard, who adds that her organization realized it would have to make both a clinical and business case for pushing CPOE adoption. “We had to ask if we could apply the savings that academic hospitals have realized to the community hospitals.”

Bethany Gilboard

A February 2008 study sponsored by MassTech and the Cambridge-based New England Health Care Institute projected possible annual savings per hospital of $2.7 million from, among other things, preventable adverse drug events. With CPOE systems costing about $2.1 million and an annual increase in operating costs of $435,000, the study projected a full payback in about 26 months.

Christopher Baldwin

Although they may be skeptical about those return-on-investment figures, community hospital CIOs recognize they must invest in CPOE, says Donald Thieme, executive director of the MCCH. “We can't allow for there to be a technology gap that affects quality between community and teaching hospitals, so we have to have CPOE,” he says. Of the approximately 60 community hospitals in the state, only five or six have fully implemented CPOE. One problem, he adds, is that many community hospitals are operating on poor margins, and there is no money in the legislation to help.

Gilboard acknowledges that community hospital CIOs face many challenges to meet the deadline, and some are nervous about it. “They are most nervous about having the infrastructure in place to make this work, such as a wireless network,” she says, adding that CPOE also involves a difficult process redesign. “It requires clinical process re-engineering. Getting community-based doctors to learn it can be very challenging.” Gilboard says hospitals that have hospitalists have better success rates.

There's also a question about the degree of expertise at community hospitals. “Some IT directors are good at the plumbing part but not strategic visionaries,” she says. “Others are both. But there is a human capital shortage of IT expertise.”

According to Greeley, Winchester Hospital is in the midst of a multi-phased CPOE rollout. Hospitalists are the primary users in three inpatient units. He says hospitals have to invest in nursing documentation and wireless infrastructure and have a stable network in place. “If you don't include those, we will spend $2.5 to $3 million on CPOE,” he says.

Other CIOs are laying the groundwork in automating clinical areas before beginning CPOE work.

“The change has to be broad-based and include things like nursing documentation and the pharmacy, not just physicians,” says Christopher Baldwin, vice president of MIS for Southcoast Health System, which has community hospitals in Fall River, New Bedford and Wareham, Mass., with a combination of approximately 800 beds.

In 2005, the Southcoast board of directors approved a multiyear plan to update clinical information systems, including funding for CPOE. Baldwin says the state mandate gives CIOs a clear goal, but that the Commonwealth needs to clarify what the deadline means. “Do they mean 75 percent of orders by CPOE by 2012?” he asks. “If they mean 95 percent, that would be a challenge. That's the gray zone right now.”

Could the Massachusetts experience with mandating hospital CPOE use be replicated elsewhere in the country? MassTech's Gilboard says she isn't sure. “There's a uniqueness to Massachusetts' collaboration,” she says. Multiple stakeholders have come together with MassTech as a neutral third party to facilitate pilot projects. She says people in other states have told her they are interested, but that the timing just isn't right.

Gilboard says she believes much more national attention will be focused on Massachusetts' 2015 EHR mandate.

Healthcare Informatics 2008 November;25(11):46-47

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