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TECHNOLOGY: CPR use– review of state of the nation report from CHCF

Continuing with its excellent work as a trailblazer in research into health care IT arena, the California HealthCare Foundation (CHCF) has put out an interesting summary report on the adoption of Computerized Patient Records (CPR) written by David Brailer and Emi Teresawa, both from health IT company Carescience. (Carescience is also the main vendor for the Santa Barbara County Care Data Exchange, funded by CHCF). The report is one of three the Foundation has put out to help push the use of the CPR.

They were reviewing other research in the field and their main conclusions are that:
— This is an extremely difficult subject to get your arms around
— The adoption line is beginning to point upwards

The piece is a good summary of several surveys trying to assess the adoption of the CPR. It’s a long piece and I haven’t digested it all, but way below I give you some of my main takeaways. Before that (and you non-wonks have permission to skip this bit but you should read it), let me explain why, as the authors correctly point out, this is such a difficult subject to assess.

1) Definition is a problem 1: The authors list some 15 terms for CPR-like things (EMR, EHR, CPOE, etc, etc, etc). We are now some 12 years on from the IOM’s original report on the subject and we can’t even figure out what to call the thing. Given none of the surveys have the chance to fully define in their questions what exactly a CPR is, it’s not surprising that the answers they are getting are different from each other.

2) Inpatient versus outpatient: The study finds much higher rates of adoption of CPRs in the clinic setting versus the hospital. Anyone who’s been to see a doctor versus been in a hospital knows that this feels wrong. My suspicion is that any type of clinical computer use  is regarded as the same as a fully fledged CPR in the outpatient setting, but not so much in the inpatient setting. This may be because the inpatient setting doesn’t get much of the data transferred over from the outpatient, and so feels outside the flow of data between different settings that is supposed toe accompany the patient in a CPR. While the inpatient setting is where most of the current action in CPOE (Computerized Physician Order Entry) is happening, clinicians in hospitals think that CPOE is just a component of a CPR not the whole thing.

3) Many surveys are methodologically useless : The methodology behind various surveys is never discussed when the results are released.  But of the many surveys they report I have been a participant in two. One is the annual survey conducted at HIMSS.  Anyone at the conference including the thousands of vendors and consultants (and me) who outnumber the hospital IT folks about 2 to 1 can take this survey, even though it’s aimed at the hospital IT community.  Consequently many of the people taking it at best don’t know the situation of the intended survey audience and at worst are trying to actively influence the outcome. The Harris surveys discussed are based on ones designed by a methodological and subject genius back in 1999–OK, OK it was me, but the methodology and the content were very carefully reviewed by survey specialists at Harris, and the content was reviewed by an expert advisory board. The people surveyed were genuine doctors who had been pre-proved as such by the AMA.  So part of the problem with looking at all surveys is that the results of some are not as valuable as others.

4) Definitions are a problem 2: Even if you know what you are doing methodologically, what you are  counting especially in the outpatient environment is a problem. In my initial Harris survey I did not directly ask if physicians were using an CPR but asked how they were performing a whole lot of tasks such as taking notes, prescribing drugs, etc, etc, that could have been done in several ways including using a computer, PDA, digital dictation, pen & paper, etc, etc.  However, after I left the way the question was changed in recent Harris surveys, and it now asked if the doctor used an EMR. I suspect the reason for that was a) it didn’t provide a one number indicator and b) there’s only so much room on a survey, and it’s expensive to survey doctors and you have other things that you want to ask.  So the trade-off of not knowing exactly what an EMR means to the doctors is worth it because of the other information you get.

The results

Well done you’ve got here! The authors estimate that 20% to 25% of doctors are using a CPR, while something between 3% and 21% are of hospitals are using CPOE (no good numbers for CPR). More controversially, they estimate that CPR adoption will increase rapidly in the outpatient setting to between 50%-60% in the next couple of years. This growth is by no means impossible.  That number is where the UK already is and well below most of Scandinavia, New Zealand and other countries such as Belgium. So what are the barriers?

A) The CPR costs too much. That can mean up to $29,000 to install and $12,000 a year to maintain.  And there is no real obvious funding stream.  That was not the case in those other countries where the government has funded the initiatives.

B) Standards: Despite HIPAA, HL7 et al, several standards are not being adopted that could help easy interoperability (i.e. the easy transfer of data between facilities). So even if many hospitals adopt the elements of the CPR, we are not likely to get the full transfer of data that the CPR is supposed to provide.

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