While adoption of CPOE has been steady, it has a long way to go. Fewer than 5 percent of hospitals in Leapfrog surveys had some form of CPOE in place as of last year. The two biggest barriers are large start-up costs--typically from $3 million to $10 million per hospital--and difficulty in showing bottom-line savings, according to an article last month in the journal Health Affairs. Fewer errors and higher productivity may more than offset the expense, but the savings are largely pocketed by health insurance carriers, not hospitals, because fewer complications and improved efficiency add up to shorter hospital stays.

Hospitals do benefit from increased patient safety, says internist Eric Poon, a coauthor of the article and a researcher at Brigham and Women's Hospital in Boston, but the high expense of CPOE still has to be justified. "Both the government and the insurance companies need to start thinking about providing financial incentives," he says. Part of the new federal program, says Mark McClellan, director of the federal Centers for Medicare and Medicaid Services, would do just that. A new Medicare pilot program will test the effect of higher payments to hospitals that meet various technology requirements.

Taking the long view, Leapfrog CEO Suzanne Delbanco is encouraged. About 16 percent of hospitals have told Leapfrog they plan to have some form of the system fully implemented by the end of 2005--which, she observes, "really is a sea change from where it was four years ago."

One Last Check

About one third of hospital medication errors happen at the front end, according to studies by Lucian Leape of the Harvard School of Public Health, when a doctor prescribes the wrong drug or the wrong dose. Another one third occur in the middle, because a hospital pharmacist misreads the doctor's handwriting or a transcriptionist writing up the doctor's dictated notes fumbles the name of the drug. That two thirds should shrink as hospitals adopt CPOE.

But then there is the back end: a medication administered to the wrong patient or to a patient who has a reaction because allergies, a health condition, potential drug interactions, or other medical information is missing from the record. To reduce those errors, more hospitals are bar-coding not only drugs but patients and nurses.

Before a medication is administered, the nurse scans in the bar codes on her badge, the patient's identification bracelet, and the medication. The computer alerts her to possible conflicts, such as a potentially dangerous interaction with another drug the patient is taking. It can also alert the nurse if the drug isn't being given at the proper time or at the proper dose.

At Eisenhower Medical Center in Rancho Mirage, Calif., 115 beds are wired for bar coding, and an additional 120 are in the works. "It's preventing medication errors daily," says Mary Ann McLaughlin, administrative director for medical-surgical services. Nurses there have come to rely on the system so much, along with pop-up screen alerts like "check blood pressure," says McLaughlin, that they don't "feel as protected" on floors still lacking the system.

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