Implementation of a commercially available inpatient EHR with CPOE appears to have quickly reduced cost of care and improved safety in our hospital. Although less commonly reported, others have found immediate benefit after implementation of CPOE. One site reported a quicker turnaround time in pharmacy, laboratory, and radiology orders.16
We have demonstrated a substantial decrease in laboratory and radiology utilization. According to the Dartmouth Atlas, our La Crosse, Wisconsin, referral region was fourth lowest in the nation in inflation-adjusted total Medicare spending per enrollee, with reported spending in 2006 of $5812, suggesting that our region's systems were very efficient, even before implementation of EHR.7
If cost of care can be reduced even in a highly efficient integrated healthcare delivery system such as ours, other less efficient systems may experience even greater reductions.
Our study demonstrated an 18% reduction in laboratory testing. Another study, one of a system without full CPOE, found that while an electronic alert of apparently redundant selected laboratory tests resulted in significantly fewer tests being ordered, the cost savings were far less than anticipated.17
In another study, Tierney et al18
found that computer entry of inpatient orders was associated with reduced bed charges, diagnostic test charges, and drug charges. This system was set up to display the patient's charge for each item, the most cost-effective tests for common problems, and only reasonable testing intervals. Others have found that the computerized display of charges for laboratory and radiology tests at the time of ordering did not significantly change the number of tests ordered.19
We are the first to report an association of inpatient electronic documentation with an option for partial dictation with a decrease in transcription costs. Others have reported a decrease in transcription of 61.5% to 88.2%, depending on note type, following a voluntary change to direct entry of documentation into the EHR by ob-gyn providers,20
but partial dictation was not used in that study. Our study found a reduction in transcription costs across our entire inpatient environment, not only in a single specialty.
Likewise, our inpatient EHR implementation was associated with a decrease in paper consumption. Because we used paper orders as a surrogate marker of paper consumption, it is possible that these variables did not correspond precisely. Although the dollar amount saved was small, the environmental impact, especially if projected over many organizations and over time, is substantial. To our knowledge, this metric has not been previously reported.
We found an increase in the percentage of near misses and concomitant reduction in the percentage of medication errors after inpatient EHR implementation. Our increase in near misses may demonstrate that EHR implementation introduced additional safety checks to identify potential errors that would not have been recognized without use of the EHR. Therefore, we agree with others that the number of near misses can increase, as ours did, to the benefit of the patient, and that the increase may represent refinement of error-prevention systems.8
Interestingly, Bates et al8
found a non-significant decrease in the number of ‘intercepted potential adverse drug events’ (ie, near misses) after CPOE was introduced, along with an overall decrease in medication errors. They showed no change in percentage of non-intercepted serious medication errors to intercepted potential adverse drug events. Two other studies observed an increase in this percentage, although the statistical significance was not reported.9
Among the strengths of this study is our inclusion of the entire hospital for metrics rather than certain units (eg, Intensive Care)11
or certain specialties (eg, ob-gyn),20
or with selected laboratory tests.17
We also report measures and findings not previously reported in the literature. In addition, we demonstrated that benefits of EHR and CPOE are attainable soon after implementation, as opposed to after system stabilization and refinement.
The single-center nature of the observations and the fact that our implementation experience may not be able to be generalized to other organizations are weaknesses of our study. Organizations of different sizes, specialty mixes, or number of residents may experience different results. In addition, the retrospective design creates bias, as other unknown variables may account for the results. Finally, in an integrated project, overall costs are difficult to determine, and this limits the impact of our study. For further detail regarding this Discussion, please see online appendix 2.
Implementation of an inpatient EHR with CPOE can result in rapid improvement in measures of cost of care and safety, even in an already highly efficient healthcare delivery system. Properly implemented systems have the potential to decrease the cost of care and to improve the safety of our nation's healthcare system.