Editorial Comments: Comments on Return on Investment (ROI) As It Applies to Clinical Systems

In the current issue of this journal, Kaushal and colleagues 1 present an exemplary, thorough analysis of the financial impact of installing computerized physician order entry (CPOE) in a major academic hospital. This excellent work quantifies quantifiable parameters clearly, estimates other parameters conservatively, and lists problems associated with measurement of the remaining small set of other factors. This work is arguably the best that can be done with respect to evaluating CPOE return on investment (ROI). Why does it not quite seem to be enough or to be sufficient to persuade? The answer to the foregoing question lies in the culture of informatics research and in the health care industry’s collective culture of decision making. The research community feels compelled to refine estimates of CPOE’s financial return to a greater and greater degree along the analytical lines in the work of Kaushal et al. Using adoption estimates and implementation plans, proponents of CPOE installation in many institutions may base their arguments solely on the Kaushal et al. financial framework. Other proponents may take a different approach, emphasizing instead the broader array of workflow and professional productivity factors that lead to greater financial return. Still other CPOE proponents pursue the challenge of extending financial models to estimate the benefits of CPOE in every hospital, in every ambulatory practice setting, and in every community. A growing body of hard data on the benefits of CPOE presents a compelling case for all who make CPOE decisions to go forward (see references cited in Kaushal et al. 1 ). They should accept, once and for all, that substantial benefits will accrue to hospitals and patients following the successful implementation of effective CPOE systems. The challenge is not to fine-tune the financial benefit models, but instead to determine how to identify and successfully install an effective CPOE system. Many other factors not included in financial models contribute to the success or failure of CPOE implementations. The challenge to society and to industry is to determine how to extend successful CPOE implementations from the setting of a premier academic medical center to every care delivery setting in the nation. We must understand more fully limitations of ROI analysis in hospitals. We must question and document the extent to which such analyses serve as a valid justification for extending CPOE into diverse, nonhospital-based settings where most medical care is delivered. Such an investigation should start with available findings from the large, sophisticated academic medical centers with adequately abundant technology, talent, and time to develop and install CPOE systems. Even in these settings, we are reminded that ‘‘many savings from CPOE are not realized in the operations budget’’ and hence preclude accurate confirmation of financial benefit.