Adding insight: a qualitative cross-site study of physician order entry

How do stakeholders experience the adoption of electronic prescribing systems in hospitals? A systematic review and thematic synthesis of qualitative studies

Background

Electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of health services, but the translation of this into reduced harm for patients remains unclear. This review aimed to synthesise primary qualitative research relating to how stakeholders experience the adoption of ePrescribing/CPOE systems in hospitals, to help better understand why and how healthcare organisations have not yet realised the full potential of such systems and to inform future implementations and research.

Methods

We systematically searched 10 bibliographic databases and additional sources for citation searching and grey literature, with no restriction on date or publication language. Qualitative studies exploring the perspectives/experiences of stakeholders with the implementation, management, use and/or optimisation of ePrescribing/CPOE systems in hospitals were included. Quality assessment combined criteria from the Critical Appraisal Skills Programme Qualitative Checklist and the Standards for Reporting Qualitative Research guidelines. Data were synthesised thematically.

Results

79 articles were included. Stakeholders’ perspectives reflected a mixed set of positive and negative implications of engaging in ePrescribing/CPOE as part of their work. These were underpinned by further-reaching change processes. Impacts reported were largely practice related rather than at the organisational level. Factors affecting the implementation process and actions undertaken prior to implementation were perceived as important in understanding ePrescribing/CPOE adoption and impact.

Conclusions

Implementing organisations and teams should consider the breadth and depth of changes that ePrescribing/CPOE adoption can trigger rather than focus on discrete benefits/problems and favour implementation strategies that: consider the preimplementation context, are responsive to (and transparent about) organisational and stakeholder needs and agendas and which can be sustained effectively over time as implementations develop and gradually transition to routine use and system optimisation.

An evaluation of variation in pathology investigations and associated factors for adult patients presenting to emergency departments with chest pain: An observational study

OBJECTIVE

To determine variation in pathology test ordering practices and identify associated factors for adult patients presenting to emergency departments (ED) with chest pain and subsequently admitted with ischaemic heart disease.

METHODS

A retrospective study across six hospital EDs in New South Wales, Australia. A total of 6769 patient presentations between January 2014 and December 2017 met the inclusion criteria. Ordered pathology tests were grouped into three categories based on Australasian College for Emergency Medicine and the Royal College of Pathologists of Australasia recommendations: category I (no restriction in ordering), category II (can be ordered after consulting a supervisor) and category III (not for routine ordering in ED). The primary outcome was the proportion of category III test ordering across study EDs. Factors associated with category III test ordering were identified using a logistic regression.

RESULTS

A total of 34 936 pathology tests were ordered: 65.6% (n = 22 932) were category I/II tests and 34.4% (n = 12 004) were category III tests. Five tests (Calcium Magnesium Phosphate, Coagulation Studies, Lipase, C-reactive Protein and Blood Gas tests) accounted for 84.7% of all category III tests. The proportion of category III tests ordered varied by hospitals from 29.8% to 45.9%. The proportion of patients with at least one category III test was 76.3% (range across hospitals: 68.3%-95.6%). Increasing age, presentation to an ED at night, and those in an imminently life-threatening triage category were significantly associated with increased likelihood of category III test ordering. The proportion of category III tests decreased over time. EDs in medium and/or regional hospitals were more likely to order a category III test.

CONCLUSION

Pathology investigations for patients presenting with chest pain varied significantly across EDs suggesting opportunities to improve standardisation of test ordering practices.

Workarounds Emerging From Electronic Health Record System Usage: Consequences for Patient Safety, Effectiveness of Care, and Efficiency of Care

BACKGROUND

Health care providers resort to informal temporary practices known as workarounds for handling exceptions to normal workflow unintendedly imposed by electronic health record systems (EHRs). Although workarounds may seem favorable at first sight, they are generally suboptimal and may jeopardize patient safety, effectiveness of care, and efficiency of care.

OBJECTIVE

Research into the scope and impact of EHR workarounds on patient care processes is scarce. This paper provides insight into the effects of EHR workarounds on organizational workflows and outcomes of care services by identifying EHR workarounds and determining their rationales, scope, and impact on health care providers' workflows, patient safety, effectiveness of care, and efficiency of care. Knowing the rationale of a workaround provides valuable clues about the source of origin of each workaround and how each workaround could most effectively be resolved. Knowing the scope and impact a workaround has on EHR-related safety, effectiveness, and efficiency provides insight into how to address related concerns.

METHODS

Direct observations and follow-up semistructured interviews with 31 physicians, 13 nurses, and 3 clerks and qualitative bottom-up coding techniques was used to identify, analyze, and classify EHR workarounds. The research was conducted within 3 specialties and settings at a large university hospital. Rationales were associated with work system components (persons, technology and tools, tasks, organization, and physical environment) of the Systems Engineering Initiative for Patient Safety (SEIPS) framework to reveal their source of origin as well as to determine the scope and the impact of each EHR workaround from a structure-process-outcome perspective.

RESULTS

A total of 15 rationales for EHR workarounds were identified of which 5 were associated with persons, 4 with technology and tools, 4 with the organization, and 2 with the tasks. Three of these 15 rationales for EHR workarounds have not been identified in prior research: data migration policy, enforced data entry, and task interference.

CONCLUSIONS

EHR workaround rationales associated with different SEIPS work system components demand a different approach to be resolved. Persons-related workarounds may most effectively be resolved through personal training, organization-related workarounds through reviewing organizational policy and regulations, tasks-related workarounds through process redesign, and technology- and tools-related workarounds through EHR redesign efforts. Furthermore, insights gained from knowing a workaround's degree of influence as well as impact on patient safety, effectiveness of care, and efficiency of care can inform design and redesign of EHRs to further align EHR design with work contexts, subsequently leading to better organization and (safe) provision of care. In doing so, a research team in collaboration with all stakeholders could use the SEIPS framework to reflect on the current and potential future configurations of the work system to prevent unfavorable workarounds from occurring and how a redesign of the EHR would impact interactions between the work system components.

Exploring Workarounds Related to Electronic Health Record System Usage: A Study Protocol

Background

Health care providers resort to informal temporary practices known as workarounds for handling exceptions to normal workflow that are unintentionally imposed by electronic health record (EHR) systems. Although workarounds may seem favorable at first sight, they are generally suboptimal and may jeopardize patient safety, effectiveness, and efficiency of care. Identifying workarounds and understanding their motivations, scope, and impact is pivotal to support the design of user-friendly EHRs and achieve closer alignment between EHRs and work contexts.

Objective

We propose a study protocol to identify EHR workarounds and subsequently determine their scope and impact on health care providers’ workflows, patient safety, effectiveness, and efficiency of care. First, knowing whether a workaround solely affects the health care provider who devised it, or whether its effects extends beyond the EHR user to the work context of other health care providers, is key to accurately assessing its degree of influence on the overall patient care workflow. Second, knowing whether the consequence of an EHR workaround is favorable or unfavorable provides insights into how to address EHR-related safety, effectiveness, and efficiency concerns. Knowledge of both perspectives can provide input on optimizing EHR designs.

Methods

In the study, a combination of direct observations, semistructured interviews, and qualitative coding techniques will be used to identify, analyze, and classify EHR workarounds. The research project will be conducted within three distinct pediatric care processes and settings at a large university hospital.

Results

Data was collected using the described approach from January 2016 to March 2017. Data analysis is underway and is expected to be completed in May 2017. We aim to report the results of this study in a follow-up publication.

Conclusions

This study protocol provides a grounded framework to explore EHR workarounds from a holistic and integral perspective. Insights from this study can inform the design and redesign of EHRs to further align with work contexts of healthcare professionals, and subsequently lead to better organization and safer provision of care.

How Physician Perspectives on E-Prescribing Evolve over Time. A Case Study Following the Transition between EHRs in an Outpatient Clinic

BACKGROUND

Physicians are expending tremendous resources transitioning to new electronic health records (EHRs), with electronic prescribing as a key functionality of most systems. Physician dissatisfaction post-transition can be quite marked, especially initially. However, little is known about how physicians' experiences using new EHRs for e-prescribing evolve over time. We previously published a qualitative case study about the early physician experience transitioning from an older to a newer, more robust EHR, in the outpatient setting, focusing on their perceptions of the electronic prescribing functionality.

OBJECTIVE

Our current objective was to examine how perceptions about using the new HER evolved over time, again with a focus on electronic prescribing.

METHODS

We interviewed thirteen internists at an academic medical center-affiliated ambulatory care clinic who transitioned to the new EHR two years prior. We used a grounded theory approach to analyze semi-structured interviews and generate key themes.

RESULTS

We identified five themes: efficiency and usability, effects on safety, ongoing training requirements, customization, and competing priorities for the EHR. We found that for even experienced e-prescribers, achieving prior levels of perceived prescribing efficiency took nearly two years. Despite the fact that speed in performing prescribing-related tasks was highly important, most were still not utilizing system short cuts or customization features designed to maximize efficiency. Alert fatigue remained common. However, direct transmission of prescriptions to pharmacies was highly valued and its benefits generally outweighed the other features considered poorly designed for physician workflow.

CONCLUSIONS

Ensuring that physicians are able to do key prescribing tasks efficiently is critical to the perceived value of e-prescribing applications. However, successful transitions may take longer than expected and e-prescribing system features that do not support workflow or require constant upgrades may further prolong the process. Additionally, as system features continually evolve, physicians may need ongoing training and support to maintain efficiency.

The Chief Clinical Informatics Officer (CCIO): AMIA Task Force Report on CCIO Knowledge, Education, and Skillset Requirements

INTRODUCTION

The emerging operational role of the "Chief Clinical Informatics Officer" (CCIO) remains heterogeneous with individuals deriving from a variety of clinical settings and backgrounds. The CCIO is defined in title, responsibility, and scope of practice by local organizations. The term encompasses the more commonly used Chief Medical Informatics Officer (CMIO) and Chief Nursing Informatics Officer (CNIO) as well as the rarely used Chief Pharmacy Informatics Officer (CPIO) and Chief Dental Informatics Officer (CDIO).

BACKGROUND

The American Medical Informatics Association (AMIA) identified a need to better delineate the knowledge, education, skillsets, and operational scope of the CCIO in an attempt to address the challenges surrounding the professional development and the hiring processes of CCIOs.

DISCUSSION

An AMIA task force developed knowledge, education, and operational skillset recommendations for CCIOs focusing on the common core aspect and describing individual differences based on Clinical Informatics focus. The task force concluded that while the role of the CCIO currently is diverse, a growing body of Clinical Informatics and increasing certification efforts are resulting in increased homogeneity. The task force advised that 1.) To achieve a predictable and desirable skillset, the CCIO must complete clearly defined and specified Clinical Informatics education and training. 2.) Future education and training must reflect the changing body of knowledge and must be guided by changing day-to-day informatics challenges.

CONCLUSION

A better defined and specified education and skillset for all CCIO positions will motivate the CCIO workforce and empower them to perform the job of a 21st century CCIO. Formally educated and trained CCIOs will provide a competitive advantage to their respective enterprise by fully utilizing the power of Informatics science.

Integrating Patient-Reported Outcomes into Spine Surgical Care through Visual Dashboards: Lessons Learned from Human-Centered Design

Introduction:

The collection of patient-reported outcomes (PROs) draws attention to issues of importance to patients—physical function and quality of life. The integration of PRO data into clinical decisions and discussions with patients requires thoughtful design of user-friendly interfaces that consider user experience and present data in personalized ways to enhance patient care. Whereas most prior work on PROs focuses on capturing data from patients, little research details how to design effective user interfaces that facilitate use of this data in clinical practice. We share lessons learned from engaging health care professionals to inform design of visual dashboards, an emerging type of health information technology (HIT).

Methods:

We employed human-centered design (HCD) methods to create visual displays of PROs to support patient care and quality improvement. HCD aims to optimize the design of interactive systems through iterative input from representative users who are likely to use the system in the future. Through three major steps, we engaged health care professionals in targeted, iterative design activities to inform the development of a PRO Dashboard that visually displays patient-reported pain and disability outcomes following spine surgery.

Findings:

Design activities to engage health care administrators, providers, and staff guided our work from design concept to specifications for dashboard implementation. Stakeholder feedback from these health care professionals shaped user interface design features, including predefined overviews that illustrate at-a-glance trends and quarterly snapshots, granular data filters that enable users to dive into detailed PRO analytics, and user-defined views to share and reuse. Feedback also revealed important considerations for quality indicators and privacy-preserving sharing and use of PROs.

Conclusion:

Our work illustrates a range of engagement methods guided by human-centered principles and design recommendations for optimizing PRO Dashboards for patient care and quality improvement. Engaging health care professionals as stakeholders is a critical step toward the design of user-friendly HIT that is accepted, usable, and has the potential to enhance quality of care and patient outcomes.

Dashboards for improving patient care: review of the literature

AIM

This review aimed to provide a comprehensive overview of the current state of evidence for the use of clinical and quality dashboards in health care environments.

METHODS

A literature search was performed for the dates 1996-2012 on CINAHL, Medline, Embase, Cochrane Library, PsychInfo, Science Direct and ACM Digital Library. A citation search and a hand search of relevant papers were also conducted.

RESULTS

One hundred and twenty two full text papers were retrieved of which 11 were included in the review. There was considerable heterogeneity in implementation setting, dashboard users and indicators used. There was evidence that in contexts where dashboards were easily accessible to clinicians (such as in the form of a screen saver) their use was associated with improved care processes and patient outcomes.

CONCLUSION

There is some evidence that implementing clinical and/or quality dashboards that provide immediate access to information for clinicians can improve adherence to quality guidelines and may help improve patient outcomes. However, further high quality detailed research studies need to be conducted to obtain evidence of their efficacy and establish guidelines for their design.

The impact of health information technology on staffing

Hospitals nationwide must demonstrate meaningful use by 2015 or face fines. For over 20 years, researchers have attempted to assess the impact of electronic record keeping technologies on the quality, safety, and efficiency of care, but results are inconclusive and hospital managers have little evidence on which to base staffing decisions as we hurtle toward the era of the paperless hospital.

Computerized physician order entry: promise, perils, and experience

Computerized physician order entry (CPOE) has been promoted as an important component of patient safety, quality improvement, and modernization of medical practice. In practice, however, CPOE affects health care delivery in complex ways, with benefits as well as risks. Every implementation of CPOE is associated with both generally recognized and unique local factors that can facilitate or confound its rollout, and neurohospitalists will often be at the forefront of such rollouts. In this article, we review the literature on CPOE, beginning with definitions and proceeding to comparisons to the standard of care. We then proceed to discuss clinical decision support systems, negative aspects of CPOE, and cultural context of CPOE implementation. Before concluding, we follow the experiences of a Chief Medical Information Officer and neurohospitalist who rolled out a CPOE system at his own health care organization and managed the resulting workflow changes and setbacks.

Stakeholder engagement: a key component of integrating genomic information into electronic health records

Integrating genomic information into clinical care and the electronic health record can facilitate personalized medicine through genetically guided clinical decision support. Stakeholder involvement is critical to the success of these implementation efforts. Prior work on implementation of clinical information systems provides broad guidance to inform effective engagement strategies. We add to this evidence-based recommendations that are specific to issues at the intersection of genomics and the electronic health record. We describe stakeholder engagement strategies employed by the Electronic Medical Records and Genomics Network, a national consortium of US research institutions funded by the National Human Genome Research Institute to develop, disseminate, and apply approaches that combine genomic and electronic health record data. Through select examples drawn from sites of the Electronic Medical Records and Genomics Network, we illustrate a continuum of engagement strategies to inform genomic integration into commercial and homegrown electronic health records across a range of health-care settings. We frame engagement as activities to consult, involve, and partner with key stakeholder groups throughout specific phases of health information technology implementation. Our aim is to provide insights into engagement strategies to guide genomic integration based on our unique network experiences and lessons learned within the broader context of implementation research in biomedical informatics. On the basis of our collective experience, we describe key stakeholder practices, challenges, and considerations for successful genomic integration to support personalized medicine.

Impact of an electronic medication management system on hospital doctors' and nurses' work: a controlled pre-post, time and motion study

OBJECTIVE

To quantify and compare the time doctors and nurses spent on direct patient care, medication-related tasks, and interactions before and after electronic medication management system (eMMS) introduction.

METHODS

Controlled pre-post, time and motion study of 129 doctors and nurses for 633.2 h on four wards in a 400-bed hospital in Sydney, Australia. We measured changes in proportions of time on tasks and interactions by period, intervention/control group, and profession.

RESULTS

eMMS was associated with no significant change in proportions of time spent on direct care or medication-related tasks relative to control wards. In the post-period control ward, doctors spent 19.7% (2 h/10 h shift) of their time on direct care and 7.4% (44.4 min/10 h shift) on medication tasks, compared to intervention ward doctors (25.7% (2.6 h/shift; p=0.08) and 8.5% (51 min/shift; p=0.40), respectively). Control ward nurses in the post-period spent 22.1% (1.9 h/8.5 h shift) of their time on direct care and 23.7% on medication tasks compared to intervention ward nurses (26.1% (2.2 h/shift; p=0.23) and 22.6% (1.9 h/shift; p=0.28), respectively). We found intervention ward doctors spent less time alone (p=0.0003) and more time with other doctors (p=0.003) and patients (p=0.009). Nurses on the intervention wards spent less time with doctors following eMMS introduction (p=0.0001).

CONCLUSIONS

eMMS introduction did not result in redistribution of time away from direct care or towards medication tasks. Work patterns observed on these intervention wards were associated with previously reported significant reductions in prescribing error rates relative to the control wards.

Using a sociotechnical framework to understand adaptations in health IT implementation

PURPOSE

When barcode medication administration (BCMA) is implemented nurses are required to integrate not only a new set of procedures or artifacts into everyday work, but also an orientation to medication safety itself that is sometimes at odds with their own. This paper describes how the nurses' orientation (the Practice Frame) can collide with the orientation that is represented by the technology and its implementation (the System Frame), resulting in adaptations at the individual and organization levels.

METHODS

The paper draws on two qualitative research studies that examined the implementation of BCMA in inpatient settings using observation and ethnographic fieldwork, content analysis of email communications, and interviews with healthcare professionals.

RESULTS

Two frames of reference are described: the System Frame and the Practice Frame. We found collisions of these frames that prompted adaptations at the individual and organization levels. The System Frame was less integrated and flexible than the Practice Frame, less able to account for all of the dimensions of everyday patient care to which medication administration is tied.

CONCLUSION

Collisions in frames during implementation of new technology result in adaptations at the individual and organization level that can have a variety of effects. We found adaptations to be a means of evolving both the work routines and the technology. Understanding the frames of clinical workers when new technology is being designed and implemented can inform changes to technology or organizational structure and policy that can preclude unproductive or unsafe adaptations.

The impact of an electronic health record on nurse sensitive patient outcomes: an interrupted time series analysis

OBJECTIVES

To evaluate the impact of electronic health record (EHR) implementation on nursing care processes and outcomes.

DESIGN

Interrupted time series analysis, 2003-2009.

SETTING

A large US not-for-profit integrated health care organization.

PARTICIPANTS

29 hospitals in Northern and Southern California.

INTERVENTION

An integrated EHR including computerized physician order entry, nursing documentation, risk assessment tools, and documentation tools.

MAIN OUTCOME MEASURES

Percentage of patients with completed risk assessments for hospital acquired pressure ulcers (HAPUs) and falls (process measures) and rates of HAPU and falls (outcome measures).

RESULTS

EHR implementation was significantly associated with an increase in documentation rates for HAPU risk (coefficient 2.21, 95% CI 0.67 to 3.75); the increase for fall risk was not statistically significant (0.36; -3.58 to 4.30). EHR implementation was associated with a 13% decrease in HAPU rates (coefficient -0.76, 95% CI -1.37 to -0.16) but no decrease in fall rates (-0.091; -0.29 to 0.11). Irrespective of EHR implementation, HAPU rates decreased significantly over time (-0.16; -0.20 to -0.13), while fall rates did not (0.0052; -0.01 to 0.02). Hospital region was a significant predictor of variation for both HAPU (0.72; 0.30 to 1.14) and fall rates (0.57; 0.41 to 0.72).

CONCLUSIONS

The introduction of an integrated EHR was associated with a reduction in the number of HAPUs but not in patient fall rates. Other factors, such as changes over time and hospital region, were also associated with variation in outcomes. The findings suggest that EHR impact on nursing care processes and outcomes is dependent on a number of factors that should be further explored.

Implementation of computerized physician order entry in National Guard Hospitals: assessment of critical success factors

OBJECTIVE

The purpose of this study is to describe the needs, process and experience of implementing a computerized physician order entry (CPOE) system in a leading healthcare organization in Saudi Arabia.

MATERIALS AND METHODS

The National Guard Health Affairs (NGHA) deployed the CPOE in a pilot department, which was the intensive care unit (ICU) in order to assess its benefits and risks and to test the system. After the CPOE was implemented in the ICU area, a survey was sent to the ICU clinicians to assess their perception on the importance of 32 critical success factors (CSFs) that was acquired from the literature. The project team also had several meetings to gather lessons learned from the pilot project in order to utilize them for the expansion of the project to other NGHA clinics and hospitals.

RESULTS

The results of the survey indicated that the selected CSFs, even though they were developed with regard to international settings, are very much applicable for the pilot area. The top three CSFs rated by the survey respondents were: The "before go-live training", the adequate clinical resources during implementation, and the ordering time. After the assessment of the survey and the lessons learned from the pilot project, NGHA decided that the potential benefits of the CPOE are expected to be greater the risks expected. The project was then expanded to cover all NGHA clinics and hospitals in a phased approach. Currently, the project is in its final stages and expected to be completed by the end of 2011.

CONCLUSION

The role of CPOE systems is very important in hospitals in order to reduce medication errors and to improve the quality of care. In spite of their great benefits, many studies suggest that a high percentage of these projects fail. In order to increase the chances of success and due to the fact that CPOE is a clinical system, NGHA implemented the system first in a pilot area in order to test the system without putting patients at risk and to learn from mistakes before expanding the system to other areas. As a result of the pilot project, NGHA developed a list of CSFs to increase the likelihood of project success for the expansion of the system to other clinics and hospitals. The authors recommend a future study for the CPOE implementation to be done that covers the implementation in all the four NGHA hospitals. The results of the study can then be generalized to other hospitals in Saudi Arabia.

Comparison of clinical knowledge management capabilities of commercially-available and leading internally-developed electronic health records

BACKGROUND

We have carried out an extensive qualitative research program focused on the barriers and facilitators to successful adoption and use of various features of advanced, state-of-the-art electronic health records (EHRs) within large, academic, teaching facilities with long-standing EHR research and development programs. We have recently begun investigating smaller, community hospitals and out-patient clinics that rely on commercially-available EHRs. We sought to assess whether the current generation of commercially-available EHRs are capable of providing the clinical knowledge management features, functions, tools, and techniques required to deliver and maintain the clinical decision support (CDS) interventions required to support the recently defined "meaningful use" criteria.

METHODS

We developed and fielded a 17-question survey to representatives from nine commercially available EHR vendors and four leading internally developed EHRs. The first part of the survey asked basic questions about the vendor's EHR. The second part asked specifically about the CDS-related system tools and capabilities that each vendor provides. The final section asked about clinical content.

RESULTS

All of the vendors and institutions have multiple modules capable of providing clinical decision support interventions to clinicians. The majority of the systems were capable of performing almost all of the key knowledge management functions we identified.

CONCLUSION

If these well-designed commercially-available systems are coupled with the other key socio-technical concepts required for safe and effective EHR implementation and use, and organizations have access to implementable clinical knowledge, we expect that the transformation of the healthcare enterprise that so many have predicted, is achievable using commercially-available, state-of-the-art EHRs.

Prescriber and staff perceptions of an electronic prescribing system in primary care: a qualitative assessment

BACKGROUND

The United States (US) Health Information Technology for Economic and Clinical Health Act of 2009 has spurred adoption of electronic health records. The corresponding meaningful use criteria proposed by the Centers for Medicare and Medicaid Services mandates use of computerized provider order entry (CPOE) systems. Yet, adoption in the US and other Western countries is low and descriptions of successful implementations are primarily from the inpatient setting; less frequently the ambulatory setting. We describe prescriber and staff perceptions of implementation of a CPOE system for medications (electronic- or e-prescribing system) in the ambulatory setting.

METHODS

Using a cross-sectional study design, we conducted eight focus groups at three primary care sites in an independent medical group. Each site represented a unique stage of e-prescribing implementation - pre/transition/post. We used a theoretically based, semi-structured questionnaire to elicit physician (n = 17) and staff (n = 53) perceptions of implementation of the e-prescribing system. We conducted a thematic analysis of focus group discussions using formal qualitative analytic techniques (i.e. deductive framework and grounded theory). Two coders independently coded to theoretical saturation and resolved discrepancies through discussions.

RESULTS

Ten themes emerged that describe perceptions of e-prescribing implementation: 1) improved availability of clinical information resulted in prescribing efficiencies and more coordinated care; 2) improved documentation resulted in safer care; 3) efficiencies were gained by using fewer paper charts; 4) organizational support facilitated adoption; 5) transition required time; resulted in workload shift to staff; 6) hardware configurations and network stability were important in facilitating workflow; 7) e-prescribing was time-neutral or time-saving; 8) changes in patient interactions enhanced patient care but required education; 9) pharmacy communications were enhanced but required education; 10) positive attitudes facilitated adoption.

CONCLUSIONS

Prescribers and staff worked through the transition to successfully adopt e-prescribing, and noted the benefits. Overall impressions were favorable. No one wished to return to paper-based prescribing.

Computerized physician order entry (CPOE) system: expectations and experiences of users

OBJECTIVES

To explore physicians' and nurses' expectations before and experiences after the implementation of a computerized physician order entry (CPOE) system in order to give suggestions for future optimization of the system as well as the implementation process.

METHOD

On four internal medicine wards of two Dutch hospitals, 18 physicians and 42 nurses were interviewed to measure expectations and experiences with the CPOE system. Using semi-structured questionnaires, expectations and experiences of physicians and nurses with the CPOE system were measured with statements on a 5-point Likert scale (1 = completely disagree, 5 = completely agree). The percentage respondents agreeing (score of 4 or 5) was calculated. Chi-squared tests were used to compare the expectations versus experiences of physicians and nurses and to assess the differences between physicians and nurses.

RESULTS

In general, both physicians and nurses were positive about CPOE before and after the implementation of this system. Physicians and nurses did not differ in their views towards CPOE except for the overview of patients' medication use that was not clear according to the nurses. Both professions were satisfied with the implementation process. CPOE could be improved especially with respect to technical aspects (including the medication overview) and decision support on drug-drug interactions.

CONCLUSION

Overall we conclude that physicians and nurses are positive about CPOE and the process of its implementation and do accept these systems. However, these systems should be further improved to fit into clinical practice.

Computerized provider order entry systems - Research imperatives and organizational challenges facing pathology services

Information and communication technologies (ICT) are contributing to major changes taking place in pathology and within health services more generally. In this article, we draw on our research experience for over 7 years investigating the implementation and diffusion of computerized provider order entry (CPOE) systems to articulate some of the key informatics challenges confronting pathology laboratories. The implementation of these systems, with their improved information management and decision support structures, provides the potential for enhancing the role that pathology services play in patient care pathways. Beyond eliminating legibility problems, CPOE systems can also contribute to the efficiency and safety of healthcare, reducing the duplication of test orders and diminishing the risk of misidentification of patient samples and orders. However, despite the enthusiasm for CPOE systems, their diffusion across healthcare settings remains variable and is often beset by implementation problems. Information systems like CPOE may have the ability to integrate work, departments and organizations, but unfortunately, health professionals, departments and organizations do not always want to be integrated in ways that information systems allow. A persistent theme that emerges from the research evidence is that one size does not fit all, and system success or otherwise is reliant on the conditions and circumstances in which they are located. These conditions and circumstances are part of what is negotiated in the complex, messy and challenging area of ICT implementation. The solution is not likely to be simple and easy, but current evidence suggests that a combination of concerted efforts, better research designs, more sophisticated theories and hypotheses as well as more skilled, multidisciplinary research teams, tackling this area of study will bring substantial benefits, improving the effectiveness of pathology services, and, as a direct corollary, the quality of patient care.

A rapid assessment process for clinical informatics interventions

Informatics interventions generally take place in rapidly changing settings where many variables are outside the control of the evaluator. Assessment must be timely so that feedback can instigate modification of the intervention. Adapting a methodology from international health and epidemiology, we have developed and refined a Rapid Assessment Process (RAP) for informatics while conducting a study of clinical decision support (CDS) in community hospitals. Using RAP, we have not only been able to provide implementers with actionable feedback, but we have also discovered that users and informaticians conceptualize CDS in vastly different ways. Further understanding of this difference will be needed if we are to improve CDS acceptance by users.

Crossing the implementation chasm: a proposal for bold action

As health care organizations dramatically increase investment in information technology (IT) and the scope of their IT projects, implementation failures become critical events. Implementation failures cause stress on clinical units, increase risk to patients, and result in massive costs that are often not recoverable. At an estimated 28% success rate, the current level of investment defies management logic. This paper asserts that there are "chasms" in IT implementations that represent risky stages in the process. Contributors to the chasms are classified into four categories: design, management, organization, and assessment. The American College of Medical Informatics symposium participants recommend bold action to better understand problems and challenges in implementation and to improve the ability of organizations to bridge these implementation chasms. The bold action includes the creation of a Team Science for Implementation strategy that allows for participation from multiple institutions to address the long standing and costly implementation issues. The outcomes of this endeavor will include a new focus on interdisciplinary research and an inter-organizational knowledge base of strategies and methods to optimize implementations and subsequent achievement of organizational objectives.

Computer-related medication errors in neonatal intensive care units

Iatrogenic medication errors in the neonatal ICU (NICU) are reported to occur up to 2.6 times per 100 NICU days. It has been learned during the last decade that well-intended but faulty implementations of technology can increase the frequency of errors and also can give rise to new types. This article compares and discusses iatrogenic medication errors in the NICU that are related to computer entry and computerized physician order entry systems. The authors also propose a possible approach for evaluating technology that is intended to prevent iatrogenic mediation errors in the NICU.

Assessing the anticipated consequences of Computer-based Provider Order Entry at three community hospitals using an open-ended, semi-structured survey instrument

OBJECTIVE

To determine what "average" clinicians in organizations that were about to implement Computer-based Provider Order Entry (CPOE) were expecting to occur, we conducted an open-ended, semi-structured survey at three community hospitals.

METHODS

We created an open-ended, semi-structured, interview survey template that we customized for each organization. This interview-based survey was designed to be administered orally to clinicians and take approximately 5 min to complete, although clinicians were allowed to discuss as many advantages or disadvantages of the impending system roll-out as they wanted to.

RESULTS

Our survey findings did not reveal any overly negative, critical, problematic, or striking sets of concerns. However, from the standpoint of unintended consequences, we found that clinicians were anticipating only a few of the events, emotions, and process changes that are likely to result from CPOE.

CONCLUSIONS

The results of such an open-ended survey may prove useful in helping CPOE leaders to understand user perceptions and predictions about CPOE, because it can expose issues about which more communication, or discussion, is needed. Using the survey, implementation strategies and management techniques outlined in this paper, any chief information officer (CIO) or chief medical information officer (CMIO) should be able to adequately assess their organization's CPOE readiness, make the necessary mid-course corrections, and be prepared to deal with the currently identified unintended consequences of CPOE should they occur.

Issues in biomedical research data management and analysis: needs and barriers

OBJECTIVES

A. Identify the current state of data management needs of academic biomedical researchers. B. Explore their anticipated data management and analysis needs. C. Identify barriers to addressing those needs.

DESIGN

A multimodal needs analysis was conducted using a combination of an online survey and in-depth one-on-one semi-structured interviews. Subjects were recruited via an e-mail list representing a wide range of academic biomedical researchers in the Pacific Northwest.

MEASUREMENTS

The results from 286 survey respondents were used to provide triangulation of the qualitative analysis of data gathered from 15 semi-structured in-depth interviews.

RESULTS

Three major themes were identified: 1) there continues to be widespread use of basic general-purpose applications for core data management; 2) there is broad perceived need for additional support in managing and analyzing large datasets; and 3) the barriers to acquiring currently available tools are most commonly related to financial burdens on small labs and unmet expectations of institutional support.

CONCLUSION

Themes identified in this study suggest that at least some common data management needs will best be served by improving access to basic level tools such that researchers can solve their own problems. Additionally, institutions and informaticians should focus on three components: 1) facilitate and encourage the use of modern data exchange models and standards, enabling researchers to leverage a common layer of interoperability and analysis; 2) improve the ability of researchers to maintain provenance of data and models as they evolve over time though tools and the leveraging of standards; and 3) develop and support information management service cores that could assist in these previous components while providing researchers with unique data analysis and information design support within a spectrum of informatics capabilities.

Cognitive analysis of physicians and nurses cooperation in the medication ordering and administration process

The objective of this study was to analyse physician-nurse cooperation in the medication ordering and administration process from a cognitive point of view. In this paper, we compared two work organizations characterized by: (1) a synchronous cooperation engendered by common doctor-nurse medical rounds and (2) an asynchronous situation characterized by split physician's and nurse's rounds. Both organizations worked with paper-based documentation systems. We relied on a cooperation cognitive architecture model and used specific methods from cognitive ergonomics to analyse physicians' and nurses' activity, communications and cooperation. The analysis of doctor-nurse dialogues during the medical rounds demonstrated that in the synchronous situation, the nurses actively participated in the medication ordering process. Such dialogues supported the elaboration of shared knowledge in the form of a common frame of reference (COFOR) which both actors rely on to control the entire medication process, and more precisely the coordination of their actions. Document analysis showed that the orders were far from exhaustively documented. However, self-confrontation interviews with the nurses demonstrated that, except for a small number of ill-documented orders, they were able to accurately retrieve the physician's complete intended orders. In this work organization, the nurse was able to control the medication administration process at a high level, because she understood the highest level of strategic control of the medication ordering carried out by the physician. In the asynchronous situation, the results were reversed. The nurses no longer participated in the decision making phase of the medication process. Doctor-nurse communications were rare, and their shared knowledge about the patient was weakened. Although written orders proved to be better documented, the nurses suffered from a lack of knowledge on the patient's medical case and the particular context of the medical decision making when confronted with incomplete or ambiguous orders. In this work organization, the nurse would find herself restrained to low level process control and confined in a reactive, instead of anticipative, management mode. This latter work organization is very similar to the CPOE situation we observed in previous studies, where the coordination of physicians' and nurses' actions was delegated to the system. We suggest that it is essential to take these organizational and cognitive aspects into account when (re-)designing CPOE applications.

What Adolescents With Type I Diabetes and Their Parents Want From Testing Technology

The presence of diabetes in an adolescent can significantly affect his/her normal development. Mobile technology may offer the ability to lessen this negative impact. We wished to learn from adolescents with diabetes and their parents how monitoring systems that incorporated mobile communication technology could potentially help to reduce hassles associated with testing, improve compliance, and ease adolescent-parent conflict about testing behavior. We recruited adolescents between the ages of 13 and 18 years, living with type 1 diabetes mellitus and their parents for focus groups. Qualitative analysis of the focus group data followed a set procedure. From the discussions, the following themes were identified: issues with blood glucose monitoring and desired technology. Elements of desired technology included hardware requirements, software requirements, communication, and miscellaneous requirements. The reported needs of this end-user group can help others to leverage maximally the capabilities of new and existing technology to care for children managing chronic disease.

Towards a hybrid method to categorize interruptions and activities in healthcare

OBJECTIVE

Interruptions are known to have a negative impact on activity performance. Understanding how an interruption contributes to human error is limited because there is not a standard method for analyzing and classifying interruptions. Qualitative data are typically analyzed by either a deductive or an inductive method. Both methods have limitations. In this paper, a hybrid method was developed that integrates deductive and inductive methods for the categorization of activities and interruptions recorded during an ethnographic study of physicians and registered nurses in a Level One Trauma Center. Understanding the effects of interruptions is important for designing and evaluating informatics tools in particular as well as improving healthcare quality and patient safety in general.

METHOD

The hybrid method was developed using a deductive a priori classification framework with the provision of adding new categories discovered inductively in the data. The inductive process utilized line-by-line coding and constant comparison as stated in Grounded Theory.

RESULTS

The categories of activities and interruptions were organized into a three-tiered hierarchy of activity. Validity and reliability of the categories were tested by categorizing a medical error case external to the study. No new categories of interruptions were identified during analysis of the medical error case.

CONCLUSIONS

Findings from this study provide evidence that the hybrid model of categorization is more complete than either a deductive or an inductive method alone. The hybrid method developed in this study provides the methodical support for understanding, analyzing, and managing interruptions and workflow.

Practitioners' views on computerized drug-drug interaction alerts in the VA system

OBJECTIVES

To assess Veterans Affairs (VA) prescribers' and pharmacists' opinions about computer-generated drug-drug interaction (DDI) alerts and obtain suggestions for improving DDI alerts.

DESIGN

A mail survey of 725 prescribers and 142 pharmacists from seven VA medical centers across the United States.

MEASUREMENTS

A questionnaire asked respondents about their sources of drug and DDI information, satisfaction with the combined inpatient and outpatient computerized prescriber order entry (CPOE) system, attitude toward DDI alerts, and suggestions for improving DDI alerts.

RESULTS

The overall response rate was 40% (prescribers: 36%; pharmacists: 59%). Both prescribers and pharmacists indicated that the CPOE system had a neutral to positive impact on their jobs. DDI alerts were not viewed as a waste of time and the majority (61%) of prescribers felt that DDI alerts had increased their potential to prescribe safely. However, only 30% of prescribers felt DDI alerts provided them with what they needed most of the time. Both prescribers and pharmacists agreed that DDI alerts should be accompanied by management alternatives (73% and 82%, respectively) and more detailed information (65% and 89%, respectively). When asked about suggestions for improving DDI alerts, prescribers most preferred including management options whereas pharmacists most preferred making it more difficult to override lethal interactions. Prescribers and pharmacists reported primarily relying on electronic references for general drug information (62% and 55%, respectively) and DDI information (51% and 79%, respectively).

CONCLUSION

Respondents reported neutral to positive views regarding the effect of CPOE on their jobs. Their opinions suggest DDI alerts are useful but still require additional work to increase their clinical utility.

Categorizing the unintended sociotechnical consequences of computerized provider order entry

OBJECTIVE

To describe the kinds of unintended consequences related to the implementation of computerized provider order entry (CPOE) in the outpatient setting.

DESIGN

Ethnographic and interview data were collected by an interdisciplinary team over a 7 month period at four clinics.

MEASUREMENTS

Instances of unintended consequences were categorized using an expanded Diffusion of Innovations theory framework.

RESULTS

The framework was clarified and expanded. There are both desirable and undesirable unintended consequences, and they can be either direct or indirect, but there are also many consequences that are not clearly either desirable or undesirable or may even be both, depending on one's perspective. The undesirable consequences include error and security concerns and issues related to alerts, workflow, ergonomics, interpersonal relations, and reimplementations.

CONCLUSION

Consequences of implementing and reimplementing clinical systems are complex. The expanded Diffusion of Innovations theory framework is a useful tool for analyzing such consequences.

Computerised order entry systems and pathology services--a synthesis of the evidence

Computerised Physician Order Entry (CPOE) systems have been promoted in Australia and internationally for their potential to improve the quality of care. The existing research of the effect of CPOE on pathology laboratories has been variable, pointing to the potential to increase efficiency and effectiveness and contribute to enhancing the quality of patient care on the one hand, while leading to significant disruptions in work organisation with a negative impact on departmental relations on the other hand. In this paper we provide an overview of the research evidence about the impact of CPOE on four areas associated with pathology services; a) efficiency of the ordering process, e.g. test turnaround times, b) effectiveness as measured by test ordering volumes and test order appropriateness, c) quality of care, particularly its effects on patient care and d) work organisation patterns, which can be severely disrupted by CPOE. We discuss the possible ramifications of CPOE and offer three broad, but important recommendations for pathology laboratories, based on our own research experience investigating CPOE implementations over three years. Firstly, pathology laboratories need to be active participants in planning the implementation of CPOE. Secondly, the importance of building a firm organisational foundation for the introduction of the new system that includes openness and responsiveness to feedback. And thirdly, the implementation process needs to be underpinned by a strong commitment to a multi-method evaluation at every stage of the process to be able to measure the impact of the system on work practices and outcomes.

Ambulatory computerized physician order entry implementation

As part of broader effort to identify success factors for implementing computerized physician order entry(CPOE), factors specific to the ambulatory setting were investigated in the field at Kaiser Permanente Northwest. A multidisciplinary team of five qualitative researchers spent seven months at four clinics conducting observations, interviews, and focus groups. The team analyzed the data using a combination of template and grounded theory approaches. The result is a description of fourteen themes, clustered into technology, organizational,personal, and environmental categories. While similar to inpatient study results in many respects,this outpatient CPO investigation generated subtly different themes.