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

Exploration and explication of the nature of online reviews of organizational corporate social responsibility initiatives

Purpose

The purpose of this paper is to comprehend the nature of online reviews received on various social networking sites and internet-based platforms regrading organizational corporate social responsibility (CSR) initiatives.

Design/methodology/approach

Given the novelty of this field, a qualitative exploratory research study was carried out. For this research, 28 Indian CSR experts on online CSR reviews were interviewed with a semi-structured open-ended questionnaire for data collection. Thematic and relational content analysis was applied for data analysis. The data was analysed based upon the theoretical anchors of micro foundations approach, organizational egoism (reputational and economic) concept and organizational logic (instrumental and integrative) literature and stakeholder salience.

Findings

The study analysis indicated that online CSR reviews that organizations received on various social networking sites and internet-based platforms from different individual and institutional stakeholders were complaints, appreciations, observations and recommendations in nature. Online CSR reviews appreciated more of integrative organizational logic than instrumental organizational logic. CSR reviews present on online platforms valued organizational reputational egoism more than organizational economic egoism. The salience of stakeholders was getting redefines in Web 2.0 based online CSR reviews. Finally, micro foundations approach was becoming a more potent perspective in the CSR narrative.

Research limitations/implications

This research study was anchored in the micro foundations approach of CSR (Hafenbrädl and Waeger, 2017). This study ascertained those individuals did matter in organizational CSR narrative (Maak et al., 2016). Furthermore, how firms were evaluated through online reviews based upon organizational egoism (reputational and economic) (Casali, 2011; Casali and Day, 2015) and organizational logic (instrumental and integrative) (Seele and Lock, 2015; Liu, 2013; Gao and Bansal, 2013; Bansal and Song, 2017) was studied. Finally, in the world of online reviews, the notion of salient stakeholders (Mitchell et al., 2011; Magness, 2008) was getting redefined, and this aspect was also covered in this research study.

Practical implications

Firms have been engaging in CSR initiatives towards provision of social benefits and community engagement. Regarding firm CSR initiatives, CSR managers traditionally used to receive feedback from the stakeholders based upon written and special surveys conducted post or during the late stages of CSR engagement. The advent and ubiquitous presence of digital mobile devices and Web 2.0-enabled internet connections altered the way firms received feedback. This was because increasingly online reviews were received from stakeholders on firm CSR web pages, social networking sites and other online spaces. Many of the online CSR reviews were regarding the compliments and achievements that the CSR initiatives had achieved. However, a significant portion of online CSR reviews were regarding the complaints regarding the CSR initiatives. Online CSR reviews received from an array of stakeholders are inputs for firm managers. Online CSR reviews are thus an asset for an organization. Managers need to develop capabilities towards applying this asset for the expressed purposed. These online CSR reviews could be used as inputs to draw new CSR initiatives, redefine extant CSR initiatives. Furthermore, these online CSR reviews could be used as inputs to alter the organizational resources, capabilities, competencies and process regarding CSR initiatives.

Originality/value

This was one of the first studies that integrated the theoretical aspects of salient stakeholders, organizational logic, organizational egoism through the lens of micro foundations approach in the context of organizational CSR initiatives. To the best of the author’s knowledge, this was indeed a novel contribution, as the same was explored and explicated based upon online CSR reviews on internet-based platforms.

Behavioral signs of an unintended error in nursing information sharing with electronic clinical pathways: a mixed research approach

Electronic clinical pathways (ECPs) strongly encourage the standardization of medical treatment and the sharing of information among medical staff. The goal of this study was to determine the influence of ECPs on information sharing among nurses in a university hospital. Four experienced nurses, selected based on ECP composing and operation experience, were recruited from the department with the most frequent users in the first-round interview, 132 nurses' questionnaire answers were analyzed, and eight nurses participated in the second-round interview. This study conducted a mixed-method (interview-questionnaire-interview) investigation to extract the behavioral signs of unintended errors in information sharing after the ethical approval was obtained. On the basis of ANOVA and t-test for the questionnaire and constant comparison for interview, this study found that the greater extent of user dependency on convenient ECPs in the frequent-use group led to mistakes under hectic conditions. This study also found evidence of poor management of ECPs when problems occurred. The immature design of ECPs provoked inappropriate behaviors among nurses even though they brought about some benefits such as mitigation of the burden of daily recording tasks. The findings empirically showed the ECP user's behavioral changes regarding the technology-induced error.

Clinician Perceptions on the Use of Free-Text Communication Orders

OBJECTIVE

The aim of this study was to investigate (1) why ordering clinicians use free-text orders to communicate medication information; (2) what risks physicians and nurses perceive when free-text orders are used for communicating medication information; and (3) how electronic health records (EHRs) could be improved to encourage the safe communication of medication information.

METHODS

We performed semi-structured, scenario-based interviews with eight physicians and eight nurses. Interview responses were analyzed and grouped into common themes.

RESULTS

Participants described eight reasons why clinicians use free-text medication orders, five risks relating to the use of free-text medication orders, and five recommendations for improving EHR medication-related communication. Poor usability, including reduced efficiency and limited functionality associated with structured order entry, was the primary reason clinicians used free-text orders to communicate medication information. Common risks to using free-text orders for medication communication included the increased likelihood of missing orders and the increased workload on nurses responsible for executing orders.

DISCUSSION

Clinicians' use of free-text orders is primarily due to limitations in the current structured order entry design. To encourage the safe communication of medication information between clinicians, the EHR's structured order entry must be redesigned to support clinicians' cognitive and workflow needs that are currently being addressed via the use of free-text orders.

CONCLUSION

Clinicians' use of free-text orders as a workaround to insufficient structured order entry can create unintended patient safety risks. Thoughtful solutions designed to address these workarounds can improve the medication ordering process and the subsequent medication administration process.

Computerized provider order entry-related medication errors among hospitalized patients: An integrative review

The Institute of Medicine estimates that 7,000 lives are lost yearly as a result of medication errors. Computerized physician and/or provider order entry was one of the proposed solutions to overcome this tragic issue. Despite some promising data about its effectiveness, it has been found that computerized provider order entry may facilitate medication errors.The purpose of this review is to summarize current evidence of computerized provider order entry -related medication errors and address the sociotechnical factors impacting the safe use of computerized provider order entry. By using PubMed and Google Scholar databases, a systematic search was conducted for articles published in English between 2007 and 2019 regarding the unintended consequences of computerized provider order entry and its related medication errors. A total of 288 articles were screened and categorized based on their use within the review. One hundred six articles met our pre-defined inclusion criteria and were read in full, in addition to another 27 articles obtained from references. All included articles were classified into the following categories: rates and statistics on computerized provider order entry -related medication errors, types of computerized provider order entry -related unintended consequences, factors contributing to computerized provider order entry failure, and recommendations based on addressing sociotechnical factors. Identifying major types of computerized provider order entry -related unintended consequences and addressing their causes can help in developing appropriate strategies for safe and effective computerized provider order entry. The interplay between social and technical factors can largely affect its safe implementation and use. This review discusses several factors associated with the unintended consequences of this technology in healthcare settings and presents recommendations for enhancing its effectiveness and safety within the context of sociotechnical factors.

Communication through the electronic health record: frequency and implications of free text orders

Communication for non-medication order (CNMO) is a type of free text communication order providers use for asynchronous communication about patient care. The objective of this study was to understand the extent to which non-medication orders are being used for medication-related communication. We analyzed a sample of 26 524 CNMOs placed in 6 hospitals. A total of 42% of non-medication orders contained medication information. There was large variation in the usage of CNMOs across hospitals, provider settings, and provider types. The use of CNMOs for communicating medication-related information may result in delayed or missed medications, receiving medications that should have been discontinued, or important clinical decision being made based on inaccurate information. Future studies should quantify the implications of these data entry patterns on actual medication error rates and resultant safety issues.

Looking Behind the Curtain: Identifying Factors Contributing to Changes on Care Outcomes During a Large Commercial EHR Implementation

Objective:

To identify factors contributing to changes on quality, productivity, and safety outcomes during a large commercial electronic health record (EHR) implementation and to guide future research.

Methods:

We conducted a mixed-methods study assessing the impact of a commercial EHR implementation. The method consisted of a quantitative longitudinal evaluation followed by qualitative semi-structured, in-depth interviews with clinical employees from the same implementation. Fourteen interviews were recorded and transcribed. Three authors independently coded interview narratives and via consensus identified factors contributing to changes on 15 outcomes of quality, productivity, and safety.

Results:

We identified 14 factors that potentially affected the outcomes previously monitored. Our findings demonstrate that several factors related to the implementation (e.g., incomplete data migration), partially related (e.g., intentional decrease in volume of work), and not related (e.g., health insurance changes) may affect outcomes in different ways.

Discussion:

This is the first study to investigate factors contributing to changes on a broad set of quality, productivity, and safety outcomes during an EHR implementation guided by the results of a large longitudinal evaluation. The diversity of factors identified indicates that the need for organizational adaptation to take full advantage of new technologies is as important for health care as it is for other services sectors.

Conclusions:

We recommend continuous identification and monitoring of these factors in future evaluations to hopefully increase our understanding of the full impact of health information technology interventions.

Effectiveness of a Best Practice Alerts at Improving Hypertension Control

BACKGROUND

Inadequately treated hypertension (HTN) leads to considerable morbidity and mortality. Despite many treatment options, blood pressure (BP) control is suboptimal. Missed opportunities due to the growing complexity of primary care office visits contribute. Electronic health records (EHRs) offer best practice alerts (BPA) tools to support clinicians in identifying poor BP control. BPAs have demonstrated effectiveness for other health outcomes.

METHODS

EHR data were collected for patients ≥18 years old seen for primary care office visits prior to, during, and after the BPA active period and used to identify patients for whom the BPA fired or would have fired during control periods. Logistic regression examined the association of BPA activation with follow-up BP check within 14-90 days and with BP control at follow-up, controlling for demographics and health conditions.

RESULTS

The BPA active period was associated with reduced patient follow-up; however, a number of covariates were predictive of increased follow-up: Black non-Hispanics, Hispanics, patients on the chronic kidney disease, HTN, or diabetes registries, as well as the morbidly obese, insurance status, and seasonal factors. For those who did follow-up, BPA activation was associated with improved BP control.

CONCLUSIONS

BPA activation was associated with worse patient follow-up but improved BP control. Some subgroups had significantly different rates of follow-up and BP control. This study did not have an experimental design as the BPA was a quality improvement initiative. These results highlight the critical importance of planning experimentally designed organizational initiatives to fully understand their impact.

A Survey of the Literature on Unintended Consequences Associated with Health Information Technology: 2014-2015

OBJECTIVE

To summarize recent research on unintended consequences associated with implementation and use of health information technology (health IT). Included in the review are original empirical investigations published in English between 2014 and 2015 that reported unintended effects introduced by adoption of digital interventions. Our analysis focuses on the trends of this steam of research, areas in which unintended consequences have continued to be reported, and common themes that emerge from the findings of these studies.

METHOD

Most of the papers reviewed were retrieved by searching three literature databases: MEDLINE, Embase, and CINAHL. Two rounds of searches were performed: the first round used more restrictive search terms specific to unintended consequences; the second round lifted the restrictions to include more generic health IT evaluation studies. Each paper was independently screened by at least two authors; differences were resolved through consensus development.

RESULTS

The literature search identified 1,538 papers that were potentially relevant; 34 were deemed meeting our inclusion criteria after screening. Studies described in these 34 papers took place in a wide variety of care areas from emergency departments to ophthalmology clinics. Some papers reflected several previously unreported unintended consequences, such as staff attrition and patients' withholding of information due to privacy and security concerns. A majority of these studies (71%) were quantitative investigations based on analysis of objectively recorded data. Several of them employed longitudinal or time series designs to distinguish between unintended consequences that had only transient impact, versus those that had persisting impact. Most of these unintended consequences resulted in adverse outcomes, even though instances of beneficial impact were also noted. While care areas covered were heterogeneous, over half of the studies were conducted at academic medical centers or teaching hospitals.

CONCLUSION

Recent studies published in the past two years represent significant advancement of unintended consequences research by seeking to include more types of health IT applications and to quantify the impact using objectively recorded data and longitudinal or time series designs. However, more mixed-methods studies are needed to develop deeper insights into the observed unintended adverse outcomes, including their root causes and remedies. We also encourage future research to go beyond the paradigm of simply describing unintended consequences, and to develop and test solutions that can prevent or minimize their impact.

A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important?

OBJECTIVES

A key element of the implementation and ongoing use of an electronic prescribing (ePrescribing) system is ensuring that users are, and remain, sufficiently trained to use the system. Studies have suggested that insufficient training is associated with suboptimal use. However, it is not clear from these studies how clinicians are trained to use ePrescribing systems or the effectiveness of different approaches. We sought to describe the various approaches used to train qualified prescribers on ePrescribing systems and to identify whether users were educated about the pitfalls and challenges of using these systems.

METHODS

We performed a literature review, using a systematic approach across three large databases: Cumulative Index Nursing and Allied Health Literature, Embase and Medline were searched for relevant English language articles. Articles that explored the training of qualified prescribers on ePrescribing systems in a hospital setting were included.

KEY FINDINGS

Our search of 'all training' approaches returned 1155 publications, of which seven were included. A separate search of 'online' training found three relevant publications. Training methods in the 'all training' category included clinical scenarios, demonstrations and assessments. Regarding 'online' training approaches; a team at the University of Victoria in Canada developed a portal containing simulated versions of electronic health records, where individuals could prescribe for fictitious patients. Educating prescribers about the challenges and pitfalls of electronic systems was rarely discussed.

CONCLUSIONS

A number of methods are used to train prescribers; however, the lack of papers retrieved suggests a need for additional studies to inform training methods.

Classification of antecedents towards safety use of health information technology: A systematic review

OBJECTIVES

This paper provides a systematic review of safety use of health information technology (IT). The first objective is to identify the antecedents towards safety use of health IT by conducting systematic literature review (SLR). The second objective is to classify the identified antecedents based on the work system in Systems Engineering Initiative for Patient Safety (SEIPS) model and an extension of DeLone and McLean (D&M) information system (IS) success model.

METHODS

A systematic literature review (SLR) was conducted from peer-reviewed scholarly publications between January 2000 and July 2014. SLR was carried out and reported based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. The related articles were identified by searching the articles published in Science Direct, Medline, EMBASE, and CINAHL databases. Data extracted from the resultant studies included are to be analysed based on the work system in Systems Engineering Initiative for Patient Safety (SEIPS) model, and also from the extended DeLone and McLean (D&M) information system (IS) success model.

RESULTS

55 articles delineated to be antecedents that influenced the safety use of health IT were included for review. Antecedents were identified and then classified into five key categories. The categories are (1) person, (2) technology, (3) tasks, (4) organization, and (5) environment. Specifically, person is attributed by competence while technology is associated to system quality, information quality, and service quality. Tasks are attributed by task-related stressor. Organisation is related to training, organisation resources, and teamwork. Lastly, environment is attributed by physical layout, and noise.

CONCLUSIONS

This review provides evidence that the antecedents for safety use of health IT originated from both social and technical aspects. However, inappropriate health IT usage potentially increases the incidence of errors and produces new safety risks. The review cautions future implementation and adoption of health IT to carefully consider the complex interactions between social and technical elements propound in healthcare settings.

Lessons learned from implementation of computerized provider order entry in 5 community hospitals: a qualitative study

Background

Computerized Provider Order Entry (CPOE) can improve patient safety, quality and efficiency, but hospitals face a host of barriers to adopting CPOE, ranging from resistance among physicians to the cost of the systems. In response to the incentives for meaningful use of health information technology and other market forces, hospitals in the United States are increasingly moving toward the adoption of CPOE. The purpose of this study was to characterize the experiences of hospitals that have successfully implemented CPOE.

Methods

We used a qualitative approach to observe clinical activities and capture the experiences of physicians, nurses, pharmacists and administrators at five community hospitals in Massachusetts (USA) that adopted CPOE in the past few years. We conducted formal, structured observations of care processes in diverse inpatient settings within each of the hospitals and completed in-depth, semi-structured interviews with clinicians and staff by telephone. After transcribing the audiorecorded interviews, we analyzed the content of the transcripts iteratively, guided by principles of the Immersion and Crystallization analytic approach. Our objective was to identify attitudes, behaviors and experiences that would constitute useful lessons for other hospitals embarking on CPOE implementation.

Results

Analysis of observations and interviews resulted in findings about the CPOE implementation process in five domains: governance, preparation, support, perceptions and consequences. Successful institutions implemented clear organizational decision-making mechanisms that involved clinicians (governance). They anticipated the need for education and training of a wide range of users (preparation). These hospitals deployed ample human resources for live, in-person training and support during implementation. Successful implementation hinged on the ability of clinical leaders to address and manage perceptions and the fear of change. Implementation proceeded smoothly when institutions identified and anticipated the consequences of the change.

Conclusions

The lessons learned in the five domains identified in this study may be useful for other community hospitals embarking on CPOE adoption.

Unintended adverse consequences of introducing electronic health records in residential aged care homes

PURPOSE

The aim of this study was to investigate the unintended adverse consequences of introducing electronic health records (EHR) in residential aged care homes (RACHs) and to examine the causes of these unintended adverse consequences.

METHOD

A qualitative interview study was conducted in nine RACHs belonging to three organisations in the Australian Capital Territory (ACT), New South Wales (NSW) and Queensland, Australia. A longitudinal investigation after the implementation of the aged care EHR systems was conducted at two data points: January 2009 to December 2009 and December 2010 to February 2011. Semi-structured interviews were conducted with 110 care staff members identified through convenience sampling, representing all levels of care staff who worked in these facilities. Data analysis was guided by DeLone and McLean Information Systems Success Model, in reference with the previous studies of unintended consequences for the introduction of computerised provider order entry systems in hospitals.

RESULTS

Eight categories of unintended adverse consequences emerged from 266 data items mentioned by the interviewees. In descending order of the number and percentage of staff mentioning them, they are: inability/difficulty in data entry and information retrieval, end user resistance to using the system, increased complexity of information management, end user concerns about access, increased documentation burden, the reduction of communication, lack of space to place enough computers in the work place and increasing difficulties in delivering care services. The unintended consequences were caused by the initial conditions, the nature of the EHR system and the way the system was implemented and used by nursing staff members.

CONCLUSIONS

Although the benefits of the EHR systems were obvious, as found by our previous study, introducing EHR systems in RACH can also cause adverse consequences of EHR avoidance, difficulty in access, increased complexity in information management, increased documentation burden, reduction of communication and the risks of lacking care follow-up, which may cause negative effects on aged care services. Further research can focus on investigating how the unintended adverse consequences can be mitigated or eliminated by understanding more about nursing staff's work as well as the information flow in RACH. This will help to improve the design, introduction and management of EHR systems in this setting.

Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems

OBJECTIVE

Medication errors in hospitals are common, expensive, and sometimes harmful to patients. This study's objective was to derive a nationally representative estimate of medication error reduction in hospitals attributable to electronic prescribing through computerized provider order entry (CPOE) systems.

MATERIALS AND METHODS

We conducted a systematic literature review and applied random-effects meta-analytic techniques to derive a summary estimate of the effect of CPOE on medication errors. This pooled estimate was combined with data from the 2006 American Society of Health-System Pharmacists Annual Survey, the 2007 American Hospital Association Annual Survey, and the latter's 2008 Electronic Health Record Adoption Database supplement to estimate the percentage and absolute reduction in medication errors attributable to CPOE.

RESULTS

Processing a prescription drug order through a CPOE system decreases the likelihood of error on that order by 48% (95% CI 41% to 55%). Given this effect size, and the degree of CPOE adoption and use in hospitals in 2008, we estimate a 12.5% reduction in medication errors, or ∼17.4 million medication errors averted in the USA in 1 year.

DISCUSSION

Our findings suggest that CPOE can substantially reduce the frequency of medication errors in inpatient acute-care settings; however, it is unclear whether this translates into reduced harm for patients.

CONCLUSIONS

Despite CPOE systems' effectiveness at preventing medication errors, adoption and use in US hospitals remain modest. Current policies to increase CPOE adoption and use will likely prevent millions of additional medication errors each year. Further research is needed to better characterize links to patient harm.

A mixed methods approach for measuring the impact of delivery-centric interventions on clinician workflow

Health interventions vary widely. Pharmaceuticals, medical devices and wellness promotion are defined as 'outcome-centric.' They are implemented by clinicians for the use and benefit of consumers, and intervention effectiveness is measured by a change in health outcome. Electronic health records, computerized physician order entry systems and telehealth technologies are defined as 'delivery-centric.' They are implemented by organizations for use by clinicians to manage and facilitate consumer health, and the impact of these interventions on clinician workflow has become increasingly important. The methodological framework introduced in this paper uses a two-phase sequential mixed methods design that qualitatively explores clinician workflow before and after implementation of a delivery-centric intervention, and uses this information to quantitatively measure changes to workflow activities. The mixed methods protocol provides a standardized approach for understanding and determining the impact of delivery-centric interventions on clinician workflow.

Adoption of health information exchange by emergency physicians at three urban academic medical centers

OBJECTIVES

Emergency physicians are trained to make decisions quickly and with limited patient information. Health Information Exchange (HIE) has the potential to improve emergency care by bringing relevant patient data from non-affiliated organizations to the bedside. NYCLIX (New York CLinical Information eXchange) offers HIE functionality among multiple New York metropolitan area provider organizations and has pilot users in several member emergency departments (EDs).

METHODS

We conducted semi-structured interviews at three participating EDs with emergency physicians trained to use NYCLIX. Among "users" with > 1 login, responses to questions regarding typical usage scenarios, successful retrieval of data, and areas for improving the interface were recorded. Among "non-users" with ≤1 login, questions about NYCLIX accessibility and utility were asked. Both groups were asked to recall items from prior training regarding data sources and availability.

RESULTS

Eighteen NYCLIX pilot users, all board certified emergency physicians, were interviewed. Of the 14 physicians with more than one login ,half estimated successful retrieval of HIE data affecting patient care. Four non-users (one login or less) cited forgotten login information as a major reason for non-use. Though both groups made errors, users were more likely to recall true NYCLIX member sites and data elements than non-users. Improvements suggested as likely to facilitate usage included a single automated login to both the ED information system (EDIS) and HIE, and automatic notification of HIE data availability in the EDIS All respondents reported satisfaction with their training.

CONCLUSIONS

Integrating HIE into existing ED workflows remains a challenge, though a substantial fraction of users report changes in management based on HIE data. Though interviewees believed their training was adequate, significant errors in their understanding of available NYCLIX data elements and participating sites persist.

Exploring the translational impact of a home telemonitoring intervention using time-motion study

OBJECTIVE

Home telemonitoring improves clinical outcomes but can generate large amounts of data. Automating data surveillance with clinical decision support could reduce the impact of translating these systems to clinical settings. We utilized time-motion methodology to measure the time spent on activities monitoring subjects in the two groups of a home spirometry telemonitoring randomized controlled trial: the manual nurse review (control) group and the automated review (intervention) group. These results are examined for potential workflow effects that could occur when the intervention translates to a clinical setting.

MATERIALS AND METHODS

Time motion is an established industrial engineering technique used to evaluate workflow by measuring the time of predefined, discrete tasks. Data were collected via direct observation of two research nurses by a single observer using the repetitive or snap-back timing method. All observed tasks were coded using a list of work activities defined and validated in an earlier study. Reliability data were collected during a 2-h session with a secondary observer.

RESULTS

Reliability of the primary observer was established. During 35 h of data collection, a sample of 938 task observations were recorded and coded using 46 previously defined and 5 newly defined work activities. Between-group comparisons of activity time for subjects in the two study groups showed significantly more time spent on data review activities for the automated review group. Reclassification of the 51 observed activities identified 15 activities that would translate to a clinical setting, of which 5 represent potentially new activities.

CONCLUSIONS

Implementing an intervention into a clinical setting could add work activities to the clinical workflow. Time-motion study of research personnel working with new clinical interventions provides a template for evaluating the workflow impact of these interventions prior to translation from a research to a clinical setting.

Computerized physician order entry: lessons learned from the trenches

Implementation of computer physician order entry (CPOE) demands planning, teamwork, and a steep learning curve. The nurse-driven team at the hospital unit level is pivotal to a successful launch. This article describes the experience of one NICU in planning, building, training, and implementing CPOE. Pitfalls and lessons learned are described. Communication between the nurse team at the unit and the clinical informatics team needs to be ongoing. Self-paced training with realistic practice scenarios and one-on-one "view then practice" modules help ease the transition. Many issues are not apparent until after CPOE has been implemented, and it is vital to have a mechanism to fix problems quickly. We describe the experience of "going live" and the reality of day-to-day order entry.

Identifying best practices for clinical decision support and knowledge management in the field

To investigate best practices for implementing and managing clinical decision support (CDS) in community hospitals and ambulatory settings, we carried out a series of ethnographic studies to gather information from nine diverse organizations. Using the Rapid Assessment Process methodology, we conducted surveys, interviews, and observations over a period of two years in eight different geographic regions of the U.S.A. We first utilized a template organizing method for an expedited analysis of the data, followed by a deeper and more time consuming interpretive approach. We identified five major categories of best practices that require careful consideration while carrying out the planning, implementation, and knowledge management processes related to CDS. As more health care organizations implement clinical systems such as computerized provider order entry with CDS, descriptions of lessons learned by CDS pioneers can provide valuable guidance so that CDS can have optimal impact on health care quality.

Does computerized provider order entry reduce prescribing errors for hospital inpatients? A systematic review

Previous reviews have examined evidence of the impact of CPOE on medication errors, but have used highly variable definitions of "error". We attempted to answer a very focused question, namely, what evidence exists that CPOE systems reduce prescribing errors among hospital inpatients? We identified 13 papers (reporting 12 studies) published between 1998 and 2007. Nine demonstrated a significant reduction in prescribing error rates for all or some drug types. Few studies examined changes in error severity, but minor errors were most often reported as decreasing. Several studies reported increases in the rate of duplicate orders and failures to discontinue drugs, often attributed to inappropriate selection from a dropdown menu or to an inability to view all active medication orders concurrently. The evidence-base reporting the effectiveness of CPOE to reduce prescribing errors is not compelling and is limited by modest study sample sizes and designs. Future studies should include larger samples including multiple sites, controlled study designs, and standardized error and severity reporting. The role of decision support in minimizing severe prescribing error rates also requires investigation.

The unintended consequences of computerized provider order entry: findings from a mixed methods exploration

OBJECTIVE

To describe the foci, activities, methods, and results of a 4-year research project identifying the unintended consequences of computerized provider order entry (CPOE).

METHODS

Using a mixed methods approach, we identified and categorized into nine types 380 examples of the unintended consequences of CPOE gleaned from fieldwork data and a conference of experts. We then conducted a national survey in the U.S.A. to discover how hospitals with varying levels of infusion, a measure of CPOE sophistication, recognize and deal with unintended consequences. The research team, with assistance from experts, identified strategies for managing the nine types of unintended adverse consequences and developed and disseminated tools for CPOE implementers to help in addressing these consequences.

RESULTS

Hospitals reported that levels of infusion are quite high and that these types of unintended consequences are common. Strategies for avoiding or managing the unintended consequences are similar to best practices for CPOE success published in the literature.

CONCLUSION

Development of a taxonomy of types of unintended adverse consequences of CPOE using qualitative methods allowed us to craft a national survey and discover how widespread these consequences are. Using mixed methods, we were able to structure an approach for addressing the skillful management of unintended consequences as well.