Invited commentary: The road to implementation of the electronic health record

Measurement of CPOE end-user satisfaction among ICU physicians and nurses

BACKGROUND: Implementation of Computerized Provider Order Entry (CPOE) can fail or meet high levels of user resistance for a variety of reasons, including lack of attention to users' needs and the significant workflow changes induced and required by CPOE. End-user satisfaction is a critical factor in IT implementation. OBJECTIVE: The goal of this study was to identify criteria to select a valid and reliable questionnaire to measure end-user satisfaction with CPOE. METHODS: We developed seven criteria that can be used to select valid and reliable questionnaires. We applied the selection criteria to existing end-user satisfaction questionnaires. RESULTS: Most of the questionnaires used to measure end-user satisfaction have been tested for reliability and validity and most of the questionnaires have reasonably reliability and some sort of validity. However, only one questionnaire, the Physician Order Entry User Satisfaction and Usage Survey (POESUS) met most of the other criteria we developed to select a questionnaire to evaluate CPOE implementation. We used the POESUS in our study and compared the results with other studies. Results show that users are moderately satisfied with CPOE. CONCLUSION: Using the seven criteria we developed, it is possible to select reliable and valid questionnaires. We hope that in the future this will lead to an increasing number of studies using the same questionnaires. That will improve the possibilities for comparing the results of one study to another (benchmarking).

Effect of computerized physician order entry on imaging study indication

PURPOSE

The effect of computerized physician order entry (CPOE) on imaging indication quality had only been measured in one institution's emergency department using a homegrown electronic health record with faculty physicians, and only with one instrument. To better understand how many US hospitals' recent CPOE implementations had affected indication quality, we measured its effect in a generalizable inpatient setting, using one existing and one novel instrument.

METHODS

We retrospectively analyzed the indications for 100 randomly selected inpatient abdominal CT studies during 2 calendar months immediately prior to a 3/3/2012 CPOE implementation (1/1/2012-2/29/2012) and during 2 subsequent calendar months (5/1/2012-6/30/2012). We excluded 2 intervening months to avoid behaviors associated with adoption. We measured indication quality using a published 8-point explicit scoring scale and our own, novel, implicit 7-point Likert scale.

RESULTS

Explicit scores increased 93% from a pre-CPOE mean ± 95% confidence interval of 1.4 ± 0.2 to a CPOE mean of 2.7 ± 0.3 (P < .01). Implicit scores increased 26% from a pre-CPOE mean of 4.3 ± 0.3 to a CPOE mean of 5.4 ± 0.2 (P < .05). When presented with a statement that an indication was "extremely helpful," and choices ranging from "strongly disagree" = 1 to "strongly agree" = 7, implicit scores of 4 and 5 signified "undecided" and "somewhat agree," respectively.

CONCLUSIONS

In an inpatient setting with strong external validity to other US hospitals, CPOE implementation increased indication quality, as measured by 2 independent scoring systems (one pre-existing explicit system and one novel, intuitive implicit system). CPOE thus appears to enhance communication from ordering clinicians to radiologists.

Changes in end-user satisfaction with Computerized Provider Order Entry over time among nurses and providers in intensive care units

BACKGROUND

Implementation of Computerized Provider Order Entry (CPOE) has many potential advantages. Despite the potential benefits of CPOE, several attempts to implement CPOE systems have failed or met with high levels of user resistance. Implementation of CPOE can fail or meet high levels of user resistance for a variety of reasons, including lack of attention to users' needs and the significant workflow changes required by CPOE. User satisfaction is a critical factor in information technology implementation. Little is known about how end-user satisfaction with CPOE changes over time.

OBJECTIVE

To examine ordering provider and nurse satisfaction with CPOE implementation over time.

METHODS

We conducted a repeated cross-sectional questionnaire survey in four intensive care units of a large hospital. We analyzed the questionnaire data as well as the responses to two open-ended questions about advantages and disadvantages of CPOE.

RESULTS

Users were moderately satisfied with CPOE and there were interesting differences between user groups: ordering providers and nurses. User satisfaction with CPOE did not change over time for providers, but it did improve significantly for nurses. Results also show that nurses and providers are satisfied with different aspects of CPOE.

Opportunities and challenges in integrating electronic health records into undergraduate medical education: a national survey of clerkship directors

BACKGROUND

Few studies have reported on the utilization and the effect of electronic health records on the education of medical students.

PURPOSE

The purpose of this study was to describe the current use of electronic health records by medical students in the United States and explore the opportunities and challenges of integrating electronic health records into daily teaching of medical students.

METHODS

A survey with 24 questions regarding the use of electronic health records by medical students was developed by the Alliance for Clinical Educators and sent to clerkship directors across the United States. Both quantitative and qualitative responses were collected and analyzed to determine current access to and use of electronic health records by medical students.

RESULTS

This study found that an estimated 64% of programs currently allow student use of electronic health records, of which only two thirds allowed students to write notes within the electronic record. Overall, clerkship directors' opinions on the effects of electronic health records on medical student education were neutral, and despite acknowledging many advantages to electronic health records, there were many concerns raised regarding their use in education.

CONCLUSIONS

Medical students are using electronic health records at higher rates than physicians in practice. Although this is overall reassuring, educators have to be cautious about the limitations being placed on student's documentation in electronic health records as this can potentially have consequences on their training, and they need to explore ways to maximize the benefits of electronic health records in medical education.

The financial and nonfinancial costs of implementing electronic health records in primary care practices

The incentives in the American Recovery and Reinvestment Act to expand the "meaningful use" of electronic health record systems have many health care professionals searching for information about the cost and staff resources that such systems require. We report the cost of implementing an electronic health record system in twenty-six primary care practices in a physician network in north Texas, taking into account hardware and software costs, as well as the time and effort invested in implementation. For an average five-physician practice, implementation cost an estimated $162,000, with $85,500 in maintenance expenses during the first year. We also estimate that the HealthTexas network implementation team and the practice implementation team needed 611 hours, on average, to prepare for and implement the electronic health record system, and that "end users"-physicians, other clinical staff, and nonclinical staff-needed 134 hours per physician, on average, to prepare for use of the record system in clinical encounters.

Development and Psychometric Qualities of the SEIPS Survey to Evaluate CPOE/EHR Implementation in ICUs

Health Information Technology (IT) implementation can fail or meet high levels of user resistance for a variety of reasons, including lack of attention to users' needs and the significant workflow changes induced and required by the technology. End-user satisfaction is a critical factor in health IT implementation. In this paper we describe the process of developing and testing a questionnaire to evaluate health IT implementation, in particular Computerized Provider Order Entry (CPOE) and Electronic Health Record (EHR) technologies. Results showed evidence for the validity and reliability of the questionnaire. The Systems Engineering Initiative for Patient Safety (SEIPS) questionnaire is relatively easy to administer and allows researchers to evaluate different aspects of health IT implementation. Results of this research can be used for benchmarking results of future studies evaluating health IT implementation.

Lessons Learned from Implementation of Information and Communication Technologies in Spain's Healthcare Services: Issues and Opportunities

BACKGROUND

Spain's health services have undertaken a number of important projects aimed at the creation of Electronic Health Records (EHR) through the incorporation of Information and Communication Technologies (ICT) into patient care practices. The objective of this endeavor is to improve care quality and efficiency and increase responsiveness to the population's needs and demands. Between 2006-2009 over 300 million Euro were invested in projects of this type.

OBJECTIVE

To better understand the success criteria, the difficulties encountered and certain issues that must be kept in mind to ensure successful implementation of ICT projects in health organizations, based on Spain's experiences in this field.

METHODS

The projects' results are analyzed using the criteria of compliance with the expected scope, cost and time frame.

RESULTS

The results can be considered satisfactory in primary care facilities, where almost 90% of Spain's general practitioners, pediatricians and primary care nurses are using electronic health record (EHR) systems. In hospitals EHR implementation is more uneven. Over 40% of Spanish primary care centers and 42% of pharmacies are using electronic prescription (the information system that connects the physician to the dispensing pharmacy and the dispensing pharmacy to the payer).

DISCUSSION

All of Spain's health services are currently carrying out projects involving ICT application in healthcare, and a priori the benefits of ICT are not questioned. However, the costs and time frames required for these projects are clearly surpassing initial expectations, while the benefits perceived by both professionals and institutions remain limited. This situation may be due in part to the absence of a project management culture in the health services, which has led them to pay insufficient attention to the main difficulties and key issues related to the implementation of EHR.