Contrasting views of physicians and nurses about an inpatient computer-based provider order-entry system

Electronic Health Record Stress and Burnout Among Clinicians in Hospital Settings: A Systematic Review

Background

There is growing evidence to suggest that EHRs may be associated with clinician stress and burnout, which could hamper their effective use and introduce risks to patient safety.

Objective

This systematic review aimed to examine the association between EHR use and clinicians' stress and burnout in hospital settings, and to identify the contributing factors influencing this relationship.

Methods

The search included peer-reviewed published studies between 2000 and 2023 in English in CINAHL, Ovid Medline, Embase, and PsychINFO. Studies that provided specific data regarding clinicians' stress and/or burnout related to EHRs in hospitals were included. A quality assessment of included studies was conducted.

Results

Twenty-nine studies were included (25 cross-sectional surveys, one qualitative study, and three mixed methods), which focused on physicians (n = 18), nurses (n = 10) and mixed professions (n = 3). Usability issues and the amount of time spent on the EHR were the most significant predictors, but intensity of the working environment influenced high EHR-related workload and thereby also contributed to stress and burnout. The differences in clinicians' specialties influenced the levels of stress and burnout related to EHRs.

Conclusions

This systematic review showed that EHR use was a perceived contributor to clinicians' stress and burnout in hospitals, primarily driven by poor usability and excessive time spent on EHRs. Addressing these issues requires tailored EHR systems, rigorous usability testing, support for the needs of different specialities, qualitative research on EHR stressors, and expanded research in Non-Western contexts.

The negotiated order and electronic patient records: A sociomaterial perspective

In this article, we consider how the notion of the negotiated order can be reinterpreted by drawing on ideas from sociomateriality. We argue that the negotiated order is an ongoing accomplishment in which a heterogeneous set of situated sociomaterial practices (or actors) are implicated. To do this, we draw upon an in-depth study of the use of a computerised physician order entry system in a hospital in Saudi Arabia. We explore how a computerised physician order entry system, as a new sociomaterial actor, performatively repositions the actors involved and hence offers the conditions of possibility for medical work practices to be renegotiated. We show that it is often contingent, mundane, situated sociomaterial practices that enact the conditions under which the negotiated order becomes re-established in terms of division of labour, legitimacy, collaboration, and social capital. We argue that as the social and material are co-constitutive, or intra-actional, it makes more sense to talk about the negotiated intra-actional order rather than the negotiated order. Importantly, such a change in conceptual vocabulary reveals the empirical and ontological issues at stake; essential for a more nuanced understanding of change/becoming.

Implementation of a new health information technology for the management of cancer chemotherapies

Background

Cancer chemotherapy drugs are classified as high-risk molecules. Safety of the cancer chemotherapy process is often achieved with the implementation of a health information technology to each step or to the entire process. However, computerisation could lead to the emergence of new unintended medication errors. The aim of the study was to evaluate the impact of new software designed for the management of anticancer chemotherapies.

Method

The cartography of the process and the failure modes, effects and criticality analysis were performed by a multidisciplinary team. Criticality indexes were calculated considering or not the implementation of the commercial software (CytoWeb). Quality and satisfactory indicators were measured before the implementation and during the use of the software.

Results

Our results demonstrated the complexity of the cancer chemotherapy process in the hospital. Risk analysis highlighted the positive impact of CytoWeb on the process safety but pointed out some steps that were not positively influenced by the software. Although a decrease of 38.6% of error rate was observed with the electronic system, new unintended medication errors emerged. These errors were due to inadequate use of the software (encoding of the wrong drug, the wrong dose, the wrong patient parameters or lab results and lack of prescriber adherence). Our satisfaction survey showed that the hospital pharmacists and doctors were less satisfied by the software than the nurses, mostly in terms of task achievement and time saving. Survey's results highlighted some weaknesses in the user training and in the collaboration between the medical staff.

Conclusions

Our work showed the emergence of unintended medication errors linked to computerisation that were due to an inadequate use of the software. Other issues were highlighted such as the lack of collaboration between the medical staff, the lack of prescriber implication and weaknesses in the user training or in the information related to CytoWeb.

Insulin Bolus Calculator in a Pediatric Hospital. Safety and User Perceptions

BACKGROUND

Insulin dosing in hospitalized pediatric patients is challenging and requires dosing to be matched with the specific clinical and nutritional circumstances. We implemented a customized subcutaneous insulin bolus dose calculator tool integrated with the electronic health record to improve patient care. Here we describe this tool, its utilization and safety, and assess user satisfaction and perceptions of the tool.

METHODS

Blood glucose results for all patients who received insulin with and without the calculator tool were compared to assess safety. To assess user perceptions and satisfaction, a survey was sent to all identified users who interacted with the tool during the period from May 2015 to the end of November 2015. Survey responses were summarized, mean user satisfaction calculated, and correlation of Likert scale items with overall satisfaction assessed.

RESULTS

Hypoglycemia rates (2.2% and 2.9%, p = 0.17) and severe hypoglycemia rates (0.04% and 0.1%, p = 0.21) were similar for the groups that received insulin with and without the calculator tool. Overall satisfaction for all survey respondents was high (4.05, SD = 0.83). Physicians indicated a slightly higher satisfaction than nurses (4.33 versus 3.94, p = 0.04). User agreement with improvement of quality of care showed the highest correlation with overall satisfaction (r = 0.80, 95% CI 0.7 - 0.87).

CONCLUSION

Implementation of an insulin calculator tool streamlined ordering and administration of insulin in a pediatric academic institution while maintaining patient safety. Users indicated high overall satisfaction with the tool.

Successful Implementation of Clinical Information Technology: Seven Key Lessons from CPOE

OBJECTIVES

To identify and describe the most critical strategic and operational contributors to the successful implementation of clinical information technologies, as deployed within a moderate sized system of U.S. community hospitals.

BACKGROUND AND SETTING

CHRISTUS Health is a multi-state system comprised of more than 350 services and 60 hospitals with over 9 000 physicians. The Santa Rosa region of CHRISTUS Health, located in greater San Antonio, Texas is comprised of three adult community hospital facilities and one Children's hospital each with bed capacities of 142-180. Computerized Patient Order Entry (CPOE) was first implemented in 2012 within a complex market environment. The Santa Rosa region has 2 417 credentialed physicians and 263 mid-level allied health professionals.

METHODS

This report focuses on the seven most valuable strategies deployed by the Health Informatics team in a large four hospital CHRISTUS region to achieve strong CPOE adoption and critical success lessons learned. The findings are placed within the context of the literature describing best practices in health information technology implementation.

RESULTS

While the elements described involved discrete de novo process generation to support implementation and operations, collectively they represent the creation of a new customer-centric service culture in our Health Informatics team, which has served as a foundation for ensuring strong clinical information technology adoption beyond CPOE.

CONCLUSION

The seven success factors described are not limited in their value to and impact on CPOE adoption, but generalize to - and can advance success in - varied other clinical information technology implementations across diverse hospitals. A number of these factors are supported by reports in the literature of other institutions' successful implementations of CPOE and other clinical information technologies, and while not prescriptive to other settings, may be adapted to yield value elsewhere.

Fostering acceptance of computerized physician order entry: insights from an implementation study

Computerized physician order entry (CPOE) allows physicians to enter orders in a computer rather than handwriting them. Computerized physician order entry is touted as a major improvement in patient safety, and although the literature suggests that such systems have the potential to improve patient outcomes, studies also suggest that CPOE may have significant drawbacks that accompany those benefits. Physicians have often been resistant to accept its implementation. This study investigates the implementation of CPOE at a 217-bed rural hospital in the southeastern United States. Drawing on a mixed-method approach, we identify correlates of change acceptance and propose a set of recommendations for health care managers to foster acceptance of CPOE. Findings from physician surveys (n = 19) indicate that older physicians are less accepting of CPOE, but high-quality change communication may overcome resistance even among older physicians. With insights derived from the organizational change literature, findings bring to the fore a set of practices that managers can use to foster acceptance of CPOE. The thrust of these practices is that managers should make physicians active participants in fine-tuning CPOE within the unique needs and constraints of the local hospital setting.

A Framework for Usable and Effective Clinical Decision Support: Experience from the iCPR Randomized Clinical Trial

INTRODUCTION

The promise of Clinical Decision Support (CDS) has always been to transform patient care and improve patient outcomes through the delivery of timely and appropriate recommendations that are patient specific and, more often than not, are appropriately actionable. However, the users of CDS-providers-are frequently bombarded with inappropriate and inapplicable CDS that often are not informational, not integrated into the workflow, not patient specific, and that may present out of date and irrelevant recommendations.

METHODS

The integrated clinical prediction rule (iCPR) project was a randomized clinical trial (RCT) conducted to determine if a novel form of CDS, i.e., clinical prediction rules (CPRs), could be efficiently integrated into workflow and result in changes in outcomes (e.g., antibiotic ordering) when embedded within a commercial electronic health record (EHR). We use the lessons learned from the iCPR project to illustrate a framework for constructing usable, useful, and effective actionable CDS while employing off-the-shelf functionality in a production system. Innovations that make up the framework combine the following: (1) active and actionable decision support, (2) multiple rounds of usability testing with iterative development for user acceptance, (3) numerous context sensitive triggers, (4) dedicated training and support for users of the CDS tool for user adoption, and (5) support from clinical and administrative leadership. We define "context sensitive triggers" as being workflow events (i.e., context) that result in a CDS intervention.

DISCUSSION

Success of the framework can be measured by CDS adoption (i.e., intervention is being used), acceptance (compliance with recommendations), and clinical outcomes (where appropriate). This framework may have broader implications for the deployment of Health Information Technology (HIT).

RESULTS AND CONCLUSION

iCPR was well adopted(57.4% of users) and accepted (42.7% of users). Usability testing identified and fixed many issues before the iCPR RCT. The level of leadership support and clinical guidance for iCPR was key in establishing a culture of acceptance for both the tool and its recommendations contributing to adoption and acceptance. The dedicated training and support lead to the majority of the residents reporting a high level of comfort with both iCPR tools strep pharyngitis (64.4 percent) and pneumonia (62.7 percent) as well as a high likelihood of using the tools in the future. A surprising framework addition resulted from usability testing: context sensitive triggers.

Cost-effectiveness of a computerized provider order entry system in improving medication safety ambulatory care

BACKGROUND

Computerized provider order entry (CPOE) is the process of entering physician orders directly into an electronic health record. Although CPOE has been shown to improve medication safety and reduce health care costs, these improvements have been demonstrated largely in the inpatient setting; the cost-effectiveness in the ambulatory setting remains uncertain.

OBJECTIVE

The objective was to estimate the cost-effectiveness of CPOE in reducing medication errors and adverse drug events (ADEs) in the ambulatory setting.

METHODS

We created a decision-analytic model to estimate the cost-effectiveness of CPOE in a midsized (400 providers) multidisciplinary medical group over a 5-year time horizon- 2010 to 2014-the time frame during which health systems are implementing CPOE to meet Meaningful Use criteria. We adopted the medical group's perspective and utilized their costs, changes in efficiency, and actual number of medication errors and ADEs. One-way and probabilistic sensitivity analyses were conducted. Scenario analyses were explored.

RESULTS

In the base case, CPOE dominated paper prescribing, that is, CPOE cost $18 million less than paper prescribing, and was associated with 1.5 million and 14,500 fewer medication errors and ADEs, respectively, over 5 years. In the scenario that reflected a practice group of five providers, CPOE cost $265,000 less than paper prescribing, was associated with 3875 and 39 fewer medication errors and ADEs, respectively, over 5 years, and was dominant in 80% of the simulations.

CONCLUSIONS

Our model suggests that the adoption of CPOE in the ambulatory setting provides excellent value for the investment, and is a cost-effective strategy to improve medication safety over a wide range of practice sizes.

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.

Development and initial evaluation of the Clinical Information Systems Success Model (CISSM)

PURPOSE

Most clinical information systems (CIS) today are technically sound, but the number of successful implementations of these systems is low. The purpose of this study was to develop and test a theoretically based integrated CIS Success Model (CISSM) from the nurse perspective.

METHODS

Model predictors of CIS success were taken from existing research on information systems acceptance, user satisfaction, use intention, user behavior and perceptions, as well as clinical research. Data collected online from 234 registered nurses in four hospitals were used to test the model. Each nurse had used the Cerner Power Chart Admission Health Profile for at least 3 months.

RESULTS

Psychometric testing and factor analysis of the 23-item CISSM instrument established its construct validity and reliability. Initial analysis showed nurses' satisfaction with and dependency on CIS use predicted their perceived CIS use Net Benefit. Further analysis identified Social Influence and Facilitating Conditions as other predictors of CIS user Net Benefit. The level of hospital CIS integration may account for the role of CIS Use Dependency in the success of CIS.

CONCLUSIONS

Based on our experience, CISSM provides a formative as well as summative tool for evaluating CIS success from the nurse's perspective.

Parent satisfaction with the electronic medical record in an academic pediatric rheumatology practice

BACKGROUND

Patient satisfaction has not been widely studied with respect to implementation of the electronic medical record (EMR). There are few reports of the impact of the EMR in pediatrics.

OBJECTIVE

The objective of this study was to assess the impact of implementation of an electronic medical record system on families in an academic pediatric rheumatology practice.

METHODS

Families were surveyed 1 month pre-EMR implementation and 3 months post-EMR implementation.

RESULTS

Overall, EMR was well received by families. Compared with the paper chart, parents agreed the EMR improved the quality of doctor care (55% or 59/107 vs 26% or 26/99, P < .001). More parents indicated they would prefer their pediatric physicians to use an EMR (68% or 73/107 vs 51% or 50/99, P = .01).

CONCLUSIONS

Transitioning an academic pediatric rheumatology practice to an EMR can increase family satisfaction with the office visit.

Evaluating the medication process in the context of CPOE use: the significance of working around the system

OBJECTIVE

To evaluate the problems experienced after implementing a computerized physician order entry (CPOE) system, their possible root causes, and the responses of providers in order to incorporate the system into daily workflow.

METHODS

A qualitative study in the medication-use process after implementation of a CPOE system in an academic hospital in The Netherlands. Data included 21 interviews with clinical end-users, paper-based and system-generated documents used daily in the process, and educational materials used to train users.

FINDINGS

The problems in the medication-use process included cognitive overload on physicians and nurses, unmet information needs, miscommunication of orders and ideas, problematic coordination of interrelated tasks between co-working professionals, a potentially faulty administration phase, and suboptimal monitoring of the medication plans. These problems were mainly rooted in the lack of mobile computer devices, the uneasy integration of coexisting electronic and paper-based systems, suboptimal usability of the system, and certain organizational factors with regard to procuring drugs affecting the technology use. Various types of workarounds were used to address the difficulties, including phone calls, taking multiple paper notes, issuing paper-based and verbal orders, double-checking, using other patients' procured drugs or another department's drug supply, and modifying and annotating the printed orders.

CONCLUSION

This study shows how providers are actively involved in working around the interruptions in workflow by bypassing the technology or adapting the work processes. Although certain workarounds help to maintain smooth workflow and/or to ensure patient safety, others may burden providers by necessitating extra time and effort and/or endangering patient safety. It is important that workarounds having a negative nature are recognized and discussed in order to find solutions to mitigate their effects.

Development and testing of a survey instrument to measure benefits of a nursing information system

Information systems (IS) benefits for nurses are outcomes related to the tangible products or improvements that nurses realize from using IS. This study examined the development and psychometric testing of a measure of nurses' benefits from IS. A random sample of 570 nurses working in hospitals, providing direct patient care, and using IS completed the study questionnaire. The internal consistency reliability of the results was .97. Exploratory factor analysis, using principal components extraction and varimax rotation, revealed items loaded on four factors (saving time and efficiency, quality of care, charting, and professional practice) that were confirmed by confirmatory factor analysis. Continued refinement of the instrument is needed with more diverse samples of nurses.

Clinicians satisfaction with CPOE ease of use and effect on clinicians' workflow, efficiency and medication safety

OBJECTIVES

To study the satisfaction of end-users of a computerized physician order entry (CPOE) system concerning ease of use and the effect on users' workflow, efficiency, and medication safety and to seek users' opinions regarding required improvements of the system. Usability evaluation had shown that this system, which was in use for almost a decade, contained a number of severe usability problems. So another objective of the study was to determine whether there was a direct relation between user satisfaction and the results of a usability evaluation of the system.

METHODS

Two survey questionnaires were distributed to CPOE system users (physicians and nurses) working in inpatient departments of a university hospital. Questionnaires included items that were rated using a five point Likert scale. Multiple choice questions with space for free text additions also were used to collect qualitative data concerning the use of the CPOE system and the users' opinion concerning system requirements for improvement. Data were analyzed using descriptive statistics and by the use of Mann-Whitney U and Kruskal Wallis tests.

RESULTS

Two hundred seventeen physicians and 587 nurses were eligible to participate in this study (response rate 49% and 56% respectively). Physicians were satisfied with the CPOE ease of use (median 3.8, interquartile range [IQR] 3.3-4), and the effect on workflow (median 3.7, IQR 3.3-4), medication safety (median 3.75, IQR 3-4), and efficiency (median 4, IQR 3-4). Nurses also had a positive attitude towards CPOE ease of use (median 3.6, IQR 3-4), and its effect on workflow (median 3, IQR 3-3.6), medication safety (median 3, IQR 2.5-3.5), and efficiency (median 3.5, IQR 3-4). Users mainly indicated that the system needs: supplementary functionalities (e.g. alerts for allergies), improvement of current functionalities, integration with other hospital information systems and improvement of information presentation (e.g. a clear medication overview). Users did not use some current functionalities because of lack of awareness of the functionalities or having difficulty in using them.

CONCLUSIONS

Users of this CPOE system, which was used for almost a decade, were satisfied with the system's ease of use and its effect on efficiency, workflow and medication safety although the system showed many usability problems and lacked some functionalities. In this case study, therefore, there seems no direct relation between the results of the earlier performed usability evaluation and user satisfaction as determined in the current study.

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.

Impact of computerized orders for pediatric continuous drug infusions on detecting infusion pump programming errors: a simulated study

Continuous infusion medications are associated with fatal adverse events in pediatric intensive care units. The effect of computerized orders on detecting infusion pumps programming errors has never been studied. Using a crossover design, we examined the effect of using computerized orders for continuous infusions as compared with that of using handwritten orders on nurse ability to detect infusion pump programming errors, time required to verify pump settings, and user satisfaction. The computerized orders saved nurses time but did not improve their ability to detect infusion pumps programming errors. Nurses preferred computerized orders. High error rate was related to manual calculations and inconsistent use of computerized orders.

Organization-wide adoption of computerized provider order entry systems: a study based on diffusion of innovations theory

Background

Computerized provider order entry (CPOE) systems have been introduced to reduce medication errors, increase safety, improve work-flow efficiency, and increase medical service quality at the moment of prescription. Making the impact of CPOE systems more observable may facilitate their adoption by users. We set out to examine factors associated with the adoption of a CPOE system for inter-organizational and intra-organizational care.

Methods

The diffusion of innovation theory was used to understand physicians' and nurses' attitudes and thoughts about implementation and use of the CPOE system. Two online survey questionnaires were distributed to all physicians and nurses using a CPOE system in county-wide healthcare organizations. The number of complete questionnaires analyzed was 134 from 200 nurses (67.0%) and 176 from 741 physicians (23.8%). Data were analyzed using descriptive-analytical statistical methods.

Results

More nurses (56.7%) than physicians (31.3%) stated that the CPOE system introduction had worked well in their clinical setting (P < 0.001). Similarly, more physicians (73.9%) than nurses (50.7%) reported that they found the system not adapted to their specific professional practice (P = < 0.001). Also more physicians (25.0%) than nurses (13.4%) stated that they did want to return to the previous system (P = 0.041). We found that in particular the received relative advantages of the CPOE system were estimated to be significantly (P < 0.001) higher among nurses (39.6%) than physicians (16.5%). However, physicians' agreements with the compatibility of the CPOE and with its complexity were significantly higher than the nurses (P < 0.001).

Conclusions

Qualifications for CPOE adoption as defined by three attributes of diffusion of innovation theory were not satisfied in the study setting. CPOE systems are introduced as a response to the present limitations in paper-based systems. In consequence, user expectations are often high on their relative advantages as well as on a low level of complexity. Building CPOE systems therefore requires designs that can provide rather important additional advantages, e.g. by preventing prescription errors and ultimately improving patient safety and safety of clinical work. The decision-making process leading to the implementation and use of CPOE systems in healthcare therefore has to be improved. As any change in health service settings usually faces resistance, we emphasize that CPOE system designers and healthcare decision-makers should continually collect users' feedback about the systems, while not forgetting that it also is necessary to inform the users about the potential benefits involved.

User satisfaction with computerized order entry system and its effect on workplace level of stress

To evaluate the impact of Computerized Provider Order Entry (CPOE) on workplace stress and overall job performance, as perceived by medical students, housestaff, attending physicians and nurses, after CPOE implementation at Penn State-Milton S. Hershey Medical Center, an academic tertiary care facility, in 2005. Using an online survey, the authors studied attitudes towards CPOE among 862 health care professionals. The main outcome measures were job performance and perceived stress levels. Statistical analyses were conducted using the Statistical Analytical Software (SAS Inc, Carey, NC). A total of413 respondents completed the entire survey (47.9 % response rate). Respondents in the younger age group were more familiar with the system, used it more frequently, and were more satisfied with it. Interns and residents were the most satisfied groups with the system, while attending physicians expressed the least satisfaction. Attending physicians and fellows found the system least user friendly compared with other groups, and also tended to express more stress and frustration with the system. Participants with previous CPOE experience were more familiar with the system, would use the system more frequently and were more likely to perceive the system as user friendly. User satisfaction with CPOE increases by familiarity and frequent use of the system. Improvement in system characteristics and avoidance of confusing terminology and inconsistent display of data is expected to enhance user satisfaction. Training in the use of CPOE should start early, ideally integrated into medical and nursing school curricula and form a continuous, long-term and user-specific process. This is expected to increase familiarity with the system, reducing stress and leading to improved user satisfaction and to subsequent enhanced safety and efficiency.

The impact of computerized provider order entry systems on inpatient clinical workflow: a literature review

Previous studies have shown the importance of workflow issues in the implementation of CPOE systems and patient safety practices. To understand the impact of CPOE on clinical workflow, we developed a conceptual framework and conducted a literature search for CPOE evaluations between 1990 and June 2007. Fifty-one publications were identified that disclosed mixed effects of CPOE systems. Among the frequently reported workflow advantages were the legible orders, remote accessibility of the systems, and the shorter order turnaround times. Among the frequently reported disadvantages were the time-consuming and problematic user-system interactions, and the enforcement of a predefined relationship between clinical tasks and between providers. Regarding the diversity of findings in the literature, we conclude that more multi-method research is needed to explore CPOE's multidimensional and collective impact on especially collaborative workflow.

Evaluating health information technology: provider satisfaction with an HIV-specific, electronic clinical management and reporting system

Health information technology (HIT) offers the potential to improve care for persons living with HIV. Provider satisfaction with HIT is essential to realize benefits, yet its evaluation presents challenges. An HIV-specific, electronic clinical management and reporting system was implemented in Louisiana's eight HIV clinics, serving over 7500. A serial cross-sectional survey was administered at three points between April 2002 and July 2005; qualitative methods were used to augment quantitative. Multivariable methods were used to characterize provider satisfaction. The majority of the sample (n = 196; T1 = 105; T2 = 46; T3 = 45) was female (80.0%), between ages of 25 and 50 years (68.3%), frequent providers at that clinic (53.7% more than 4 days per week), and had been at the same clinic for a year or more (85.0%). Improvements in satisfaction were observed in patient tracking ( p < 0.05), distribution of educational materials ( p < 0.04), and belief that electronic systems improve care ( p < 0.05). Provider self-reports of time to complete critical functions decreased for all tasks, two significantly so. Time (in minutes) to find current CD4 count decreased at each time point (mean 3.9 [standard deviation {SD} 5.8], 2.9 [2.3], 2.1 [2.6], p>0.05), current viral load decreased at each time point (mean 4.0 [SD 5.6], 2.9 [2.5], 1.8 [2.6], p = 0.08], current antiretroviral status decreased at each time point (mean 3.9 [SD 4.7], 2.9 [3.7], 1.5 [1.1], p < 0.04), history of antiretroviral use decreased at each time point (mean 15.1 [SD 21.9], 6.0 [5.4], 5.4 [7.2], p < 0.04]. Time savings were realized, averaging 16.1 minutes per visit ( p < 0.04). Providers were satisfied with HIT in multiple domains, and significant time savings were realized.

Same system, different outcomes: comparing the transitions from two paper-based systems to the same computerized physician order entry system

OBJECTIVE

To compare how nurses in two different paper-based systems perceive the impact of a computerized physician order entry (CPOE) system on their medication-related activities.

SETTING

13 non-surgical, adult inpatient wards in a Dutch academic hospital.

METHODS

Questionnaire survey of 295 nurses before and 304 nurses after the implementation of a CPOE system. These nurses worked with two different paper-based medication systems before the implementation: 'Kardex-system' and 'TIMED-system'. In the Kardex-system, the structure of the nursing medication work was similar to that of after the CPOE implementation, while in the TIMED-system, it was different. 'Adaptive Structuration Theory' (AST) was used to interpret the results.

RESULTS

The response rates were 52.2% (154/295) before and 44.7% (136/304) after the implementation. Kardex-nurses reported more positive effects than TIMED-nurses. TIMED-nurses reported that the computerized system was more inflexible, more difficult to work with, and slower than the TIMED-system. In the TIMED group, the overall mean score of the computerized process was not significantly different from that of the paper-based process. Moreover, nurses in both groups were more satisfied with the post-implementation process than with the pre-implementation process. Nevertheless, none of groups reported a better workflow support in the computerized system when compared to that of the paper-based systems.

CONCLUSIONS

Our findings suggest that not only the technology but also large differences between pre- and post-implementation work structure influence the perceptions of users, and probably make the transition more difficult. This study also suggests that greater satisfaction with a system may not necessarily be a reflection of better workflow support.

EHR safety: the way forward to safe and effective systems

Diverse stakeholders--clinicians, researchers, business leaders, policy makers, and the public--have good reason to believe that the effective use of electronic health care records (EHRs) is essential to meaningful advances in health care quality and patient safety. However, several reports have documented the potential of EHRs to contribute to health care system flaws and patient harm. As organizations (including small hospitals and physician practices) with limited resources for care-process transformation, human-factors engineering, software safety, and project management begin to use EHRs, the chance of EHR-associated harm may increase. The authors propose a coordinated set of steps to advance the practice and theory of safe EHR design, implementation, and continuous improvement. These include setting EHR implementation in the context of health care process improvement, building safety into the specification and design of EHRs, safety testing and reporting, and rapid communication of EHR-related safety flaws and incidents.

Reasons for declining computerized insulin protocol recommendations: application of a framework

Clinical decision support systems (CDS) can interpret detailed treatment protocols for ICU care providers. In open-loop systems, clinicians can decline protocol recommendations. We capture their reasons for declining as part of ongoing, iterative protocol validation and refinement processes. Even though our protocol was well-accepted by clinicians overall, noncompliance patterns revealed potential protocol improvement targets, and suggested ways to reduce barriers impeding software use. We applied Rita Kukafka and colleagues' (2003) IT implementation framework to identify and categorize reasons documented by ICU nurses when declining recommendations from an insulin-titration protocol. Two methods were used to operationalize the framework: reasons for declining recommendations from actual software use, and a nurse questionnaire. Applying the framework exposed limitations of our data sources, and suggested ways to address those limitations; and facilitated our analyses and interpretations.

Multiple perspectives on the impact of electronic ordering on hospital organisational and communication processes

Electronic ordering systems provide many potential benefits for improving the efficiency and effectiveness of healthcare delivery. They also have major implications for organisational and communication processes within hospitals. We undertook a qualitative study using focus groups and interviews with doctors, nurses, IT managers, and pathology laboratory managers to investigate the impact of the system on their work processes and relations within a major teaching hospital. This study revealed that the new electronic ordering system involved major alterations to the information management processes within the hospital, which in turn affected communication processes and work relations.

Nurses' views on the use, quality and user satisfaction with electronic medical records: questionnaire development

AIM

This paper is a report of the development of an instrument to measure nurses' views on the use, quality and user satisfaction with electronic medical records systems.

BACKGROUND

Use of electronic medical records systems in hospitals is steadily increasing, yet no validated instruments have assessed the effectiveness of these systems from the viewpoint of nurses.

METHOD

Items were designed following a literature review based on three main constructs: use, quality and user satisfaction with electronic medical records. Reliability and validity were examined based on responses from 1,666 nurses from 42 hospitals in Japan in February 2006. Exploratory factor analysis was conducted to determine the degree to which each item within a construct was associated. The reliability of each resultant factor was computed using Cronbach's alpha coefficient. Content validity was addressed by basing the items on previous surveys and review of the instrument by a panel of nurses experienced in nursing informatics. Construct validity was examined through factor analysis and correlational analyses.

FINDINGS

Extent of 'use' of electronic medical records resulted into three factors with good factor loadings, but only two had acceptable reliability. 'Quality' of electronic medical records had two factors with good factor loadings and reliability. 'User satisfaction' with electronic medical records had three factors, but only one had acceptable reliability. 'Use' and 'quality' constructs were positively correlated with 'user satisfaction'.

CONCLUSION

The final instrument incorporates 34 items from the original 44-item pool. Initial validity results were positive and therefore the instrument can be used in evaluating electronic medical records in hospitals.

Barriers to the adoption of electronic health records: using concept mapping to develop a comprehensive empirical model

The study attempts to unify prior research and develop a comprehensive, empirically based conceptual model of the barriers to EHR adoption among community physicians. The model uses concept mapping, which taps the shared expertise of a group and provides reliable estimates with relatively small sample sizes. The methodology includes brainstorming of barrier statements and sorting and rating of issue statements. The model illuminates the larger structure of barriers as well as the finer details of constituent issues. Core issues are standardization and interoperability; also important are technical issues and the cost-benefit of adopting EHRs. However, psychosocial issues, the main focus of diffusion research, seem relatively peripheral. We believe the development of this model is an important first step in creating effective and measurable interventions that enhance the adoption of EHRs in healthcare.

Informatics systems to promote improved care for chronic illness: a literature review

OBJECTIVE

To understand information systems components important in supporting team-based care of chronic illness through a literature search.

DESIGN

Systematic search of literature from 1996-2005 for evaluations of information systems used in the care of chronic illness.

MEASUREMENTS

The relationship of design, quality, information systems components, setting, and other factors with process, quality outcomes, and health care costs was evaluated.

RESULTS

In all, 109 articles were reviewed involving 112 information system descriptions. Chronic diseases targeted included diabetes (42.9% of reviewed articles), heart disease (36.6%), and mental illness (23.2%), among others. System users were primarily physicians, nurses, and patients. Sixty-seven percent of reviewed experiments had positive outcomes; 94% of uncontrolled, observational studies claimed positive results. Components closely correlated with positive experimental results were connection to an electronic medical record, computerized prompts, population management (including reports and feedback), specialized decision support, electronic scheduling, and personal health records. Barriers identified included costs, data privacy and security concerns, and failure to consider workflow. CONCLUSION The majority of published studies revealed a positive impact of specific health information technology components on chronic illness care. Implications for future research and system designs are discussed.

Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial

Introduction

Medication errors in the intensive care unit (ICU) are frequent and lead to attributable patient morbidity and mortality, increased length of ICU stay and substantial extra costs. We investigated if the introduction of a computerized ICU system (Centricity Critical Care Clinisoft, GE Healthcare) reduced the incidence and severity of medication prescription errors (MPEs).

Methods

A prospective trial was conducted in a paper-based unit (PB-U) versus a computerized unit (C-U) in a 22-bed ICU of a tertiary university hospital. Every medication order and medication prescription error was validated by a clinical pharmacist. The registration of different classes of MPE was done according to the National Coordinating Council for Medication Error Reporting and Prevention guidelines. An independent panel evaluated the severity of MPEs. We identified three groups: minor MPEs (no potential to cause harm); intercepted MPEs (potential to cause harm but intercepted on time); and serious MPEs (non-intercepted potential adverse drug events (ADE) or ADEs, being MPEs with potential to cause, or actually causing, patient harm).

Results

The C-U and the PB-U each contained 80 patient-days, and a total of 2,510 medication prescriptions were evaluated. The clinical pharmacist identified 375 MPEs. The incidence of MPEs was significantly lower in the C-U compared with the PB-U (44/1286 (3.4%) versus 331/1224 (27.0%); P < 0.001). There were significantly less minor MPEs in the C-U than in the PB-U (9 versus 225; P < 0.001). Intercepted MPEs were also lower in the C-U (12 versus 46; P < 0.001), as well as the non-intercepted potential ADEs (21 versus 48; P < 0.001). There was also a reduction of ADEs (2 in the C-U versus 12 in the PB-U; P < 0.01). No fatal errors occurred. The most frequent drug classes involved were cardiovascular medication and antibiotics in both groups. Patients with renal failure experienced less dosing errors in the C-U versus the PB-U (12 versus 35 serious MPEs; P < 0.001).

Conclusion

The ICU computerization, including the medication order entry, resulted in a significant decrease in the occurrence and severity of medication errors in the ICU.

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.

Cognitive factors influencing perceptions of clinical documentation tools

Identifying healthcare providers' perceptions of clinical documentation methods can inform the design of computer-based documentation tools. The authors investigated the cognitive factors underlying such perceptions by performing a qualitative analysis that included open-ended in-depth interviews of a convenience sample of healthcare providers who use a variety of documentation methods. A total of 16 providers participated in the study; subjects included physicians and nurse practitioners from medical and surgical specialties who used paper- and computer-based documentation tools. Based on interview data, authors identified five factors that influenced satisfaction with clinical documentation tools: document system time efficiency, availability, expressivity, structure, and quality. These factors, if validated by subsequent investigations, can be used to develop a formal conceptual model of providers' perceptions of their satisfaction with various documentation systems.

Physician characteristics, attitudes, and use of computerized order entry

BACKGROUND

Computerized physician order entry (CPOE) is a widely advocated patient safety intervention, yet little is known about its adoption by attending physicians or community hospitals.

METHODS

We calculated the order entry rates of attending physicians at 2 hospitals by measuring the number of orders entered directly and dividing this by the sum of orders entered directly and those written by hand. These findings were paired with the results of a survey that assessed attitudes concerning the impact of CPOE on personal efficiency, quality of care, and patient safety.

RESULTS

Three hundred and fifty-six (71%) of the 502 surveys were returned by physicians, whose median order entry rate was 66%. Forty-two percent of respondents placed at least 80% of their orders electronically (high use), 26% placed 21%-79% of their orders electronically (intermediate use), and 32% placed 20% or less of their orders electronically (low use). Sex, years since medical school graduation, years in practice at the study institution, and use of computers in the outpatient arena were not meaningfully different among the 3 groups. However, use of the system to place orders varied by specialty, and those with intermediate or high use of the system were more likely than low users to have used CPOE during training and to be regular users of computers for personal activities. These physicians were more likely to believe that CPOE enabled orders to be placed efficiently, that directly entered orders were carried out more rapidly, and that such orders were associated with fewer errors.

CONCLUSIONS

The adoption of CPOE by attending physicians at community hospitals varies widely. In addition to purchasing systems that support physician work flow, hospitals intent on successfully implementing CPOE should emphasize the benefits in safety and quality of this new technology.

A risk assessment of two interorganizational clinical information systems

A risk analysis framework was used to examine the implementation barriers that may hamper the successful implementation of interorganizational clinical information systems (ICIS). In terms of study design, an extensive literature review was first performed in order to elaborate a comprehensive model of project risk factors. To test the applicability of the model, we next conducted a longitudinal multiple-case study of two large-scale ICIS demonstration projects carried out in Quebec, Canada. Variations in the levels of several risk dimensions measured throughout the duration of the projects were analyzed to determine their impact on successful implementation. The analysis shows that the proposed framework, composed of five risk dimensions, was very robust, and suitable for conducting a thorough risk analysis. The results also show that there are links between the quality of the risk management and the level of project outcomes. To be successful, it is important that the implementation efforts be distributed proportionally according to the importance of each of the risk factors. Furthermore, because the risks evolve dynamically, there is a need for high responsiveness to emerging implementation problems. Thus, implementation success lies in the ability of the project management team to be aware of and to manage several risk threats simultaneously and coherently since they evolve dynamically through time and interact with one another.

Reviewing the Benefits and Costs of Electronic Health Records and Associated Patient Safety Technologies

In the current paper, we describe the challenges in measuring return on investment (ROI) and review published ROI studies on health IT. In addition, given the absence of a robust ROI literature base, we review the general benefits and potential costs of various health IT applications including electronic health records (EHRs), computerized physicians order entry (CPOE) systems, and clinical decision support systems (CDSS). We conclude that articles examining these benefits are much more common than studies examining ROI itself. This trend suggests the early stage of this knowledge base. Additional research utilizing broader perspectives and multidisciplinary techniques will be needed before a better understanding of ROI from health IT is achieved.

Embedded guideline information without patient specificity in a commercial emergency department computerized order-entry system

BACKGROUND

Clinical practice guidelines and computerized provider order entry (CPOE) have potential for improving clinical care. Questions remain about feasibility and effectiveness of CPOE in the emergency department (ED). However, successful implementations in other settings typically incorporate decision support functions that are lacking in many commercially available ED information systems.

OBJECTIVES

To compare acute coronary syndrome (ACS) guideline compliance before and after implementation of a locally implemented ACS guideline, first on paper and then in a commercially available ED information system without patient-specific clinical decision support.

METHODS

Clinical data were abstracted retrospectively on patients seen before and after introduction of paper and, subsequently, CPOE versions of ACS guideline-based order-sets. Order-set use was determined. Risk category assignments were made retrospectively using guideline criteria and compliance with the guideline regarding beta-blockers, heparin, and aspirin was determined. Association between order-set use and compliance was determined.

RESULTS

The authors found increasing use of order-sets over the period of study. However, there was poor association between the order-sets used and risk stratification category. Some association between ED beta-blocker use and use of CPOE order-sets was found, but there was no improvement in overall compliance with any of the guideline recommendations.

CONCLUSIONS

Adherence to an ACS guideline did not improve with implementation of a commercial ED information system without provision for patient-specific decision support. This suggests that the lack of patient-specific decision-support functionality in most current ED information system products may hamper progress in the development of effective decision support.

The influence of information technology on patient-physician relationships

Interpersonal relationships and information are intertwined as essential cornerstones of health care. Although information technology (IT) has done much to advance medicine, we are not even close to realizing its full potential. Indeed, issues related to mismanaging health information often undermine relationship-centered care. Information technology must be implemented in ways that preserve and uplift relationships in care, while accommodating major deficiencies in managing information and making medical decisions. Increased collaboration between experts in IT and relationship-centered care is needed, along with inclusion of relationship-based measures in informatics research.

Designing an EMR planning process based on staff attitudes toward and opinions about computers in healthcare

Electronic medical record (EMR) systems have been in use for more than 2 decades. Studies documenting nursing satisfaction with an EMR system, the benefits of an EMR, implementation barriers, user acceptance, the importance of staff buy-in, and the importance of attitudes toward and expectations from user buy-in are in the literature. Central to many studies is the importance of nursing staff buy-in to the successful implementation and ongoing use of an EMR, as well as the dependency of buy-in on staff attitudes and expectations. Buy-in is a precursor to effective use. Consequently, staff buy-in is a prerequisite to collecting and making optimum use of the data contained in an EMR. Data collected from an EMR containing rich, accurate documentation of nursing interventions and patient responses support evidence-based practice changes and documentation of the import of the care provided by nurses.

The effect of computerized provider order entry on medical student clerkship experiences

OBJECTIVE

To describe medical students' attitudes toward placing orders during training, and the effect of computerized provider order entry (CPOE) on their learning experiences.

DESIGN

Prospective, controlled study of all 143 Johns Hopkins University School of Medicine students who began the Basic Medicine clerkship between March 2003 and April 2004 at one of three teaching hospitals: one using CPOE, one paper orders, and one that began using CPOE midway through this study.

MEASUREMENTS

Survey of students at the start and after the first month of the clerkship.

RESULTS

Ninety-six percent of students responded. Students expressed a desire to place 100% of orders for their patients. Ninety-five percent of students believed that placing orders helps students learn what tests and treatments patients need. Eighty-four percent reported that being unavailable due to conferences and teaching sessions was a significant barrier to participating in the ordering process. Students at hospitals using CPOE reported placing significantly fewer of their patients' follow-up orders compared to students at hospitals using paper orders (25% vs. 50%, p < 0.01) and were more likely to report that their resident or intern did not want them to enter orders (40% vs. 16%, p < 0.01). Comparisons of students at hospitals using CPOE to each other showed that these differences were attributable to one of the hospitals. Thirty-two percent of students at both hospitals using CPOE reported that the extra length of time required for housestaff to review their orders in the computer was a significant barrier.

CONCLUSION

Hospitals need to ensure that the educational potential of medical students' clinical experiences is maximized when implementing CPOE.

Information retrieval performance of probabilistically generated, problem-specific computerized provider order entry pick-lists: a pilot study

OBJECTIVE

The aim of this study was to preliminarily determine the feasibility of probabilistically generating problem-specific computerized provider order entry (CPOE) pick-lists from a database of explicitly linked orders and problems from actual clinical cases.

DESIGN

In a pilot retrospective validation, physicians reviewed internal medicine cases consisting of the admission history and physical examination and orders placed using CPOE during the first 24 hours after admission. They created coded problem lists and linked orders from individual cases to the problem for which they were most indicated. Problem-specific order pick-lists were generated by including a given order in a pick-list if the probability of linkage of order and problem (PLOP) equaled or exceeded a specified threshold. PLOP for a given linked order-problem pair was computed as its prevalence among the other cases in the experiment with the given problem. The orders that the reviewer linked to a given problem instance served as the reference standard to evaluate its system-generated pick-list.

MEASUREMENTS

Recall, precision, and length of the pick-lists.

RESULTS

Average recall reached a maximum of .67 with a precision of .17 and pick-list length of 31.22 at a PLOP threshold of 0. Average precision reached a maximum of .73 with a recall of .09 and pick-list length of .42 at a PLOP threshold of .9. Recall varied inversely with precision in classic information retrieval behavior.

CONCLUSION

We preliminarily conclude that it is feasible to generate problem-specific CPOE pick-lists probabilistically from a database of explicitly linked orders and problems. Further research is necessary to determine the usefulness of this approach in real-world settings.

VA QUERI informatics paper: information technology for clinical guideline implementation: perceptions of multidisciplinary stakeholders

OBJECTIVE

This multisite study compared the perceptions of three stakeholder groups regarding information technologies as barriers to and facilitators of clinical practice guidelines (CPGs).

DESIGN

The study settings were 18 U.S. Veterans Affairs Medical Centers. A purposive sample of 322 individuals participated in 50 focus groups segmented by profession and included administrators, physicians, and nurses. Focus group participants were selected based on their knowledge of practice guidelines and involvement in facility-wide guideline implementation.

MEASUREMENTS

Descriptive content analysis of 1,500 pages of focus group transcripts.

RESULTS

Eighteen themes clustered into four domains. Stakeholders were similar in discussing themes in the computer function domain most frequently but divergent in other domains, with workplace factors more often discussed by administrators, system design issues discussed most by nurses, and personal concerns discussed by physicians and nurses. Physicians and nurses most often discussed barriers, whereas administrators focused most often on facilitation. Facilitators included guideline maintenance and charting formats. Barriers included resources, attitudes, time and workload, computer glitches, computer complaints, data retrieval, and order entry. Themes with dual designations included documentation, patient records, decision support, performance evaluation, CPG implementation, computer literacy, essential data, and computer accessibility.

CONCLUSION

Stakeholders share many concerns regarding the relationships between information technologies and clinical guideline use. However, administrators, physicians, and nurses hold different opinions about specific facilitators and barriers. Health professionals' disparate perceptions could undermine guideline initiatives. Implementation plans should specifically incorporate actions to address these barriers and enhance the facilitative aspects of information technologies in clinical practice guideline use.

Clinicians' perceptions of clinical decision support integrated into computerized provider order entry

Computerized provider order entry systems can improve patient care by integrating clinical decision support. Decision support is most effective when its content and delivery are acceptable. The authors report the results of a multifaceted survey of the attitudes of housestaff and medical student users of a provider order entry system with integrated decision support at an academic medical center. The survey contained 16 items covering four themes: efficiency, quality of care, results reporting and embedded guidelines. Responses were captured using a five point Likert scale, and were compared using ANOVA and Bartlett's testing. Out of 491 housestaff and 128 medical students, response rates were 47 and 29%, respectively. Among respondents, 72% agreed or strongly agreed that the provider order entry system improves the quality of care that they provide, 54% that the decision support usually help them to provide quality patient care, and 62% that it improves the efficiency of order entry. Respondents were least likely to agree that the display of prior laboratory results influenced their decision to order a subsequent test. There were no significant differences between subspecialties and by advancing years of training among housestaff. Respondents agreed that the integrated clinical decision support enhanced their medical training.