Unintended consequences of pharmacy information systems: A case study

BACKGROUND

Pharmacy information systems (PhIS) can cause medication errors that pharmacists may overlook due to their increased workload and lack of understanding of maintaining information quality. This study seeks to identify factors influencing unintended consequences of PhIS and how they affect the information quality, which can pose a risk to patient safety.

MATERIALS AND METHODS

This qualitative, explanatory case study evaluated PhIS in ambulatory pharmacies in a hospital and a clinic. Data were collected through observations, interviews, and document analysis. We applied the socio-technical interactive analysis (ISTA) framework to investigate the socio-technical interactions of pharmacy information systems that lead to unintended consequences. We then adopted the human-organization-process-technology-fit (HOPT-fit) framework to identify their contributing and dominant factors, misfits, and mitigation measures.

RESULTS

We identified 28 unintended consequences of PhIS, their key contributing factors, and their interrelations with the systems. The primary causes of unintended consequences include system rigidity and complexity, unclear knowledge, understanding, skills, and purpose of using the system, use of hybrid paper and electronic documentation, unclear and confusing transitions, additions and duplication of tasks and roles in the workflow, and time pressure, causing cognitive overload and workarounds. Recommended mitigating mechanisms include human factor principles in system design, data quality improvement for PhIS in terms of effective use of workspace, training, PhIS master data management, and communication by standardizing workarounds.

CONCLUSION

Threats to information quality emerge in PhIS because of its poor design, a failure to coordinate its functions and clinical tasks, and pharmacists' lack of understanding of the system use. Therefore, safe system design, fostering awareness in maintaining the information quality of PhIS and cultivating its safe use in organizations is essential to ensure patient safety. The proposed evaluation approach facilitates the evaluator to identify complex socio-technical interactions and unintended consequences factors, impact, and mitigation mechanisms.

Physician-Nurse Communication Surrounding Computerized Physician Order Entry Systems From Social and Technical Perspective: An Ethnographic Study

Although computerized physician order entry systems improve order transmission and patient safety, overdependence on these systems can impede users' communication. This ethnographic study explored physician-nurse communication surrounding computerized physician order entry systems using a sociotechnical framework. Fieldwork conducted in a tertiary teaching hospital comprised 89 hours of participant observation, and individual semistructured interviews were held with seven nurses and five physicians. In addition, documents and artifacts were collected. Three core themes emerged. First, computerized physician order entry quality-related issues undermined the work efficiency of physicians and nurses. Specifically, usability was error prone because of cognitive overload, and the system was unable to perform relevant traces and raise alerts, demonstrating poor interoperability. Second, social factors, including insufficient training, unclear responsibilities, and a lack of awareness concerning interdisciplinary communication, compounded communication problems. Last, environmental factors, including noncoterminous spaces and times and insufficient technical support, impeded the resolution of communication problems. Technical and social contextual factors relating to computerized physician order entry systems jointly affected physician-nurse communication. Cognitive issues and insufficient alerts impacted work efficiency the most and were compounded by contextual individual- and team-related factors and environmental factors. Therefore, improved functions of computerized physician order entry systems and interprofessional communication training are required to optimize technical and social aspects of physician-nurse communication.

The appropriateness of clinical decision support systems alerts in supporting clinical workflows: A systematic review

A CDSS generates a high number of inappropriate alerts that interrupt the clinical workflow. As a result, clinicians silence, disable, or ignore alerts, thereby undermining patient safety. Therefore, the effectiveness and appropriateness of CDSS alerts need to be evaluated. A systematic review was carried out to identify the factors that affect CDSS alert appropriateness in supporting clinical workflow. Seven electronic databases (PubMed, Scopus, ACM, Science Direct, IEEE, Ovid Medline, and Ebscohost) were searched for English language articles published between 1997 and 2018. Seventy six papers met the inclusion criteria, of which 26, 24, 15, and 11 papers are retrospective cohort, qualitative, quantitative, and mixed-method studies, respectively. The review highlights various factors influencing the appropriateness and efficiencies of CDSS alerts. These factors are categorized into technology, human, organization, and process aspects using a combination of approaches, including socio-technical framework, five rights of CDSS, and Lean. Most CDSS alerts were not properly designed based on human factor methods and principles, explaining high alert overrides in clinical practices. The identified factors and recommendations from the review may offer valuable insights into how CDSS alerts can be designed appropriately to support clinical workflow.

Evaluating the alert appropriateness of clinical decision support systems in supporting clinical workflow

The overwhelming number of medication alerts generated by clinical decision support systems (CDSS) has led to inappropriate alert overrides, which may lead to unintended patient harm. This review highlights the factors affecting the alert appropriateness of CDSS and barriers to the fit of CDSS alert with clinical workflow. A literature review was conducted to identify features and functions pertinent to CDSS alert appropriateness using the five rights of CDSS. Moreover, a process improvement method, namely, Lean, was used as a tool to optimise clinical workflows, and the appropriate design for CDSS alert using a human automation interaction (HAI) model was recommended. Evaluating the appropriateness of CDSS alert and its impact on workflow provided insights into how alerts can be designed and triggered effectively to support clinical workflow. The application of Lean methods and tools to analyse alert efficiencies in supporting workflow in this study provides an in-depth understanding of alert-workflow fit problems and their root cause, which is required for improving CDSS design. The application of the HAI model is recommended in the design of CDSS alerts to support various levels and stages of alert automations, namely, information acquisition and analysis, decision action and action implementation.

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

Background

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

Methods

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

Results

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

Conclusions

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

The impact of implementing a hospital electronic prescribing and administration system on clinical pharmacists' activities - a mixed methods study

Background

The increasing adoption of hospital electronic prescribing and medication administration (ePA) systems has driven a wealth of research around the impact on patient safety. Yet relatively little research has sought to understand the effects on staff, particularly pharmacists. We aimed to investigate the effects of ePA on pharmacists’ activities, including interactions with patients and health professionals, and their perceptions of medication safety risks.

Methods

A mixed methods study comprising quantitative direct observations of ward pharmacists before and after implementation of ePA in an English hospital, and semi-structured interviews post-ePA. Quantitative data comprised multi-dimensional work activity sampling to establish the proportion of time ward pharmacists spent on different tasks, with whom and where. These data were extrapolated to estimate task duration. Qualitative interviews with pharmacists explored perceived impact on (i) ward activities, (ii) interactions with patients and different health professionals, (iii) locations where tasks were carried out, and (iv) medication errors.

Results

Observations totalled 116 h and 50 min. Task duration analysis suggested screening inpatient medication increased by 16 mins per 10 patients reviewed (p = 0.002), and searching for paper drug charts or computer decreased by 2 mins per 10 patients reviewed (p = 0.001). Pharmacists mainly worked alone (58% of time pre- and 65% post-ePA, p = 0.17), with patient interactions reducing from 5 to 2% of time (p = 0.03). Seven main themes were identified from the interviews, underpinned by a core explanatory concept around the enhanced and shifting role of the ward pharmacist post-ePA. Pharmacists perceived there to be a number of valuable safety features with ePA. However, paradoxically, some of these may have also inadvertently contributed to medication errors.

Conclusion

This study provides quantitative and qualitative insights into the effects of implementing ePA on ward pharmacists’ activities. Some tasks took longer while others reduced, and pharmacists may spend less time with patients with ePA. Pharmacists valued a number of safety features associated with ePA but also perceived an overall increase in medication risk. Pharmacy staff demonstrated a degree of resilience to ensure ‘business as usual’ by enhancing and adapting their role.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3986-4) contains supplementary material, which is available to authorized users.

The impact of computerised physician order entry and clinical decision support on pharmacist-physician communication in the hospital setting: A qualitative study

BACKGROUND

The implementation of Computerised Physician Order Entry (CPOE) and Clinical Decision Support (CDS) has been found to have some unintended consequences. The aim of this study is to explore pharmacists and physicians perceptions of their interprofessional communication in the context of the technology and whether electronic messaging and CDS has an impact on this.

METHOD

This qualitative study was conducted in two acute hospitals: the University Hospitals Birmingham NHS Foundation Trust (UHBFT) and Guy's and St Thomas' NHS Foundation Trust (GSTH). UHBFT use an established locally developed CPOE system that can facilitate pharmacist-physician communication with the ability to assign a message directly to an electronic prescription. In contrast, GSTH use a more recently implemented commercial system where such communication is not possible. Focus groups were conducted with pharmacists and physicians of varying grades at both hospitals. Focus group data were transcribed and analysed thematically using deductive and inductive approaches, facilitated by NVivo 10.

RESULTS

Three prominent themes emerged during the study: increased communication load; impaired decision-making; and improved workflow. CPOE and CDS were found to increase the communication load for the pharmacist owing to a reduced ability to amend electronic prescriptions, new types of prescribing errors, and the provision of technical advice relating to the use of the system. Decision-making was found to be affected, owing to the difficulties faced by pharmacists and physicians when trying to determine the context of prescribing decisions and knowledge of the patient. The capability to communicate electronically facilitated a non-interruptive workflow, which was found to be beneficial for staff time, coordination of work and for limiting distractions.

CONCLUSION

The increased communication load for the pharmacist, and consequent workload for the physician, has the potential to impact on the quality and coordination of care in the hospital setting. The ability to communicate electronically has some benefits, but functions need to be designed to facilitate collaborative working, and for this to be optimised through interprofessional training.

[Problems encountered by hospital pharmacists with information systems: Analysis of exchanges within social networks]

OBJECTIVE

The development of information systems in French hospitals is mandatory. The aim of this work was to analyze the content of exchanges carried out within social networks, dealing with problems encountered with hospital pharmacies information systems.

METHODS

Messages exchanged via the mailing list of the Association pour le Digital et l'Information en Pharmacie and abstracts of communications presented at hospital pharmacists trade union congresses were analyzed. Those referring to information systems used in hospital pharmacies were selected.

RESULTS

From March 2015 to June 2016, 122 e-mails sent by 80 pharmacists concerned information systems. From 2002 to 2016, 45 abstracts dealt with this topic. Problems most often addressed in these 167 documents were "parameterization and/or functionalities" (n=116), interfaces and complexity of the hospital information systems (n=52), relationship with health information technologies vendors and poor reactivity (n=32), additional workload (n=32), ergonomics (n=30), insufficient user training (n=22). These problems are interdependent, lead to errors and in order to mitigate their consequences, they compel pharmacy professionals to divert a significant amount of working hours to the detriment of pharmaceutical care and dispensing and preparing drugs.

CONCLUSION

Hospital pharmacists are faced with many problems of insecurity and inefficiency generated by information systems. Researches are warranted to determine their cost, specify their deleterious effects on care and identify the safest information systems.

Physician satisfaction with transition from CPOE to paper-based prescription

INTRODUCTION

In January 2015, Rouen University Hospital's information system experienced serious issues. It was necessary to rapidly switch from the computerized provider order entry (CPOE) system towards a paper-based order entry (PBOE) system. This was an opportunity to evaluate prescriber opinion on the two provider order entry (POE) systems.

METHODS

All residents were asked to fill an augmented version of the POE satisfaction and usage survey for both POE systems. The results were compared to identify the strengths and weaknesses of each system.

RESULTS

Fifty-one respondents had used the CPOE system and the PBOE system. Overall, satisfaction was higher with PBOE than CPOE (odds ratio (OR)=3.74; p<0.001). Usability (OR=4.00; p<0.001), reliability (OR=8.54; p<0.001), time consumption (OR=0.50; p<0.05 - survey statement was formulated negatively), and communication with nurses (OR=14.27; p<0.0001) reached statistically better agreement. The more experience with CPOE the more residents were disillusioned with the reliability (OR=6.55; p<0.01), the usability (OR=5.68; p<0.01) and the patient safety (OR=0.27; p<0.05 - survey statement was formulated negatively) of CPOE. Although safety issues were reported for both systems, the causes were different; PBOE imposed frequent rewriting of the order while CPOE lack of usability might be unsafe. Another important issue with both POE systems was time consumption.

CONCLUSION

Residents did not report any increase in safety issues with the rapid switch from CPOE to PBOE. They even seemed more satisfied with the rollback to paper, which remains a possible degraded mode in case of health information technology collapse.

Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts in a computerized provider order entry system

OBJECTIVE

Computerized provider order entry systems commonly contain alerting mechanisms for patient allergies, incorrect doses, or drug-drug interactions when ordering medications. Providers have the option to override (bypass) these alerts and continue with the order unchanged. This study examines the effect of customizing medication alert override options on the appropriateness of override selection related to patient allergies, drug dosing, and drug-drug interactions when ordering medications in an electronic medical record.

MATERIALS AND METHODS

In this prospective, randomized crossover study, providers were randomized into cohorts that required a reason for overriding a medication alert from a customized or non-customized list of override reasons and/or by free-text entry. The primary outcome was to compare override responses that appropriately correlate with the alert type between the customized and non-customized configurations. The appropriateness of a subset of free-text responses that represented an affirmative and active acknowledgement of the alert without further explanation was classified as "indeterminate." Results were analyzed in three different ways by classifying indeterminate answers as either appropriate, inappropriate, or excluded entirely. Secondary outcomes included the appropriateness of override reasons when comparing cohorts and individual providers, reason selection based on order within the override list, and the determination of the frequency of free-text use, nonsensical responses, and multiple selection responses.

RESULTS

Twenty-two clinicians were randomized into 2 cohorts and a total of 1829 alerts with a required response were generated during the study period. The customized configuration had a higher rate of appropriateness when compared to the non-customized configuration regardless of how indeterminate responses were classified (p<0.001). When comparing cohorts, appropriateness was significantly higher in the customized configuration regardless of the classification of indeterminate responses (p<0.001) with one exception: when indeterminate responses were considered inappropriate for the cohort of providers that were first exposed to the non-customized list (p=0.103). Free-text use was higher in the customized configuration overall (p<0.001), and there was no difference in nonsensical response between configurations (p=0.39).

CONCLUSION

There is a benefit realized by using a customized list for medication override reasons. Poor application design or configuration can negatively affect provider behavior when responding to important medication alerts.