Computerized Provider Order Entry Adoption: Implications for Clinical Workflow

Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR 97239-3098, USA.
Journal of General Internal Medicine (Impact Factor: 3.42). 12/2008; 24(1):21-6. DOI: 10.1007/s11606-008-0857-9
Source: PubMed


To identify and describe unintended adverse consequences related to clinical workflow when implementing or using computerized provider order entry (CPOE) systems.
We analyzed qualitative data from field observations and formal interviews gathered over a three-year period at five hospitals in three organizations. Five multidisciplinary researchers worked together to identify themes related to the impacts of CPOE systems on clinical workflow.
CPOE systems can affect clinical work by 1) introducing or exposing human/computer interaction problems, 2) altering the pace, sequencing, and dynamics of clinical activities, 3) providing only partial support for the work activities of all types of clinical personnel, 4) reducing clinical situation awareness, and 5) poorly reflecting organizational policy and procedure.
As CPOE systems evolve, those involved must take care to mitigate the many unintended adverse effects these systems have on clinical workflow. Workflow issues resulting from CPOE can be mitigated by iteratively altering both clinical workflow and the CPOE system until a satisfactory fit is achieved.

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    • "The need to address the role of theory in HCI emerged as a prominent theme. Among those issues discussed were the significant barriers to successful design and implementation of Health Information Technologies (HIT) and the unanticipated consequences on the work practices of physicians and nurses that indicate problems in integrating technology solutions with existing work practices [1] [3]. In addition, factors related to regulation, organizational culture and political climate in healthcare, also influence technology implementation and adoption in healthcare settings. "
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    ABSTRACT: Theory has an important place in HCI research in healthcare. However, resources on this area are spread across different multidisciplinary journals. It is timely for the community to reflect on the classic, modern, and contemporary theories they use, to map where strengths and weaknesses lie, and where emerging opportunities are unfolding. This workshop aims to encourage dialogue and exchange of ideas with examples of current and emerging theory in HCI and healthcare to support researchers and practitioners as they address the challenges and opportunities of this domain. We aim to produce a journal special issue to map the state of the art in this area.
    International Conference on Human Factors in Computing Systems , Workshop Proposal, Toronto, Canada; 04/2014
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    • "The socio-technical perspective – recognising the interplay between an organisation's social and technical systems – provides an overarching framework for understanding workarounds and the reasons underlying them. [39] When healthcare IT systems do not integrate well with existing work processes and practices, users struggle with a system that does not fully support them to do their work and they develop workarounds in order to live with the IT system while avoiding system demands that are perceived to be unrealistic.[40], [37] "
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    ABSTRACT: To investigate the perceptions and reported practices of mental health hospital staff using national hospital electronic health records (EHRs) in order to inform future implementations, particularly in acute mental health settings. Thematic analysis of interviews with a wide range of clinical, information technology (IT), managerial and other staff at two early adopter mental health National Health Service (NHS) hospitals in London, UK, implementing national EHRs. We analysed 33 interviews. We first sought out examples of workarounds, such as delayed data entry, entering data in wrong places and individuals using the EHR while logged in as a colleague, then identified possible reasons for the reported workarounds. Our analysis identified four main categories of factors contributing to workarounds (i.e., operational, cultural, organisational and technical). Operational factors included poor system integration with existing workflows and the system not meeting users' perceived needs. Cultural factors involved users' competence with IT and resistance to change. Organisational factors referred to insufficient organisational resources and training, while technical factors included inadequate local technical infrastructure. Many of these factors, such as integrating the EHR system with day-to-day operational processes, staff training and adequate local IT infrastructure, were likely to apply to system implementations in various settings, but we also identified factors that related particularly to implementing EHRs in mental health hospitals, for example: EHR system incompatibility with IT systems used by mental health-related sectors, notably social services; the EHR system lacking specific, mental health functionalities and options; and clinicians feeling unable to use computers while attending to distressed psychiatric patients. A better conceptual model of reasons for workarounds should help with designing, and supporting the implementation and adoption of, EHRs for use in hospital mental health settings.
    PLoS ONE 01/2014; 9(1):e77669. DOI:10.1371/journal.pone.0077669 · 3.23 Impact Factor
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    • "Literature Sources Standardization Solutions for Handoff Problems Procedures Medium Data clinical pathway (*) 5 rights, sign-outs memory aids, (acronyms, checklists) low-tech, e.g.: white-boards, type-written, written + spoken hybrid (hi+low tech) clinical systems (**) (CPOE, EMR, etc.) audit and verification Panella and Vanhaecht 2010, Vanhaecht et al. 2009, Montori and Guyatt 2008, De Bleser et al. 2006, Claridge and Fabian 2005, Doherty 2005, Guyatt et al. 2004, Whittle et al. 2004 X Wurmb et al. 2008 X X Cohen and Hilligoss 2010 X X X Haynes et al. 2009, Quin et al. 2009 X X Arora 2009 X X Gawande 2010, Weiser et al. 2010, Belfrage et al. 2009, Philibert and Leach 2005 X Clark et al. 2009, Hatten-Masterson and Griffiths 2009, Porteous et al. 2009, Patterson 2008, Catchpole et al. 2007, Kelly and Berger 2006, Patterson et al. 2004 X Sehgal et al. 2010 X Aron et al. 2011, Shim and Kumar 2010, Ash et al. 2009, Berente et al. 2009, Campbell et al. 2009, Reckmann et al. 2009, Ash et al. 2007, Kramer et al. 2007, Campbell et al. 2006, Poon et al. 2006, Cheah et al. 2005, Koppel et al. 2005, Ash et al. 2004, Laguna and Marklund 2004, Grover and Malhotra 1997 X Pothier et al. 2005 X Arora et al. 2009 X Barnsteiner 2008, Smith et al. 2008, McFetridge et al. 2007 X Streitenberger et al. 2006 X Steinberger et al. 2009 X X Wayne et al. 2008, Solet et al. 2005 "
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    ABSTRACT: Purpose ‐ The purpose of this paper is to examine how clinical handoffs affect clinical information quality (IQ) and medication administration quality. Design/methodology/approach ‐ A case study was conducted in a US hospital. The authors applied a business process management (BPM) perspective to analyze an end-to-end medication administration process and related handoffs, and accounting control theory (ACT) to examine the impact of handoffs on IQ and medication errors. Findings ‐ The study reveals how handoffs can lead to medication errors (by passing information that is not complete, accurate, timely or valid) and can help reduce errors (by preventing, detecting and correcting information quality flaws or prior clinical mistakes). Research limitations/implications ‐ The paper reports on one case study on one hospital unit. Future studies can investigate the impact of clinical IQ on patient safety across the multitude of health information technologies (e.g. computerized provider order entry (CPOE), electronic medication administration records (EMAR), and barcode medication administration systems (BCMA)) and approaches to process design and support (e.g. use of clinical pathways and checklists). Practical implications ‐ The findings can contribute to more successful design, implementation and evaluation of medication administration and other clinical processes, ultimately improving patient safety. Originality/value ‐ The paper's main contribution is the use of accounting control theory to systematically focus on IQ to evaluate and improve end-to-end medical administration processes.
    Business Process Management Journal 04/2013; 19(2). DOI:10.1108/14637151311308286
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