Kenneth Guappone

Publications of Kenneth Guappone

• Computerized Provider Order Entry Adoption: Implications for Clinical Workflow.

  Authors: Emily Campbell, Kenneth Guappone, Dean Sittig, Richard Dykstra, Joan Ash

  Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine. 12/2008;

  OBJECTIVE: To identify and describe unintended adverse consequences related to clinical workflow when implementing or using computerized provider order entry (CPOE) systems. METHODS: We analyzedOBJECTIVE: To identify and describe unintended adverse consequences related to clinical workflow when implementing or using computerized provider order entry (CPOE) systems. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

• The unintended consequences of computerized provider order entry: Findings from a mixed methods exploration.

  Authors: Joan S Ash, Dean F Sittig, Richard Dykstra, Emily Campbell, Kenneth Guappone

  International journal of medical informatics. 10/2008;

  OBJECTIVE: To describe the foci, activities, methods, and results of a 4-year research project identifying the unintended consequences of computerized provider order entry (CPOE). METHODS: Using aOBJECTIVE: To describe the foci, activities, methods, and results of a 4-year research project identifying the unintended consequences of computerized provider order entry (CPOE). METHODS: Using a mixed methods approach, we identified and categorized into nine types 380 examples of the unintended consequences of CPOE gleaned from fieldwork data and a conference of experts. We then conducted a national survey in the U.S.A. to discover how hospitals with varying levels of infusion, a measure of CPOE sophistication, recognize and deal with unintended consequences. The research team, with assistance from experts, identified strategies for managing the nine types of unintended adverse consequences and developed and disseminated tools for CPOE implementers to help in addressing these consequences. RESULTS: Hospitals reported that levels of infusion are quite high and that these types of unintended consequences are common. Strategies for avoiding or managing the unintended consequences are similar to best practices for CPOE success published in the literature. CONCLUSION: Development of a taxonomy of types of unintended adverse consequences of CPOE using qualitative methods allowed us to craft a national survey and discover how widespread these consequences are. Using mixed methods, we were able to structure an approach for addressing the skillful management of unintended consequences as well.

• Categorizing the unintended sociotechnical consequences of computerized provider order entry.

  Authors: Joan S Ash, Dean F Sittig, Richard H Dykstra, Kenneth Guappone, James D Carpenter, Veena Seshadri

  International journal of medical informatics. 07/2007; 76 Suppl 1:S21-7.

  OBJECTIVE: To describe the kinds of unintended consequences related to the implementation of computerized provider order entry (CPOE) in the outpatient setting. DESIGN: Ethnographic and interviewOBJECTIVE: To describe the kinds of unintended consequences related to the implementation of computerized provider order entry (CPOE) in the outpatient setting. DESIGN: Ethnographic and interview data were collected by an interdisciplinary team over a 7 month period at four clinics. MEASUREMENTS: Instances of unintended consequences were categorized using an expanded Diffusion of Innovations theory framework. RESULTS: The framework was clarified and expanded. There are both desirable and undesirable unintended consequences, and they can be either direct or indirect, but there are also many consequences that are not clearly either desirable or undesirable or may even be both, depending on one's perspective. The undesirable consequences include error and security concerns and issues related to alerts, workflow, ergonomics, interpersonal relations, and reimplementations. CONCLUSION: Consequences of implementing and reimplementing clinical systems are complex. The expanded Diffusion of Innovations theory framework is a useful tool for analyzing such consequences.

• Exploring the unintended consequences of computerized physician order entry.

  Authors: Joan S Ash, Dean F Sittig, Richard Dykstra, Emily Campbell, Kenneth Guappone

  Studies in health technology and informatics. 02/2007; 129(Pt 1):198-202.

  This paper summarizes the foci, activities, methods, and results of a three-year research project. Using a mixed methods approach, the Physician Order Entry Team has identified and categorized theThis paper summarizes the foci, activities, methods, and results of a three-year research project. Using a mixed methods approach, the Physician Order Entry Team has identified and categorized the unintended consequences of computerized physician order entry (CPOE). After analyzing 380 examples of unintended adverse consequences, the team described in detail nine major types and conducted a national survey in the U.S. to discover how hospitals recognize and deal with unintended consequences. With the assistance of a panel of experts, the team identified strategies for managing unintended adverse consequences and outlined contents of a toolkit for CPOE implementers for addressing them.

• An unintended consequence of CPOE implementation: shifts in power, control, and autonomy.

  Authors: Joan S Ash, Dean F Sittig, Emily Campbell, Kenneth Guappone, Richard H Dykstra

  AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 02/2006;

  Having found that an unintended consequence of computerized provider order entry (CPOE) implementation is "changes in the power structure" of the organization, we sought a deeper understanding ofHaving found that an unintended consequence of computerized provider order entry (CPOE) implementation is "changes in the power structure" of the organization, we sought a deeper understanding of what was happening and why. If such consequences can be anticipated, they can be better managed. Using qualitative methods to study five successful CPOE sites, a multidisciplinary team found that CPOE enables shifts in power related to work redistribution and safety initiatives and causes a perceived loss of control and autonomy by clinicians. With recognition of the extent of these shifts, clinicians can anticipate them and will no longer be surprised by them. Greater provider involvement in planning, quality initiatives, and the work of clinical information coalitions/committees can benefit the organization and provide a different kind of power and satisfaction to clinicians.

• The extent and importance of unintended consequences related to computerized provider order entry.

  Authors: Joan S Ash, Dean F Sittig, Eric G Poon, Kenneth Guappone, Emily Campbell, Richard H Dykstra

  Journal of the American Medical Informatics Association : JAMIA. 14(4):415-23.

  BACKGROUND: Computerized provider order entry (CPOE) systems can help hospitals improve health care quality, but they can also introduce new problems. The extent to which hospitals experienceBACKGROUND: Computerized provider order entry (CPOE) systems can help hospitals improve health care quality, but they can also introduce new problems. The extent to which hospitals experience unintended consequences of CPOE, which include more than errors, has not been quantified in prior research. OBJECTIVE: To discover the extent and importance of unintended adverse consequences related to CPOE implementation in U.S. hospitals. DESIGN, SETTING, AND PARTICIPANTS: Building on a prior qualitative study involving fieldwork at five hospitals, we developed and then administered a telephone survey concerning the extent and importance of CPOE-related unintended adverse consequences to representatives from 176 hospitals in the U.S. that have CPOE. MEASUREMENTS: Self report by key informants of the extent and level of importance to the overall function of the hospital of eight types of unintended adverse consequences experienced by sites with inpatient CPOE. RESULTS We found that hospitals experienced all eight types of unintended adverse consequences, although respondents identified several they considered more important than others. Those related to new work/more work, workflow, system demands, communication, emotions, and dependence on the technology were ranked as most severe, with at least 72% of respondents ranking them as moderately to very important. Hospital representatives are less sure about shifts in the power structure and CPOE as a new source of errors. There is no relation between kinds of unintended consequences and number of years CPOE has been used. Despite the relatively short length of time most hospitals have had CPOE (median five years), it is highly infused, or embedded, within work practice at most of these sites. CONCLUSIONS: The unintended consequences of CPOE are widespread and important to those knowledgeable about CPOE in hospitals. They can be positive, negative, or both, depending on one's perspective, and they continue to exist over the duration of use. Aggressive detection and management of adverse unintended consequences is vital for CPOE success.

• A Rapid Assessment Process for Clinical Informatics Interventions

  Authors: Joan S Ash, Dean F Sittig, Carmit K McMullen, Kenneth Guappone, Richard Dykstra, James Carpenter

  Informatics interventions generally take place in rapidly changing settings where many variables are outside the control of the evaluator. Assessment must be timely so that feedback can instigateInformatics interventions generally take place in rapidly changing settings where many variables are outside the control of the evaluator. Assessment must be timely so that feedback can instigate modification of the intervention. Adapting a methodology from international health and epidemiology, we have developed and refined a Rapid Assessment Process (RAP) for informatics while conducting a study of clinical decision support (CDS) in community hospitals. Using RAP, we have not only been able to provide implementers with actionable feedback, but we have also discovered that users and informaticians conceptualize CDS in vastly different ways. Further understanding of this difference will be needed if we are to improve CDS acceptance by users.