Article

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

ABSTRACT

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.

Full-text

Available from: Dean Forrest Sittig
Computerized Provider Order Entry Adoption: Implications
for Clinical Workflow
Emily M. Campbell, R.N, M.S.
1
, Kenneth P. Guappone, M.D., Ph.D.
1,2
, Dean F. Sittig, Ph.D.
3
,
Richard H. Dykstra, M.D., M.S.
1
, and Joan S. Ash, M.B.A., Ph.D.
1
1
Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA;
2
, Providence
Portland Medical Center, Portland, USA;
3
UT-Memorial Hermann Center for Healthcare Quality and Safety, University of Texas School of Health
Information Sciences, Houston, TX, USA.
OBJECTIVE: To identify and describe unintended ad-
verse consequences related to clinical workflow when
implementin g or using computerized provider order
entry (CPOE) systems.
METHO DS: We analyzed qualitative data from field
observations and formal interviews gathered over a
three-year period at five hospitals in three organiza-
tions. Five multidisciplinary researchers worked togeth-
er 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 dyna-
mics of clinical activities, 3) p roviding 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 in-
volved 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.
KEY WORDS: attitude to computers; hospital information systems;
usercomputer interface; physician order entry.
J Gen Intern Med 24(1):216
DOI: 10.1007/s11606-008-0857-9
© Society of General Internal Medicine 2008
INTRODUCTION
Health care providers use computerized provider order entry
(CPOE) systems to place orders for medications, laboratory
tests and other ancillary services.
1
CPOE has been shown to
decrease medication ordering errors and redundant test order-
ing, promote practice s tandardization, and redu ce overall
healthcare costs.
24
Despite these benefits, CPOE systems have
yet to be widely adopted for several reasons, including the high
cost of implementation, clinician resistance to technology, worry
regarding practice disruption and loss of productivity, fear of
technology failure, and the inability of some CPOE implementa-
tions to integrate with existing healthcare systems.
57
Further-
more, there is evidence that unintended adverse consequences
can surround the implementation and ongoing maintenance of
these systems.
810
Recent, conflicting reports about the role of
CPOE in the reduction of medication errors and associated costs
have cast some doubt on the actual scale of improvements to be
gained as CPOE systems have generated new kinds of medical
errors, negatively affected patient outcomes, and resulted in
higher overall medical costs for those institutions implementing
them.
9,1113
Thus, there remains a need for ongoing analysis of
CPOE to understand the causes of these issues and help find
solutions.
A growing body of research explores the impact of integrat-
ing clinical information systems, including CPOE, within
healthcare.
1,1417
Regardless of the study focus, one theme
consistently emerges: embedding CPOE in healthcare funda-
mentally changes the way clinicians coordinate their work
activities and collaborate to deliver care.
1821
Indeed, in our
prior work we identified nine broad categories of unintended
adverse consequences related to CPOE, negative impact on
workflow emerged as the most frequently occurring theme.
18,22
The purpose of this current study was to explore these workflow
issues in greater detail.
BACKGROUND
We broadly define workflow as the activities, tools, and
processes needed to produce or modify work, products, or
services.
23
More specifically, clinical workflow encompasses all
of the 1) activities, 2) technologies, 3) environments, 4) people,
and 5) organizations engaged in providing and promoting
health care.
A sociotechnical evaluation framework
18,2325
views these
five components of clinical work as a single work system; that
is, the components cannot be effectively analyzed in isolation.
To understand the effects of embedding CPOE into existing
care delivery systems, we must focus on how the systems as a
whole responds to the change. When using this approach, one
should not separate the information technology system from
its implementation. Even exquisitely designed and coded
software can be implemented poorly. Conversely, poorly engi-
neered software can promote process improvements if it is well
implemented. Thus any evaluation of a CPOE system must
study the system as configured, implemented and used
26
.
Received July 28, 2008
Revised October 9, 2008
Accepted October 16, 2008
Published online November 20, 2008
21
Page 1
METHODS
Site Selection
Over the past three years, we visited five hospitals in three
different healthcare delivery organizations using CPOE. The
sites were selected based on their reputations for excellence in
the use of CPOE; all sites have fully operational and functional
systems that capture a minimum of 90% of all medical orders,
and have been operating at this level for several years. In
addition,wewantedtoevaluatedifferenttypesofCPOE
systems (e.g., commercially built as well as home-grown)in
different types of hospitals. The research sites included
Wishard Memorial Hospital in Indianapolis, IN, using the
locally developed Regenstrief system, Brigham and Womens
and Massachusetts General hospitals in Boston, both using
in-house developed systems, The Faulkner Hospital in Boston,
MA, using MediTech (Westwood, MA), and Alamance Regional
Medical System in Burlington, NC, using Eclipsys (Boca Raton,
FL). Complete site details are presented in Table 1.
Data Collection
The Institutional Review Boards of Oregon Health & Science
University as well as each of our study sites approved this
study. The research team consisted of two physicians, a nurse,
a pharmacist, a librarian, a public health researcher, and a
technically-oriented informaticist.
Our fieldwork used two approaches to data collection. The
first consisted of hour-long, semi-structured oral history
interviews with hospital administrators, physicians, nurses,
pharmacists, and others suggested to us by local principal
investigators. Our team leader (JA) conducted these interviews
to elicit historical and current perspectives on the unintended
consequences, whether positive or negative, related to CPOE
implementation at each of the institutions. Table 2 includes a
list of questions that served as a starting point for these
interviews. Interviewee responses generated additional probing
questions which differed during each interview. Interviews
were recorded and later transcribed. All interviewees were
formally consented.
Our second approach to data collection involved shadowing
clinicians and other personnel interacting with CPOE systems
during their work. The clinicians shadowed were selected by
prior arrangement with study collaborators so that skeptics as
well as accepting users were included. Subjects who agreed to
be shadowed were formally consented. Researchers then
unobtrusively observed the subjects for periods from 26
hours at various times during the day and night. W hen
clinicians offered comments about the systems, we noted
them. In addition, when we were unclear about specific
activities, we asked questions for clarification. In addition to
shadowing individuals, we also observed general work activi-
ties in ambulatory care centers, hospital wards, emergency
rooms, surgical recovery areas, and other critical care units.
Data were collected from August 2004 through April 2005.
During this time we conducted 32 semi-structured oral history
interviews totaling 43 hours. We performed over 400 hours of
observation that included shadowing 95 clinical providers
(40% medical residents and staff physicians, 30% nurses,
10% pharmacists, and 20% other clinical personnel or IT staff)
using CPOE systems in diverse settings. All transcripts and
field notes were analyzed using N6 software (N6, QSR Interna-
tional Pty. Ltd., Melbourne, Australia, 2002).
Data Analysis
Each project team member independe ntly reviewed an
assigned selection of transcribed field notes or interviews to
identify unintended consequences. The entire project team
then met 36 times to collectively determine which data
represented u nintended consequences, and how the data
could be meaningfully categorized. We specifically focused on
unintended adverse consequences because these need to be
carefully managed. We ultimately identified 324 instances of
these related to CPOE. We used a card sort method
22
to
develop provisional categories for those consequences that
appeared to relate to the same content. Once initial groupings
were assigned, the team iteratively reviewed each item in each
category using a grounded theory approach, to confirm
commonality among elements and to allow themes to emerge
from the data.
22
Nine categories emerge d and have been
described in detail elsewhere.
18
Following this initial categori-
zation we performed in-depth analysis of the nine categories
using axial coding techniques
25
to better understand the
properties and dimensions of each. As noted, the largest
unintended consequence category was workflow, which is our
focus here. Axial coding resulted in five themes within that
category.
Table 1. Description of Sites Studied
Hospital Size
(beds)
Type of institution CPOE system Up since Percent orders
entered
Wishard Memorial,
Indianapolis, IN
340 Acute care county teaching
hospital associated with Indiana
University School of Medicine
Homegrown: Regenstrief
Medical Records
System (RMRS)
1973 100%
Massachusetts General
Hospital, Boston, MA
893 Large, academic, general hospital;
part of Partners HealthCare System;
associated with Harvard Medical School
Homegrown: Clinical
Application Suite
1994 100%
The Faulkner, Boston, MA 150 Community teaching hospital with a
private medical staff, affiliated with
Harvard Medical School
Meditech 2003 95%
Brigham & Womens
Hospital, Boston, MA
725 Large, academic, general hospital; part
of Partners HealthCare System; associated
with Harvard Medical School
Homegrown: BICS 1991 90%
Alamance Regional Medical
Center, Burlington, NC
238 Community hospital Eclipsys 1998 95%
22 Campbell et al.: Implications of Computerized Provider Order Entry Adoption JGIM
Page 2
RESULTS
We discuss each of the five themes below and provide
representative exa mples of each. Although we note that
general themes existed in all settings we studied, the repre-
sentative examples we use to elaborate the themes are site-
specific.
CPOE Introduction Exposes HumanComputer
Interaction Problems
We found that ergonomic issues can disrupt workflow. For
example, some disruptions arise when environments designed
prior to the computer era cannot adequately accommodate
new hardware. Mobile computers have little flat space to
accommodate paper charts. One physician noted: A computer
that doesnt have a place to put the chart down is no computer I
am willing to use. In addition, when workstations are in short
supply, contention for computers can be high in busy work
areas, especially after morning rounds.
We noticed many issues related to poor CPOE usability.
These included overly cluttered screen design, poor use of
available screen space, and inconsistencies in screen design.
More specifically, we saw lists that could not be easily sorted,
screens that were hard to read o r annotate, minimum
availability of system defaults, and lack of appropriate safe-
guards to prevent selecting the wrong patient or entering
incorrect data, to name just a few. Not all of these problems
occurred at all sites, though all sites reported software design
issues that made some work processes awkward. For example,
a researcher observed this example of suboptimal design: I
notice that the resident has to perform four mouse clicks to
access an element on a list: 1) click on the pick list, 2) open the
list with the down arrow, 3) select an item from the list, and 4)
hit the return key to exit the pick list. Normally, this wouldntbe
much of a problem, but the list only contains one element!
CPOE Changes Work Pace, Sequence,
and Dynamics
With some CPOE systems, providers find it difficult to access
patient information housed in clinical systems that are not
inte grated wi th CPOE, require separate system logins, or
cannot be accessed simultaneously. A physician explained:
For me to get lab values I would have to exit out of the
discharge summary, [look up the lab values] then bring [the
discharge summary] up again. It is just easier for me to look up
values on a separate computer.
In addition, CPOE can force the provider to accommodate
the system. For example, many systems provide minimal space
for free-text entry or limit the use of timesaving shorthand
(such as abbreviations or acronyms) and instead require data
entry using nested menus, order sets, and pre-configured pick
lists. A resident noted “…the order sets are organized in a linear
fashion, for one problem at a timemost of [my patients]
problems are multidimensional Ihavetofilloutseveral
different order setsone for each problem.
The CPOE systems we studied often do not smoothly handle
transitions in level or location of care. For example, it is quite
common for an admitting clinician to begin to write orders for
an emergency department patient prior to transfer to an
inpatient bed. Because some CPOE implementations associate
orders with a patients physical location, the system may
prevent the admitting clinician from entering these orders.
There is a major problem with confusion over whether it is the
floor accepting the patient or the ER transferring. The difference
is who is responsible."
CPOE systems can force rigid scheduling of tests and
medications. Some systems assign medication start times
when the order becomes active (as opposed to when the
medication is given) making it difficult for staff to alter the
timing to match reality. This may cause delays in medication
administration. One problem was that the start time in our
system doesnt mean the time the medication is first adminis-
teredit means the time the order becomes active and then the
administration times are automatically calculated based on
that. [A physician ordered] a Q 12 medication. The first
scheduled administration time was about 11 hours later so the
patients post-transplant medication was delayed 11 hours. In
addition some CPOE systems make it difficult for clinical staff
to alter the timing of doses when they cannot be given on
schedule, such as when patients are absent from the nursing
unit when medications a re due. Even in systems where
medication dosage times can be changed, often the system
cannot automatically reschedule subsequent doses after this
modification, requiring staff to alter each of the remaining
dosage times manually to match the new, corrected adminis-
tration schedule.
CPOE Provides Only Partial Support for the Work
Activities of Involved Clinical Staff
These systems do not fully support the activities of all clinical
staff who must process orders entered in the system. Nurses
were the most vocal of the non-physician groups: This is not a
nursing system the nurses are just saying Give me a
Table 2. General Interview Guide for Semi-Structured Interviews
Interview subject Question topic Introductory question
All interviewees Personal background Could you please briefly describe your background and professional experience?
End-users System changes Could you please describe what its like for a user when changes are made in the CPOE system?
Various personnel* System history Could you please give us a brief history of your experience with the system?
Various personnel* System implementation Can you describe lessons learned in the implementation process?
Various personnel* Surprises Could you tell us about your memories of any surprises?
Various personnel* End-user perceptions What are your perceptions of how people felt about the consequences of CPOE?
Various personnel* Problem resolution Can you tell us how problems identified by critics were solved?
Various personnel* Future issues How do you describe the future of CPOE here?
*Various personnel: End-users, information and technology leaders and implementers
23Campbell et al.: Implications of Computerized Provider Order Entry AdoptionJGIM
Page 3
template nurses can use. Give me standard order sets I can sign
off with a single review. Get the standard nursing orders into the
doctors order templates, so we dont have to remind them to
write an order for something like drawing arterial blood gases
every 8 hours unless the patient condition changes.’”
Non-physician staff found it bothersome to receive alerts not
applicable to them or their clinical setting. For example, some
drugdrug interaction alerts may be highly desirable in one
context and not another. One intensive care nurse observed:
" the [alerts] warning against prescribing heparin and aspirin
these are CCU patients, the system should know we are going
to give these two meds together on this floor and quit warning
us about them." In addition, because nurses do not prescribe
medications, this alert is targeted at the wrong clinician.
CPOE Reduces Situation Awareness
Dourish and Bellotti define situation awareness as the under-
standing of the activities of others which provides a context for
your own activity.
27
Collaboration understandably improves
when people develop and maintain awareness of what is going
on around them.
28
We found that CPOE systems, because they
allow orders to be entered at any time by providers located
outside of the hospit al, can contribute to loss of situation
awareness. For example: It was not at all unusual in the paper
world to have two or three people generate orders very close to
each other but the common thing they had was a paper or a
sheet. In the emergency department [there] was literally a
different workstation about every two inches down there. We
had a lot more instances of within thirty seconds of each other,
two, sometimes three providers would enter the same order at
approximately the same time and so it really forced us to go back
and do more education on being careful to look and see what
[orders are] active before you enter a new order.
Finally, interesting situation awareness issues emerge when
providers from different clinical services use CPOE to enter
orders simultaneously on the same patient. The orders might
appear to conflict, when in fact they do not. I was sitting there
in the ICU looking at my patient and boom, an order for
dopamine shows up. I didnt write thatand I look at itand
turned out that it was written by the anesthesiologist getting
ready for the case tomorrow. So I was seeing all of the pre-op
medicinesa good thing, right? Except it surprised me. Id
never seen those orders before, and [the patient] looked like he
didnt need dopamine to me, so I just cancelled the order.
CPOE Can Highlight Ineffective Implementation
of Policy and Procedures
CPOE systems help to formalize organizational policies and
procedures.
29
In many cases, actual practice does not match
this rigid letter of the law, so the CPOE system may introduce
a significant amount of extra work (perceived or real): We
found that [obstetrics] was one of the most complex places in the
hospital because patients were going from the screening room to
the pod room to a labor room to the delivery room to postpartum
and each of those are a different level of care and so orders
need to be rewritten. Although nurses are very good about
blending the orders as need be from one [level] to the other, the
computer isnt nearly as flexible."
Difficulties arise when standards are hard to interpret or
implement, as when one clinician initiates patient care that
must be monitored by other specialists: "Some orders [are]
written by certain specialists like anesthesiologists [for] epidur-
als. No one wants to rewrite those orders. So how should those
[orders] traverse the levels of care when the epidural catheter
moves with the patient? In such cases, CPOE can complicate
already difficult issues.
DISCUSSION
By observing and interviewing clinicians, we found that
embedding CPOE systems in clinical practice can disrupt work
processes in several general ways, regardless of the site
studied. Specifically: 1) CPOE systems can expose new hu-
mancomputer interaction problems and exacerbate space
constraints, 2) CPOE can alter the pacing, sequencing, and
dynamics of work patterns,3) De spite the f act that these
systems are ostensibly provider systems, they remain, at least
in the sites we studied, predominantly physician systems,
such that the workflow needs of non-physician personnel are
not yet being addressed, 4) CPOE ca n impact situa tion
awareness for providers, so that clinicians cannot guarantee
that they are acting on complete information at all times, and
5) CPOE can be leveraged to poorly implement organizational
policies and procedures, creating extra work or slowing down
current work processes for providers. We observed these types
of workflow disruptions at all institutions we visited, regardless
of the CPOE system in use. As a result, these general themes
provide the following focus points for improvements in CPOE
system design, implementation, and evaluation.
CPOE Introduction Exposes HumanComputer
Interaction Problems
End-users strug gle with many humancomputer interface
issues when moving from a pen and paper environment that
is flexible and highly portable to an electronic system that is
much more rigid and fixed. Poor system interface design (e.g.,
overly complex screens, inconsistencies in the interface, poor
grouping of like terms, etc.) can exacerbate this transition. It is
imperative that system engineers use proven usability design
standards to avoid implementing systems that violate basic
principles. We look forward to the development of explicit
interface design and usability criteria that must be met in
order to certify CPOE systems through such organizations as
the Certification Commission for Healthcare Information Tech-
nology (http://www.cchit.org).
CPOE Changes Work Pace, Sequence,
and Dynamics
Alterations in work pace, sequence, and dynamics represent
changes that emerge primarily from the difficulties inherent in
attempting to customize the non-linear, iterative, ad hoc, inter-
ruption and exception driven activities of clinical care.
18,23
Computerization of ordering can dramatically affect the care
delivery process, as patterns of communication, cooperation, and
collaborative work must shift to accommodate the technology. It
is not surprising that the National Health Policy forum reported
that clinician productivity can drop approximately 20% within
the first three months of CPOE implementation,
6
though other
24 Campbell et al.: Implications of Computerized Provider Order Entry Adoption JGIM
Page 4
studies
29,30
have indicated that productivity often improves over
time as users gain proficiency with the system. CPOE can be
improved through development of interoperability with and
access to other clinical information systems and research about
how users circumvent the system to get their work done. We
acknowledge that these systems are relatively new, and that as
they mature, they should be able to handle more complex care
scenarios. We encourage careful design that incorporates non-
standard scenarios into the workflow mix.
CPOE Design Affects all Clinical Personnel
Healthcare delivery is a complex activity system requiring the
expertise of various professionals whose respective skills are
interrelated and inseparable. Indeed, this distribution of work
adds to the robustness of the health care system. However,
current CPOE systems do not always accommodate the work
needs of all levels of clinical personnel. In fact, many CPOE
systems seem to provide support for only the physicians work
activities. Although physicians bear the legal responsibility for
ordering and have the expertise needed for t he decision-
making required, the entire ordering-to-completion process
includes many different levels of healthcare personnel. For
these reasons, it is paramount that the roles of nursing,
clerical, pharmacy and other ancillary staff are considered
when CPOE systems are designed, implemented, and modified
if clinical workflow is to proceed with minimal disruption. This
does not imply that all care activities for all personnel must be
incorporated into CPOE; instead, those activities pertaining to
order management must be considered.
CPOE Can Impact Situation Awareness
CPOE systems can vastly improve situation awareness through
functionality that integrates with other systems and subse-
quently displays information derived from these differing
sources in a single location. In addition, clinical decision
support tools can alert clinicians to potential problems that
might otherwise go unnoticed (e.g., drugdrug or drugallergy
interactions). Because CPOE can standardize practice (e.g.,
through order sets, codification of procedures, etc.), it can
provide a level of consistency in practice that can enhance
situation awareness, as users can "expect" certain CPOE
behavior, and adapt to CPOE processes. However, CPOE can
also contribute to a general loss of situation awareness as it can
change the pattern, style and timing of provider interactions. A
certain degree of ite rative and interactive communication
among the various players is essential to promote and support
situation awareness in medical work and decision making.
Such awareness is vitally important for effective performance in
any complex and dynamic environme nt.
31
Without careful
design to facilitate multiple provider communication the com-
puterization of the health record can serve to isolate users from
each other, depriving each of the benefit of coworkers under-
standing and insights regarding the clinical situation.
CPOE Can Highlight Ineffective or Incomplete
Implementation of Policy and Procedures
While CPOE can be a highly effective and efficient tool for
implementing organizational policy or procedure, using CPOE
in this manner can bias workflow design towards an organiza-
tional perspective, one that emphasizes an explicit view of
work: "those things that are documented, visible, and articu-
lable [sic],
20
such as procedures and methods. This view fails
to acknowledge the more tacit aspects of work processes-those
activities carried out in everyday practice, which rely on
human ingenuity and depend on rules of thumb or individual
judgment for synthesis and completion.
20
As a result, rote
implementation of policy or procedure can highlight pro-
nounced differences between organizational intention and
provider practice, leading to the adoption of system work-
arounds by clinicians struggling to use a system that does not
fully support their work.
26
Any implementation of organiza-
tional rules or directives should be undertaken only after
careful assessment of the impact of such changes on actual
clinical work, to determine whether or not these rules can be
practically integrated into workflow. In addition, care must be
taken to a ssure that w ork practices mandated in CPOE
systems are actually formally required, as opposed to repre-
senting "the way things have always been done." CPOE can
make it easy to implement organizational changes. It is thus
imperative that organizational mandates implemented through
CPOE are rigorously tested using real-time scenarios to assure
that these requirements not only make practical sense, but do
not negatively impact workflow.
18
LIMITATIONS
In this study, we only observed users interacting with CPOE
systems. It is possible we might find different unintended
adverse consequences had we evaluated user interactions with
other systems. As a qualitative study, this i nvestig ation
produced rich, in depth knowledge about five carefully selected
sites. It is possible that these sites are not truly representative
of all sites using CPOE.
CONCLUSION
The introduction of CPOE into the healthcare environment has
a dramatic effect on clinical workflow. CPOE systems are tools
intended to support and improve the delivery of care, and are
not solutions for all problems related to clinical practice. We
must take care to continually improve these systems if they are
to fit seamlessly into clinical workflow. As we identify how,
when, and where workflow problems arise, we gain insight for
better system design and implementation. As CPOE systems
evolve, ongoing care must be taken to reduce or resolve the
many unintended adverse effects these systems have on
clinical workflow. The five kinds of unintended and unantici-
pated consequences related to workflow with CPOE can be
mitigated by iteratively altering both clinical workflow and the
CPOE system until a comfortable and optimized fit is achieved.
Acknowledgements: We would like to thank all the individuals
who allowed us to observe or interview them, and the experts who
participated in the Menucha Conference. Special thanks go to the
site principal investigators J. Marc Overhage, M.D., Ph.D., Eric G.
Poon, M.D., M.P.H., and Carol Hudson, R.N. This work was funded
25Campbell et al.: Implications of Computerized Provider Order Entry AdoptionJGIM
Page 5
by research grant LM06942 and training grant ASMM10031 from
the U.S. National Library of Medicine, National Institutes of Health.
Conflict of Interest: The authors state no conflicts of interest
regarding the research or publication of this manuscript.
Corresponding Author: Joan S. Ash, M.B.A., Ph.D.; Department of
Medical Informatics and Clinica l Ep idemiol ogy, Oregon Health
Science University, Mail Code: BICC, 3181 SW Sam Jackson Park
Road, Portland, OR 97239-3098, USA (e-mail: ash@ohsu.edu).
REFERENCES
1. Poon E, Blumenthal D, Jaggi T, Honour M, Bates D, Kaushal R.
Overcoming barriers to adopting and implementing computerized phy-
sician order entry systems in U.S. hospitals. Health Aff. 2004;23(4):
18490.
2. Committee on Quality Health Care in America. To Err is Human:
Building a Safer Health System. Washington, DC: Institute of Medicine;
1999.
3. Committee on Quality Health Care in America. Crossing the Quality
Chasm: A New Health System for the 21st Century. Washington, DC:
Institute of Medicine; 2001.
4. The Leapfrog Group. Factsheet: Computer physician order entry.
2004 [accessed August 29, 2008]; Available from: http:// www.leap
froggroup.org/media/file/Leapfrog-Computer_Physician_Order_Entry_
Fact_Sheet.pdf
5. Oren E, Shaffer E, Guglielmo B. Impact of emerging technologies on
medication errors and adverse drug events. Am J Health Syst Pharm.
2003;6014:144758.
6. Sprague L. Electronic health records: How close? How far to go. NHPF
Issue Brief. 2004;800:117.
7. Wears R, Berg M. Computer technology and clinical work: still waiting
for Godot. JAMA. 2005;293(10):12611263.
8. Ash J, Berg M, Coiera E. Some unintended consequences of information
technology in health care: the nature of patient care information system-
related errors. J Am Med Inform Assoc. 2004;11(2):104112.
9. Koppel R, Metlay J, Cohen A, Abaluck B, Localio A, SE K. Role of
computerized physician order entry systems in facilitating medication
errors. JAMA. 2005;293:10:11971203.
10. Kremsdorf R. CPOE: not the first step toward patient safety. Health
Manag Technol. 2005;26(1):66.
11. Berger R, Kichak J. Computerized physician order entry: helpful or
harmful. J Am Med Inform Assoc. 2004;11(2):1003.
12. Han Y, Carcillo J, Venkataraman S, Clark R, Watson R, Nguyen T, et
al. Unexpected increased mortality after implementation of a commer-
cially sold computerized physician order entry system. Pediatrics.
2005;116(6):150612.
13. Wang J, Lee H, Huang F, Chang P, Sheu J. Unexpected mortality in
pediatric patients with postoperative Hirschsprungs disease. Pediatr
Surg Int. 2004;20(7):5258.
14. Aarts J, Berg M. A tale of two hospitals: a sociotechnical appraisal of the
introduction of computerized physician order entry in two Dutch hospitals.
2004;11(Pt 2):. Stud Health Technol Inform. 2004;107(Pt 2):9991002.
15. Ash J, Anderson J, Gorman P, Zielstorff R, Norcross N, Pettit J, et al.
Managing change: analysis of a hypothetical case. J Am Med Inform
Assoc. 2000;7(2)12534.
16. Lorenzi N, Smith J, Conner S, Campion T. The success factor profile
for clinical computer innovation. Stud Health Technol Inform. 2004;107
(Pt 2)107780.
17. Poon E, Blumenthal D, Jaggi T, Honour M, Bates D, Kaushal R.
Overcoming the barriers to the implementing computerized physician
order entry systems in US hospitals: perspectives from senior manage-
ment. AMIA Annu Symp Proc. 2003:975.
18. Campbell E, Sittig D, Ash J, Guapp one K, Dykstra R. Types of
unintended consequences related to computerized provider order entry.
J Am Med Inform Assoc. 2006;13(5):54756. Sep
Oct.
19. Rinkus S, Walji M, Johnson-Throop K, Malin J, Turley J, Smith J, et
al. Human-centered design of a distributed knowledge management
system. J Biomed Inform. 2005;38(1)417.
20. Sachs P. Transforming work: Collaboration, learning, and design.
Commun ACM. 1995;38(9):3644.
21. Pratt W, Reddy M, McDonald D, Tarczy-Hornoch P, Gennari J.
Incorporating ideas from computer-supported cooperative work. J
Biomed Inform. 2004;37(2):2837.
22. Lincoln Y, Guba E. Natualistic Inquiry. Newbury Park, CA: Sage
Publications, Inc.; 1985.
23. Berg M. Medical work a nd the computer-based patient rec ord : a
sociological perspective. Methods Inf Med. 1998;37(3)294301.
24. Berg M. Patient care information systems and health care work: a
sociotechnical approach. Int J Med Inform. 1999;55(2):87101.
25. Crabtree B, Miller WL. Doing Qualitative Research. 2nd ed. Thousand
Oaks, CA: Sage Publications, Inc; 1999.
26. HarrisonM,KoppelR,Bar-LevS.Unintended consequences of
information technologies in health careAn Interactive sociotechnical
analysis. J Am Med Inform Assoc. 2007;14(5):5429.
27. Dourish P, Bellotti V. Awareness and coordination in shared work
spaces. ACM Conference on Computer-Supported Cooperative Work
(CWSW 92). 1992:107 14.
28. Endsley M. Toward a theory of situation awareness in dynamic systems.
Hum Factors. 1995;37(1)3264.
29. Kuperman G, Gibson R. Computer physician order entry: Benefits,
costs, and issues. Ann Intern Med. 2003;139(1):319.
30. Overhage J, Perkins S, Tierney W, McDonald C. Controlled trial of
direct physician order entry: effects on physicians time utilization in
ambulatory primary care internal medicine practices 2001;8(4):36171.
31. Hazlehurst B, McMullen C, Gorman P. Distributed cognition in the
heart room: How situation awareness arises from coordinated commu-
nications during cardiac surgery. J Biomed Inform. 2007;40(5):53951.
26 Campbell et al.: Implications of Computerized Provider Order Entry Adoption JGIM
Page 6
    • "Based on the full-text review, 428 papers were also excluded. Nine publications were excluded due to quality concerns in the reporting style: either the usability flaws and the method applied were not precisely described, or the discussion of the results confused flaws of different systems323334353637383940. Finally, a total of 26 papers met our inclusion criteria and were used for detailed analysis. "
    [Show abstract] [Hide abstract] ABSTRACT: Medication-related alerting functions may include usability flaws that limit their optimal use. A first step on the way to preventing usability flaws is to understand the characteristics of these usability flaws. This systematic qualitative review aims to analyze the type of usability flaws found in medication-related alerting functions. Papers were searched via PubMed, Scopus and Ergonomics Abstracts databases, along with references lists. Paper selection, data extraction and data analysis was performed by two to three Human Factors experts. Meaningful semantic units representing instances of usability flaws were the main data extracted. They were analyzed through qualitative methods: categorization following general usability heuristics and through an inductive process for the flaws specific to medication-related alerting functions. From the 6,380 papers initially identified, 26 met all eligibility criteria. The analysis of the papers identified a total of 168 instances of usability flaws that could be classified into 13 categories of usability flaws representing either violations of general usability principles (i.e. they could be found in any system, e.g. guidance and workload issues) or infractions specific to medication-related alerting functions. The latter refer to issues of low signal-to-noise ratio, incomplete content of alerts, transparency, presentation mode and timing, missing alert features, tasks and control distribution. The list of 168 instances of usability flaws of medication-related alerting functions provides a source of knowledge for checking the usability of medication-related alerting functions during their design and evaluation process and ultimately constructs evidence-based usability design principles for these functions. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Mar 2015 · Journal of Biomedical Informatics
  • Source
    • "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. "
    [Show abstract] [Hide abstract] 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.
    Full-text · Conference Paper · Apr 2014
  • Source
    • "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] "
    [Show abstract] [Hide abstract] 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.
    Full-text · Article · Jan 2014 · PLoS ONE
Show more